SARS CoV2 Omicron Infections Among Vaccinated Maintenance Hemodialysis Patients- outcomes and comparison to Delta variant.

Background Infections with B.1.1.529 (Omicron) variants of SARS-CoV-2 became predominant worldwide since late 2021, replacing the previously dominant B.1.617.2 variant (Delta). While those variants are highly transmissible and can evade vaccine protection, population studies suggested that outcomes from infection with Omicron variants are better compared with Delta. Data regarding prognosis of maintenance hemodialysis (MHD) patients infected with Omicron vs. Delta variants, however, is scarce. Methods This retrospective cohort study includes all patients with end-stage kidney disease treated with MHD in Meir Medical Center, Kfar-Saba, Israel that were diagnosed with SARS-CoV-2 infection between June 2021 and May 2022. Results Twenty-six subjects were diagnosed with the Delta variant and 71 with Omicron. Despite comparable age between groups and higher mean vaccine doses prior to the infection among Omicron group (p<0.001), SARS-CoV-2 infection severity was significantly worse among MHD infected with the Delta variant: 50% developed severe or critical COVID-19 vs. 5% in the Omicron group (p<0.001). Over half of MHD infected with Omicron (57%) were asymptomatic during their illness. 30-day mortality rate for the whole cohort was 5.2%. It was significantly higher among MHD in the Delta group than in the Omicron group (5/26, 19.2% vs. 0/71, p<0.001), as was 90-day mortality rate (5/26, 19.2% vs. 3/71, 4.2%, p=0.02). Conclusions Infection with the SARS-CoV-2 Delta variant was associated with worse outcomes compared with Omicron, among subjects on MHD. However, despite mild disease among vaccinated MHD patients, infection with Omicron variant was still associated with significant 90-day mortality rate.

Comparison of clinical remission criteria for severe asthma patients receiving biologic therapy.

BACKGROUND: The concept of remission on biological treatment has been suggested as a therapeutic target for patients with severe asthma, composed of 1. no chronic use of systemic steroids, 2. no exacerbations, 3. minimal symptoms, and 4. optimized lung function, for a significant time. However, the criteria for remission are not clearly defined. OBJECTIVE: Our objective was to compare different criteria for remission in subjects receiving biologicals for severe asthma. METHODS: A cross-sectional study of adult subjects who receive a stable regimen of a biological for severe asthma for at least 6-months. We compared the proportion of subjects who fulfilled different specific criteria in the four domains, as well as those who achieved different composite outcome measures of clinical remission. RESULTS: Of 39 subjects, 28 were females (71.8%), mean age 60.4. Twelve were current or past smokers (30.8%). Twelve had prior different biological treatment (30.8%), and 3/39 had more than one previous treatment (7.7%). Current biological included mepolizumab 12/39 (30.8%), dupilumab 11/39 (28.2%), benralizumab 10/39 (25.6%), omalizumab 5/39 (12.8%), reslizumab 1/39 (2.6%). Different specific criteria were achieved in 39-80% of subjects, being highest for no chronic steroid use and lowest for symptoms control and lung function. Overall remission was obtained by 20-41%, depending on definition, with significant variability in agreement between different sets of remission criteria (Cohen's kappa 0.33-0.89). CONCLUSION: Clinical remission is achievable in real-world severe asthmatics on biological therapies. The core criteria for remission should be better defined.

The humoral response to COVID-19 vaccinations can predict the booster effect on health care workers-toward personalized vaccinations?

BACKGROUND: Waning immunity after the coronavirus disease 2019 (COVID-19) vaccinations creates the constant need of boosters. Predicting individual responses to booster vaccines can help in its timely administration. We hypothesized that the humoral response to the first two doses of the BNT162b2 vaccine can predict the response to the booster vaccine. METHODS: A prospective cohort of hospital health care workers (HCW) that received three doses of the BNT162b2 vaccine. Participants completed serological tests at 1 and 6 months after the second vaccine dose and 1 month after the third. We analyzed predictive factors of antibody levels after the booster using multivariate regression analyses. RESULTS: From 289 eligible HCW, 89 (31%) completed the follow-up. Mean age was 48 (±10) and 46 (52%) had daily interaction with patients. The mean (±standard deviation) antibody level 1 month after the second vaccine was 223 (±59) AU/ml, and 31 (35%) had a rapid antibody decline (>50%) in 6 months. Low antibody levels 1 month after the second vaccine and a rapid antibody decline were independent predictors of low antibody levels after the booster vaccine. CONCLUSIONS: The characteristics of the humoral response to COVID-19 vaccinations show promise in predicting the humoral response to the booster vaccines.

Interactions and clinical implications of serological and respiratory variables 3 months after acute COVID-19.

Medical follow-up of symptomatic patients after acute Coronavirus Disease 2019 (COVID-19) results in major burdens on patients and healthcare systems. The value of serological markers as part of this follow-up remains undetermined. We aimed to evaluate the clinical implications of serological markers for follow-up of acute COVID-19. For this purpose, we conducted an observational cohort study of patients 3 months after acute COVID-19. Participants visited a respiratory-clinic between October 2020 and March 2021, and completed pulmonary function tests (PFTs), serological tests, symptom-related questionnaires, and chest CT scans. Overall, 275 patients were included at a median of 82 days (IQR 64-111) post infection. 162 (59%) patients had diffusing capacity for carbon monoxide corrected for hemoglobin (DLCOc) below 80%, and 69 (25%) had bilateral chest abnormalities on CT scan. In multivariate analysis, anti-S levels were an independent predictor for DLCOc (ß = - 0.14, p = 0.036). Anti-S levels were also associated with severe COVID-19 and older age, and correlated with anti-nucleocapsid (r = 0.30, p < 0.001) and antibodies to receptor binding domain (RBD, r = 0.37, p < 0.001). Other serological variables were not associated with clinical outcomes. In conclusion, symptomatic patients 3-months after COVID-19 had high respiratory symptomatic burden, in which anti-S levels were significantly associated with previous severe COVID-19 and DLCOc.

Assessment of a close respiratory follow-up schedule at 3 and 6 months after acute COVID-19 and its related investigations.

BACKGROUND: Respiratory sequela after acute COVID-19 is common and requires medical follow-up. Considering its vast economic impact, there is still no consensus regarding the mid-term follow-up plan after recovery. OBJECTIVE: To evaluate the necessity of a close pulmonary follow-up schedule after acute COVID-19 and its related investigations. METHODS: A prospective cohort study including adult patients after acute COVID-19 pneumonia. Patients were invited or referred to a 3- and 6-month follow-up visits at a large pulmonary institute in a tertiary center. Before each visit, patients completed demographic and clinical questionnaires, pulmonary function tests (PFTs), and chest CT scans. RESULTS: 168 patients were included after completing both visits (medians of 80 and 177 days). Their mean age was 58 ± 15 and 52% recovered from severe or critical COVID-19. Between the two visits, there was no change in DLCOc (mean 73 ± 18 %predicted in both visits) and FVC (mean 90 ± 16 vs. 89 ± 16 %predicted). The COPD assessment tool and modified Medical Research Council scale had inverse correlations with the DLCOc, and similarly did not change between the visits. Occupational exposures were the only factor associated with a change in DLCOc during follow-up (3% decrease, p = 0.04). An improvement in chest CT findings at the second visit was not associated with a change in PFTs. CONCLUSIONS: Most clinical variables did not change during a close follow-up schedule in the first six months after acute COVID-19. Such a follow-up plan does not appear necessary and should be personalized to limit excessive costs and resources.

One-year dynamics of antibody titers after three doses of SARS-CoV-2 BNT162b2 vaccine.

BACKGROUND: A third dose of the BNT162b2 SARS-CoV-2 vaccine leads to a significant increase in antibody levels, however, concerns regarding the long-term persistence of this response exist. We assessed the humoral response for one year following vaccination. METHODS: A prospective study among immunocompetent healthcare workers (HCW) who received three doses of BNT162b2. anti-spike antibody titers were measured at six predefined timepoints, from before the second vaccine dose, and up to one year afterwards, which is 4-6 months after the third dose. HCW with a history of SARS-CoV-2 infection were excluded. RESULTS: Seventy-six HCW had all the six serological measurements. Antibody titers significantly increased shortly following the third vaccine dose, and while declining, remained higher from all previous measurements for up to six months. CONCLUSIONS: A third dose of BNT162b2 leads to a profound humoral response, which remains significantly higher than previous measurements, even after 6 months.

Assessment of Predictors for SARS-CoV-2 Antibodies Decline Rate in Health Care Workers after BNT162b2 Vaccination-Results from a Serological Survey.

Background: SARS-CoV-2 is a novel human pathogen causing Coronavirus Disease 2019 that has caused widespread global mortality and morbidity. Since health workers in Israel were among the first to be vaccinated, we had a unique opportunity to investigate the post-vaccination level of IgG anti-S levels antibodies (Abs) and their dynamics by demographic and professional factors. Methods: Prospective Serological Survey during December 2020−August 2021 at Barzilai Medical Center among 458 health care workers (HCW) followed for 6 months after the second BNT162b2 vaccine dose. Results: Antibody levels before the second dose, and 30, 90 and 180 days after were 57.1 ± 29.2, 223 ± 70.2, 172.8 ± 73.3 and 166.4 ± 100.7 AU/mL, respectively. From GEE analysis, females had higher Abs levels (ß = 26.37 AU/mL, p = 0.002). Age was negatively associated with Abs, with a 1.17 AU/mL decrease for each additional year (p < 0.001). Direct contact with patients was associated with lower Abs by 25.02 AU/mL (p = 0.009) compared to working with no such contact. The average decline rate overall for the study period was 3.0 ± 2.9 AU/mL per week without differences by demographic parameters and was faster during the first 3 months after vaccination than in the subsequent 3 months. Conclusions: All demographic groups experienced a decline in Abs over time, faster during the first 3 months. Findings of overall Abs lower in males, workers with direct contact with patients, and older workers, should be considered for policy-making about choosing priority populations for additional vaccine doses in hospital settings.

Computed Tomography-Guided Lung Biopsy: Does a Rural Hospital Do Better?

BACKGROUND: Lung percutaneous needle biopsy (PNB) is routinely used to diagnose lung cancer. The most prevalent complications of PNB are pneumothorax and bleeding. Differences in characteristics of medical procedures between rural and urban hospitals are well known. OBJECTIVES: To compare characteristics of patients and lesions between two hospitals and to evaluate whether lung PNB complications differ in rural vs. urban settings. METHODS: The authors examined case records of 561 patients who underwent lung biopsy at two different medical centers in Israel: Tel Aviv Sourasky Medical Center (urban) and Barzilai Medical Center (rural). To evaluate the complication rates, the authors analyzed findings from chest X-ray performed 2 hours after biopsy and computed tomography (CT) images at the site of biopsy. RESULTS: The study comprised 180 patients who underwent lung biopsy at Barzilai and 454 at Sourasky. The rate of pneumothorax did not differ between centers (12% at Barzilai and 19% at Sourasky, P = 0.08). Distance from pleura was positively correlated to pneumothorax occurrence in both centers; however, neither lesion size nor lesion locus was found to be a risk factor for pneumothorax. Mild bleeding at the biopsy site occurred equally at Barzilai and Sourasky (32% vs. 36%, P = 0.3, respectively). Furthermore, immediate CT post-biopsy at Barzilai showed 95% negative predictive value, showing that a CT scan performed immediately after lung biopsy cannot replace the routine follow-up chest X-ray in predicting iatrogenic pneumothorax. CONCLUSIONS: CT-guided percutaneous lung biopsies are comparable between rural and urban hospitals regarding procedure characteristics and complication rates.

The diagnostic value of tissue button technique for specimen accusation during endobronchial ultrasound-guided transbronchial fine-needle aspiration.

INTRODUCTION: The quality of tissue acquisition during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a major determinant of the diagnostic yield of the procedure. In the tissue button (TB) technique, the retrieved cellular specimen is fixed in ethanol and subsequently scraped from slide using surgical blade into formaldehyde and processed like ordinary tissue biopsy thus potentially increasing its diagnostic value. OBJECTIVES: To retrospectively evaluate the diagnostic yield of a TB technique in patients undergoing EBUS-TBNA for various malignant and benign conditions. METHODS: The diagnostic yield of specimen obtained by two methods (TB and traditional cell-block technique) performed during the same procedure are outlined in 46 patients who underwent EBUS-TBNA (median age = 65, range 19-85 years). RESULTS: Overall, in both malignant and benign conditions, TB resulted in clear diagnostic material in 43/46 (93.4%) patients. Specifically, TB provided clear histological diagnosis of malignancy (either primary lung cancer or metastases from extra-thoracic cancer) in 30/46 (65.2%) patients and granulomatous inflammation in 11/46 (23.9%) of patients. Only in two patients TB did not provide diagnostic material. CONCLUSIONS: The newly introduced TB technique provides valuable histological diagnostic material during EBUS-TBNA both malignant and benign conditions. Given its simplicity and its high diagnostic yield, TB should be considered to be used as one of the preferred specimen acquisition modalities during EBUS-TBNA specimen processing. Direct comparison to alternative tissue processing techniques during EBUS-TBNA should be explored in further randomized prospective studies.