Bulk IgG glycosylation predicts COVID-19 severity and vaccine antibody response.

Although vaccination efforts have expanded, there are still gaps in our understanding surrounding the immune response to SARS-CoV-2. Measuring IgG Fc glycosylation provides insight into an infected individual's inflammatory state, among other functions. We set out to interrogate bulk IgG glycosylation changes from SARS-CoV-2 infection and vaccination, using plasma from mild or hospitalized COVID-19 patients, and from vaccinated individuals. Inflammatory glycans are elevated in hospitalized COVID-19 patients and increase over time, while mild patients have anti-inflammatory glycans that increase over time, including increased sialic acid correlating with RBD antibody levels. Vaccinated individuals with low RBD antibody levels and low neutralization have the same IgG glycan traits as hospitalized COVID-19 patients. In addition, a small vaccinated cohort reveals a decrease in inflammatory glycans associated with peak IgG concentrations and neutralization. This report characterizes the bulk IgG glycome associated with COVID-19 severity and vaccine responsiveness and can help guide future studies into SARS-CoV-2 protective immunity.

Divergent Antibody Repertoires Found for Omicron versus Wuhan SARS-CoV-2 Strains Using Ig-MS.

SARS-CoV-2 Omicron (B.1.1.529) and its subvariants are currently the most common variants of concern worldwide, featuring numerous mutations in the spike protein and elsewhere that collectively make Omicron variants more transmissible and more resistant to antibody-mediated neutralization provided by vaccination, previous infections, and monoclonal antibody therapies than their predecessors. We recently reported the creation and characterization of Ig-MS, a new mass spectrometry-based serology platform that can define the repertoire of antibodies against an antigen of interest at single proteoform resolution. Here, we applied Ig-MS to investigate the evolution of plasma antibody repertoires against the receptor-binding domain (RBD) of SARS-CoV-2 in response to the booster shot and natural viral infection. We also assessed the capacity for antibody repertoires generated in response to vaccination and/or infection with the Omicron variant to bind to both Wuhan- and Omicron-RBDs. Our results show that (1) the booster increases antibody titers against both Wuhan- and Omicron- RBDs and elicits an Omicron-specific response and (2) vaccination and infection act synergistically in generating anti-RBD antibody repertoires able to bind both Wuhan- and Omicron-RBDs with variant-specific antibodies.

De novo emergence of SARS-CoV-2 spike mutations in immunosuppressed patients.

BACKGROUND: The continuing evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with decreased susceptibility to neutralizing antibodies is of clinical importance. Several spike mutations associated with immune escape have evolved independently in association with different variants of concern (VOCs). How and when these mutations arise is still unclear. We hypothesized that such mutations might arise in the context of persistent viral replication in immunosuppressed hosts. METHODS: Nasopharyngeal specimens were collected longitudinally from two immunosuppressed patients with persistent SARS-CoV-2 infection. Plasma was collected from these same patients late in disease course. SARS-CoV-2 whole genome sequencing was performed to assess the emergence and frequency of mutations over time. Select Spike mutations were assessed for their impact on viral entry and antibody neutralization in vitro. RESULTS: Our sequencing results revealed the intrahost emergence of spike mutations that are associated with circulating VOCs in both immunosuppressed patients (del241-243 and E484Q in one patient, and E484K in the other). These mutations decreased antibody-mediated neutralization of pseudotyped virus particles in cell culture, but also decreased efficiency of spike-mediated cell entry. CONCLUSIONS: These observations demonstrate the de novo emergence of SARS-CoV-2 spike mutations with enhanced immune evasion in immunosuppressed patients with persistent infection. These data suggest one potential mechanism for the evolution of VOCs and emphasize the importance of continued efforts to develop antiviral drugs for suppression of viral replication in hospitalized settings.

Environmental Impact of Telerehabilitation Visits in an Urban Setting

Background : Climate change has been described as the largest public health concern of the 21st century. In response to climate change over 50 countries have pledged to go carbon neutral in the provision of health care service and telemedicine can be an integral part of decreasing emissions related travel associated with health care. While telemedicine rapidly expanded to increase access to care during the Covid-19 pandemic, the impact of telerehabilitation on climate change as part of the provision of physical rehabilitation services has not been assessed. This study focuses on physical medicine and rehabilitation physicians in an urban physical medicine and rehabilitation (PM&R) department and assesses patient satisfaction with synchronous video visits (SVVs) as well as the estimated value of SVVs in travel savings and carbon emissions. Materials and Methods : We conducted a retrospective chart review, implemented a patient survey, and conducted a commuter analysis to report our experience using SVVs to provide follow-up care across multiple rehabilitation sub-specialties Results : A total of 154 SVVs were conducted before the pandemic over an 18-month period. The most commonly addressed issues during the SVVs were rehabilitation and medication management, followed by equipment, lab and imaging results. About one-third of the patients (31%) were non-ambulatory at the time of their SVV. On average, SVVs reduced travel distance (95 miles), travel time (2.23 hours), travel cost ($15) and carbon emissions. Discussion : The use of telerehabilitation should be an integral part of decreasing the carbon footprint of provision of physical medicine and rehabilitation services.

Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19.

Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

6-Mercaptopurine and Macrophage Activation Syndrome Case Report and Review of the Literature.

Macrophage activation syndrome is a life-threatening syndrome of uncontrolled immune activation with variable clinical presentation making early diagnosis difficult. It is often manifested by the development of multi-organ failure due to systemic inflammatory response. Patients with ulcerative colitis (UC) on purine antimetabolites are at high risk for severe myelosuppression due to the mechanism of thiopurine toxicity which potentially contributes to the development of macrophage activation syndrome. We present a case of a 39-year-old woman with a 2-year history of UC previously treated with 6-mercaptopurine (6-MP) and recent COVID-19 infection, who was admitted to our emergency department for C. difficile infection and subsequently developed macrophage activation syndrome. This case report also raises the question of whether abrupt discontinuation of 6-MP may have contributed to the worsening of the patient's symptoms of underlying hemophagocytic lymphohistiocytosis (HLH) and her rapid deterioration. Both macrophage activation syndrome and COVID-19 infection can produce a large number of pro-inflammatory cytokines termed "cytokine storm," but a pro-inflammatory cytokine panel breakdown helps to differentiate between the two. Our case report emphasizes the importance of close monitoring of patients on purine antimetabolite therapy who present with signs and symptoms of systemic toxicity.

Dynamic Monitoring of Seroconversion using a Multianalyte Immunobead Assay for Covid-19.

Multiplex technologies for interrogating multiple biomarkers in concert have existed for several decades; however, methods to evaluate multiple epitopes on the same analyte remain limited. This report describes the development and optimization of a multiplexed immunobead assay for serological testing of common immunoglobulin isotypes (e.g., IgA, IgM, and IgG) associated with an immune response to SARS-CoV-2 infection or vaccination. Assays were accomplished using a flow-based, multiplex fluorescent reader with dual-channel capability. Optimizations focused on analyte capture time, detection antibody concentration, and detection antibody incubation time. Analytical assay performance characteristics (e.g., assay range (including lower and upper limits of quantitation); and intra- and inter-assay precision) were established for either IgG/IgM or IgA/IgM serotype combination in tandem using the 'dual channel' mode. Analyte capture times of 30 min for IgG, 60 min for IgM, and 120 min for IgA were suitable for most applications, providing a balance of assay performance and throughput. Optimal detection antibody incubations at 4 µg/mL for 30 min was observed and are recommended for general applications, given the overall excellent precision (percent coefficient of variance (%CV) ≤ 20%) and sensitivity values observed. The dynamic range for the IgG isotype spanned several orders of magnitude for each assay (Spike S1, Nucleocapsid, and Membrane glycoproteins), which supports robust titer evaluations at a 1:500 dilution factor for clinical applications. Finally, the optimized protocol was applied to monitoring Spike S1 seroconversion for subjects (n = 4) that completed a SARS-CoV-2 vaccine regimen. Within this cohort, Spike S1 IgG levels were observed to reach maximum titers at 14 days following second dose administration, at a much higher (~40-fold) signal intensity than either IgM or IgA isotypes. Interestingly, we observed highly variable Spike S1 IgG titer decay rates that were largely subject-dependent were observed, which will be the topic of future studies.

Clinician Distress and Inappropriate Antibiotic Prescribing for Acute Respiratory Tract Infections: A Retrospective Cohort Study.

BACKGROUND: The National Academy of Medicine's 2019 consensus study on clinician burnout identified a need for research evaluating the impact of clinician distress on health care quality. This study examined the association between clinician distress and the inappropriate use of antibiotic prescriptions for acute respiratory tract infections (RTIs) in adult outpatients. METHODS: A retrospective cohort study was conducted using electronic health record visit data linked to annual wellness surveys administered to all clinicians at Boston Medical Center from May 4 to June 20, 2017, and June 5 to July 6, 2018. Included were outpatient visits occurring in Family Medicine, General Internal Medicine, or the emergency department in which an acute RTI for an otherwise healthy adult was listed as a primary diagnosis. The study examined the association of clinician depression, anxiety, and burnout with the visit-level odds of a clinician inappropriately prescribing an antibiotic for an acute RTI. RESULTS: Out of the 2,187 visits eligible for inclusion, 1,668 visits were included in the final sample. Overall, 33.8% and 51.0% of clinicians reported depression/anxiety and burnout symptoms, respectively. Each 1 standard deviation increase in a clinician's composite depression and anxiety score was associated with a 28% increase (odds ratio = 1.28, 95% confidence interval = 1.02-1.61) in the adjusted odds of an inappropriate antibiotic prescription for an acute RTI. Clinician burnout had no significant association with inappropriate antibiotic prescribing for acute RTIs. CONCLUSION: These findings suggest that clinician depression and anxiety may be important indicators of health care quality in routine outpatient care.

Multiple expansions of globally uncommon SARS-CoV-2 lineages in Nigeria.

Disparities in SARS-CoV-2 genomic surveillance have limited our understanding of the viral population dynamics and may delay identification of globally important variants. Despite being the most populated country in Africa, Nigeria has remained critically under sampled. Here, we report sequences from 378 SARS-CoV-2 isolates collected in Oyo State, Nigeria between July 2020 and August 2021. In early 2021, most isolates belonged to the Alpha "variant of concern" (VOC) or the Eta lineage. Eta outcompeted Alpha in Nigeria and across West Africa, persisting in the region even after expansion of an otherwise rare Delta sub-lineage. Spike protein from the Eta variant conferred increased infectivity and decreased neutralization by convalescent sera in vitro. Phylodynamic reconstructions suggest that Eta originated in West Africa before spreading globally and represented a VOC in early 2021. These results demonstrate a distinct distribution of SARS-CoV-2 lineages in Nigeria, and emphasize the need for improved genomic surveillance worldwide.

Next-Generation Serology by Mass Spectrometry: Readout of the SARS-CoV-2 Antibody Repertoire.

Methods of antibody detection are used to assess exposure or immunity to a pathogen. Here, we present Ig-MS, a novel serological readout that captures the immunoglobulin (Ig) repertoire at molecular resolution, including entire variable regions in Ig light and heavy chains. Ig-MS uses recent advances in protein mass spectrometry (MS) for multiparametric readout of antibodies, with new metrics like Ion Titer (IT) and Degree of Clonality (DoC) capturing the heterogeneity and relative abundance of individual clones without sequencing of B cells. We applied Ig-MS to plasma from subjects with severe and mild COVID-19 and immunized subjects after two vaccine doses, using the receptor-binding domain (RBD) of the spike protein of SARS-CoV-2 as the bait for antibody capture. Importantly, we report a new data type for human serology, that could use other antigens of interest to gauge immune responses to vaccination, pathogens, or autoimmune disorders.

44 Examining the Impact of the COVID-19 Pandemic on Participants in a Longitudinal Study of Burn Outcomes

Introduction The COVID-19 pandemic has had widespread effects on healthcare and society at large. There are limited data on the impact of the pandemic on the long-term recovery of the burn survivor. This study aims to compare physical and psychosocial outcomes of the burn survivor population before and during the COVID-19 pandemic. Methods Data from the Burn Model System National Database (2015-present) were analyzed. Data were divided into pre- and during-pandemic groups (before and after March 1st, 2020). Outcomes were compared at four cross-sectional time points: 6, 12, 24, and 60 months after burn injury. The following patient reported outcome measures were examined: SF-12 Health Survey, PROMIS-29, Post-Traumatic Growth Indicator, Community Integration Questionnaire, Patient Civilian Checklist, Satisfaction with Life Scale, Burn Specific Health Scale, NeuroQOL Stigma, 4-D Itch, and CAGE Questionnaire (drug/alcohol misuse). Given the cross-sectional design, potential differences in clinical and demographic characteristics were examined for each group at each time point. Adjusted mean outcome scores at each time point were compared between groups using a two stage multi-variable regression model with propensity score matching. For each time point, subjects from each group were matched. The propensity score was calculated using the following matching variables: gender, age, race, ethnicity, etiology, length of stay, and burn size. The mean score difference of outcomes within each matched sample was examined. Results Sample sizes varied by time point with a range from 420 at 6 months to 94 at 60 months. The during-COVID group comprised 10% of the total sample size. There were no significant differences in demographic and clinical characteristics between the groups at any time point. There were no significant differences between the groups in adjusted mean outcome scores across the different time points. Conclusions This preliminary examination showed no differences in myriad long-term outcomes at multiple time points after injury among burn survivors before and during the start of the COVID-19 pandemic. The results may suggest an element of resilience, however given the sample size and cross-sectional limitations further investigation is required to better understand the impact of COVID-19 on the burn population.

Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection.

OBJECTIVE: To characterize the functional impairments of a cohort of patients undergoing inpatient rehabilitation after surviving severe COVID-19 illness, in order to better understand the ongoing needs of this patient population. METHODS: This study consisted of a retrospective chart review of consecutive patients hospitalized for COVID-19 and admitted to a regional inpatient rehabilitation hospital from April 29th to May 22nd, 2020. Patient demographics, clinical characteristics and complications from acute hospitalization were examined. Measures of fall risk (Berg Balance Scale), endurance (6 Minute Walk Test), gait speed (10 Meter Walk Test), mobility (transfer and ambulation independence), cognition, speech and swallowing (American Speech and Hearing Association National Outcomes Measurement System Functional Communication Measures) were assessed at rehabilitation admission and discharge. RESULTS: The study population included 29 patients and was 70% male, 58.6% white and with a mean age of 59.5. The mean length of acute hospitalization was 32.2 days with a mean of 18.7 days intubated. Patients spent a mean of 16.7 days in inpatient rehabilitation and 90% were discharged home. Patients demonstrated significant improvement from admission to discharge in measures of fall risk, endurance, gait speed, mobility, cognition, speech and swallowing, (p< 0.05). At discharge, a significant portion of the population continued to deficits in cognition (attention 37%; memory 28%; problem solving 28%), balance (55%) and gait speed (97%). CONCLUSION: Patients admitted to inpatient rehabilitation after hospitalization with COVID-19 demonstrated deficits in mobility, cognition, speech and swallowing at admission and improved significantly in all of these domains by discharge. However, a significant number of patients exhibited residual deficits at discharge highlighting the post-acute care needs of this patient population.