Cellular and humoral immunogenicity of the COVID-19 vaccine and COVID-19 disease severity in individuals with immunodeficiency.

Background: A well-coordinated adaptive immune response is crucial for limiting COVID-19 disease. Some individuals with immunodeficiency are at a high risk of developing severe COVID-19. Therefore, the development of standardized methods for measuring different arms of the vaccine response in the setting of immunodeficiency is of particular interest. In this study, we compared the vaccine response of individuals living with immunodeficiency with healthy controls in terms of interferon gamma (IFN-γ) production and spike protein-specific antibody level post primary COVID-19 vaccination and booster vaccines. Additionally, the disease severity of those individuals who contracted COVID-19 was assessed. Methods: Whole blood was stimulated overnight from 71 participants and 99 healthy controls. Commercially available PepTivator® peptide pool and trimeric spike protein stimulation were used. ELISA was used to analyze IFN-γ levels. The total SARS-CoV-2 spike protein antibody titre was measured using a Roche Elecsys® S total antibody assay. Patient characteristics, COVID-19 infection status and IDDA 2.1 'Kaleidoscope' scores were recorded. Vaccine responses were scored from zero to three. Results: 99% of healthy controls, 89% of individuals with IEI and 76% with secondary immunodeficiency (SID) had an IFN-γ level above the validated reference range after peptide mix stimulation following primary vaccination. There was an increase in IFN-γ levels in patients with inborn errors of immunity (IEI) following the booster vaccine (p = 0.0156). 100% of healthy controls, 70% of individuals living with IEI and 64% of individuals living with SID had detectable spike protein-specific antibody levels following the primary vaccination. 55% of immunodeficiency patients who had mild COVID-19 and 10% with moderate/severe COVID-19 had detectable antibody and IFN-γ levels post vaccine. The mean pre-infection IDDA 2.1 scores were higher in individuals who developed moderate/severe COVID-19 (25.2 compared to 9.41). Conclusions: Covid whole-blood IGRA is a highly accurate, straightforward and robust assay and can be easily adapted to measure cellular response to COVID-19. A complete evaluation of the vaccine response may be particularly important for individuals living with immunodeficiency. A clinical immunodeficiency score and a validated vaccine response score may be valuable tools in estimating COVID-19 disease risk and identifying individuals living with immunodeficiency who may benefit from enhanced vaccination schedules.

Operating in the outpatient department: The future of flexor tendon repair?

Aims: Flexor tendon injuries are debilitating with rupture of repair leading to significant morbidity. The SARS-CoV-2 pandemic has led to a shift to out-of-theatre operating, with many flexor tendon repairs being performed on The same day as initial assessment in our outpatient Department (OpD) procedure room. We aimed to compare The rupture rates before and after The start of The pandemic to assess The safety of this change in practice. Method(s): Patients who underwent repair of one or more flexor tendons were included from two six-month periods: July to December 2019 and April to September 2020. Patient records were reviewed to identify operation location, number of flexor tendons repaired per patient and rupture incidence. In The second period, patients whose operation was performed in theatre were excluded. Result(s): 28 patients were included for The initial period with a total of 49 flexor tendons injured. All repairs were performed in theatre and 3 ruptures were recorded (6%). 17 patients underwent flexor tendon repair during The second period. 11 patients were operated on in The OpD with a total of 16 flexor tendons injured. 1 rupture was recorded (6%). Conclusion(s): The rupture rate of OpD operating is comparable to that of The traditional theatre pathway. OpD operating also allowed us to circumvent theatre waiting lists and thus avoid costly delays to patient care. This project demonstrates maintained safety for patients and of fers a platform for further Research to confirm OpD operating as a viable and sustainable alternative for future practice.

Optimising outpatient care after paediatric burns: The development of a chatbot to identify complications and provide clinical advice

Aim: More than 6000 children require specialist care from one of fourteen regional burns services in England and Wales each year. Families often have to travel long distances and may not have access to specialist care with restricted services due to Covid-19. This quality improvement project aimed to: 1) Determine national practice in paediatric burn follow up 2) Investigate whether chatbots have been used in outpatient settings 3) Develop a novel application (a chatbot) that patients and parents can interact with for advice and reassurance following paediatric burns. Method: We conducted a national service evaluation of children's burns services in England and Wales. We then conducted a PRISMA compliant systematic review up to September 2020 to identify studies reporting chatbot use to deliver outpatient care. A chatbot was then developed using Dialogflow to identify complications and provide advice to families. Results: Across England and Wales, 11 children's burns services reported outpatient practice: six services follow up all children at three months, three have variable follow-up and two discharge all patients. Our systematic review identified 10 studies reporting chatbot use although none were used following burns. A frame-based system-focused chatbot was developed in conjunction with expert burns surgeons and patient representatives. Conclusions: Chatbots are effective and acceptable alternatives for inperson follow up. We demonstrate national variation in the provision of outpatient paediatric burn care and have developed a chatbot that can address clinical concerns and provide reassurance to patients and family members. Future studies will determine the acceptability and safety of this chatbot.

STING. steroid injections during covid-19. a cross speciality call

Introduction: An important clinical question during the Covid-19 pandemic is the safety of steroid use. Guidelines published by rheumatology, physiotherapy, orthopaedic and pain medicine societies have advised on the restricted use of corticosteroids for musculoskeletal and rheumatic conditions. For clinicians across the specialities there is a challenge to safely conducting best practice, yet ensuring patients have access to the significant functional benefits of steroid injections. Methods: The STING prospective service evaluation will collect data on steroid injections undertaken during this part of the pandemic. Clinicians will be able to input information on patient demographics, background Covid risk and steroid injection specifics. At follow up at 4-6 weeks complications and Covid specific outcomes will be recorded, as well as patient perceived symptom improvement. Each unit collecting data will have assigned collaborator(s), with a senior consultant validating the data. Data will be collected and managed using Research Electronic Data Capture (REDCap). Data collection and management will adhere to Caldicott II principles and GDPR. Results: Results will be analysed through RedCap and compared to national Covid incidence. Local complication and patient reported outcomes will be compared between specialities, environments and steroid specifics (volume, location etc.). Conclusion: A pan-speciality look at steroid injection use during the pandemic will be useful primarily to contribute to understanding the safety of steroid use. Secondarily to look at cross speciality differences in administration, PROMs and to appreciate patient groups who may be excluded from steroid treatment.

Skin cancer surgery during the COVID-19 pandemic: A national, multicentre, prospective cohort study and survey of plastic surgeons

Skin cancer is the most common malignancy worldwide. The COVID-19 pandemic has caused an unprecedented reorganization of healthcare services. This study established what effect the pandemic has had on the provision of skin cancer surgery by plastic surgeons in the U.K., one of the worst affected countries globally. A national, multicentre, prospective cohort study of nonmelanoma skin cancer excisions was undertaken. Retrospective data were collected on melanoma surgery. Consecutive monthly surveys from plastic surgeons ascertained how national guidance was implemented. The primary outcome was surgical provision by tumour type. In total, 2050 patients (1549 with nonmelanoma skin cancer and 501 with melanoma) from 32 plastic surgery units were enrolled between 16 March and 14 June 2020. Surgeon surveys were received from 34 plastic surgery units. The number of nonmelanoma skin cancers treated per week fell by 27% to 44% during lockdown. The median number of general anaesthetic operating lists per week per institution fell sixfold from three before the pandemic to 0.5 in April (P < 0.001) and gradually increased in May and June but did not reach pre-'lockdown' levels. Excision of squamous cell carcinomas (SCCs) was prioritized over basal cell carcinomas (BCCs). At the peak of the pandemic, SCCs made up 71% of excisions (normally 28%;P < 0.001). Sentinel lymph node biopsies for melanoma (Breslow thickness ≥ 0.8 mm) occurred in only 26%, suggesting many patients were not accurately staged, restricting their access to adjuvant therapy. Two patients (0.7%) developed COVID-19 after melanoma surgery. High-risk tumours were particularly affected, as 77% of surgeons reported Mohs micrographic surgery was stopped and radiotherapy was run at a reduced service in 70% of units. Surgeons reported that surveillance for melanoma and SCC stopped in 10% and operating on BCCs was stopped in 73% of units. All skin cancers suffered a significant and abrupt disruption, but high-risk and complex lesions were worst affected. The majority of changes observed were in line with speciality association pandemic guidelines. In contrast to previous studies, we have demonstrated that operating on skin cancer during the pandemic was safe. To reduce further mortality and morbidity from the COVID-19 pandemic, skin services must be resumed urgently.