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1.
Arthritis Rheumatol ; 74(2): 284-294, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-34347939

RESUMEN

OBJECTIVE: To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multiethnic/multiracial cohort of patients with systemic lupus erythematosus (SLE). METHODS: Ninety SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; interferon-γ (IFNγ) production was measured by enzyme-linked immunospot (ELISpot) assay in order to assess T cell responses. Disease activity was measured by the hybrid SLE Disease Activity Index (SLEDAI), and flares were identified according to the Safety of Estrogens in Lupus Erythematosus National Assessment-SLEDAI flare index. RESULTS: Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD compared to fully vaccinated controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-double-stranded DNA antibody level prior to vaccination were associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and correlated with antigen-specific IFNγ production determined by ELISpot. In a subset of patients with poor antibody responses, IFNγ production was similarly diminished. Pre- and postvaccination SLEDAI scores were similar in both groups. Postvaccination flares occurred in 11.4% of patients; 1.3% of these were severe. CONCLUSION: In a multiethnic/multiracial study of SLE patients, 29% had a low response to the COVID-19 vaccine which was associated with receiving immunosuppressive therapy. Reassuringly, severe disease flares were rare. While minimal protective levels remain unknown, these data suggest that protocol development is needed to assess the efficacy of booster vaccination.


Asunto(s)
Antirreumáticos/uso terapéutico , Vacunas contra la COVID-19/uso terapéutico , COVID-19/prevención & control , Huésped Inmunocomprometido , Inmunogenicidad Vacunal , Inmunosupresores/uso terapéutico , Lupus Eritematoso Sistémico/tratamiento farmacológico , Vacuna nCoV-2019 mRNA-1273/uso terapéutico , Ad26COVS1/uso terapéutico , Adulto , Anticuerpos Antivirales/inmunología , Linfocitos B/inmunología , Vacuna BNT162/uso terapéutico , Vacunas contra la COVID-19/inmunología , Estudios de Casos y Controles , Estudios de Cohortes , Ensayo de Immunospot Ligado a Enzimas , Femenino , Glucocorticoides/uso terapéutico , Humanos , Inmunoglobulina G/inmunología , Interferón gamma/inmunología , Lupus Eritematoso Sistémico/inmunología , Lupus Eritematoso Sistémico/fisiopatología , Masculino , Persona de Mediana Edad , Pruebas de Neutralización , Prednisona/uso terapéutico , SARS-CoV-2 , Glicoproteína de la Espiga del Coronavirus/inmunología , Brote de los Síntomas
2.
HEC Forum ; 32(3): 253-267, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32240442

RESUMEN

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.


Asunto(s)
Hospitalización/tendencias , Caminata/ética , Endocarditis/complicaciones , Endocarditis/psicología , Hospitalización/legislación & jurisprudencia , Humanos , Jurisprudencia , Masculino , Persona de Mediana Edad , Política Organizacional , Caminata/psicología
4.
Resuscitation ; 130: 1-5, 2018 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-29935341

RESUMEN

BACKGROUND: In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. OBJECTIVE: To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DESIGN: Retrospective chart review. SETTING/SUBJECTS: Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. MEASUREMENTS: Logistic regression was used to identify demographic and medical data associated with code status. RESULTS: Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). CONCLUSIONS: Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.


Asunto(s)
Current Procedural Terminology , Paro Cardíaco/terapia , Intubación Intratraqueal , Órdenes de Resucitación , Adulto , Directivas Anticipadas , Anciano , Femenino , Humanos , Intubación Intratraqueal/métodos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Planificación de Atención al Paciente/organización & administración , Planificación de Atención al Paciente/normas , Mejoramiento de la Calidad , Estudios Retrospectivos , Centros de Atención Terciaria/estadística & datos numéricos , Estados Unidos , Privación de Tratamiento
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