The effect of immunomodulators on seroconversion after BNT162b2 and AZD1222 vaccines in patients with immune-mediated inflammatory diseases: a prospective cohort study.

BACKGROUND: Biologic and nonbiologic immunomodulators, used to treat immune-mediated inflammatory diseases (IMIDs), could impair the immune response to COVID-19 vaccines and thus vaccine effectiveness. OBJECTIVES: Our objective was to investigate the association between biologic and nonbiologic immunomodulators and seroconversion following the first and second dose of COVID-19 vaccines in patients with IMIDs. METHODS: Serum samples were collected following the first or second dose of the BNT162b2 or AZD1222 vaccines from patients receiving biologic and/or nonbiologic immunomodulators for one or more of psoriasis, psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease or systemic lupus erythematosus. Seroconversion was defined as a positive Roche Elecsys® Anti-SARS-CoV-2 S (spike protein subunit S1/receptor binding domain) immunoassay (≥ 0.8 U mL-1). Association between immunomodulator exposure and seroconversion was assessed using logistic regression, adjusting for age and sex. RESULTS: After excluding those with prior COVID-19, post-first vaccine dose samples from 193 participants and post-second dose samples from 312 participants were included in the analysis. Following the first vaccine dose, 17.6% (n = 34) of participants did not seroconvert. Seroconversion was reduced for those on nonbiologic [adjusted odds ratio (OR) 0.29, 95% confidence interval (CI) 0.12-0.69] or combined nonbiologic and biologic treatment (adjusted OR 0.14, 95% CI 0.045-0.45) compared with those on biologic monotherapy. Subgroup analysis demonstrated reduced odds of seroconversion in those on methotrexate (adjusted OR 0.097, 95% CI 0.19-0.49) or prednisolone treatment (adjusted OR 0.044, 95% CI 0.002-1.00) relative to tumour necrosis factor-α inhibitor monotherapy. No participants receiving rituximab (n < 5) seroconverted after the first vaccine dose. Following the second vaccine dose, 1.6% of all participants did not seroconvert. Non-seroconversion was associated with receiving rituximab (n = 3 of 4) compared with those receiving other therapies (n = 2 of 308, P < 0.001). Post hoc analyses demonstrated that non-seroconversion was associated with age [adjusted OR 0.18, 95% CI 0.037-0.93 for those aged 60 years and over (reference category age 18-39 years)], but not sex, ethnicity or vaccine type. CONCLUSIONS: Treatment with nonbiologics, particularly methotrexate, is associated with impaired seroconversion following two BNT162b2 or AZD1222 vaccine doses, in patients with IMIDs. These findings are consistent with those of other published studies. While this could indicate reduced protection against COVID-19, the immunological parameters that correlate most closely with vaccine effectiveness need to be defined to reach this conclusion.

Hemodilution Increases the Susceptibility of Red Blood Cells to Mechanical Shear Stress During In Vitro Hemolysis Testing.

The American Society for Testing and Materials (ASTM) F1841 standard for the assessment of hemolysis in blood pumps recommends using phosphate-buffered saline (PBS) for hemodilution to standardize hematocrit (HCT). However, PBS increases red blood cell mechanical fragility and hemolysis. Herein, we investigated diluents and dilutions during in vitro testing to reduce hemodilution bias when assessing hemolysis. Bovine blood was diluted with either PBS or PBS + 4/6 g% bovine serum albumin (BSA) to a 70/90% blood dilution, or to an HCT of 30% ± 2%, and pumped with the CentriMag or RotaFlow under hemodynamic conditions. Separately, bovine and human blood were subjected to ventricular assist device-like shear stress using a vortex. Plasma-free hemoglobin levels, normalized milligram index of hemolysis (mgNIH), and protein concentrations were analyzed. Hemolysis depended on the diluent and final blood concentration. Seventy percent of blood diluted with PBS alone caused significantly greater hemolysis than PBS + 4/6 g% BSA. However, at 90% blood, PBS + 4/6 g% BSA caused significantly greater hemolysis than PBS alone. Hence, a positive correlation between mgNIH and hemodilution was observed with PBS and a negative correlation with PBS + 4g% BSA. PBS alone significantly reduced the total protein concentration. Hemodilution with BSA maintains protein concentration within a physiologic range and reduces bias during hemolysis testing at high blood dilutions. Thus, American Society for Testing and Materials standards could consider including BSA as a diluent, when and as required: where large dilution is required (<83%) use PBS + 4 g% BSA, otherwise use PBS alone.

Injury rate and pattern among Brazilian jiu-jitsu practitioners: A survey study.

OBJECTIVE: To determine the 6-month incidence rate and pattern of Brazilian jiu-jitsu (BJJ)-related injuries and characterize associations between injuries and experience level, demographic factors, and training variables. DESIGN: Descriptive epidemiology study. SETTING: Online survey. PARTICIPANTS: 1287 adult BJJ practitioners. OUTCOME MEASURES: 6-month BJJ-related injury incidence, anatomical pattern of injuries, and injury-associated demographic and training variable identification. RESULTS: 59.2% of practitioners reported at least one injury over 6 months. The knee was the most common site. Logistic regression analysis demonstrated 6-month injury incidence was negatively associated with years of training and body weight, and positively associated with training days per week and instructor status. More experienced athletes were more likely to report low back injury, while less experienced athletes more frequently reported head, upper extremity, and elbow injuries. None of the following variables were predictive of injury risk: gi preference, instruction on break-falling, and participation in a structured beginner's program. CONCLUSIONS: The risk factor analysis is applicable to BJJ instructors interested in reducing student injury risk. The widespread pattern of injuries and the distinction between types of injuries sustained at different levels of experience are notable findings that sports medicine practitioners should keep in mind when working with BJJ athletes.

Laparoscopic sacrocolpopexy: operative times and efficiency in a high-volume female pelvic medicine and laparoscopic surgery practice.

INTRODUCTION AND HYPOTHESIS: There has been a trend toward robotic sacrocolpopexy in the United States despite longer operating times and higher costs compared with traditional laparoscopy. The current study objective was to evaluate incision to closure times of laparoscopic sacrocolpopexy in a urogynecologic practice with extensive experience in the laparoscopic approach for pelvic reconstruction. METHODS: We conducted a single-center retrospective evaluation of consecutive patients undergoing laparoscopic sacrocolpopexy for vaginal vault prolapse using a permanent polypropylene Y-mesh over a 1-year period. Standard operative technique for sacrocolpopexy was used. Four to six sutures were placed on the anterior leaflet of the mesh, and six to eight sutures were placed posteriorly. Two sutures were placed in the presacral ligament. Mesh was retroperitonealized with a running 2-0 monocryl suture. Primary outcomes were total operating time and time to complete laparoscopic sacrocolpopexy. RESULTS: One hundred and twenty-seven consecutive patients with an average age of 60.04 ± 10.14 years, body mass index (BMI) 25.79 ± 4.52 kg/m2, underwent laparoscopic sacrocolpopexy for vaginal vault prolapse. Ninety-two patients had other procedures performed intraoperatively: laparoscopic-assisted vaginal hysterectomy, laparoscopic paravaginal repair, laparoscopic enterocele repair, and/or laparoscopic enterolysis. Mean total operative time for all laparoscopic procedures completed was 107.45 ± 34.00 min. The average time to perform sacrocolpopexy, including incision and closure, was 52.78 ± 13.09 min. CONCLUSION: This retrospective evaluation provides further evidence that traditional laparoscopic sacrocolpopexy should be considered a primary therapy for vaginal vault prolapse.

Surgically shortened vagina lengthened by laparoscopic Davydov procedure.

BACKGROUND: The laparoscopic Davydov procedure is a neovagina surgical technique most commonly used in patients with vaginal agenesis. We present a unique case of vaginal length restoration using this procedure in a patient with vaginal shortening after multiple vaginal surgeries. CASE: A 62-year-old patient presented to our office after multiple vaginal surgeries with symptoms suggestive of cystocele, rectocele, vaginal vault prolapse, and dyspareunia. Excessive vaginal shortening and a painful vaginal apex were also noted upon initial examination. A laparoscopic Davydov procedure was performed to lengthen the vagina and to eliminate the apical pain. CONCLUSION: The laparoscopic Davydov procedure is a surgical option for patients with surgically shortened vaginas and dyspareunia.

Laparoscopic Davydov correction of a failed gracilis flap neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome with a pelvic kidney.

The laparoscopic Davydov procedure is a surgical technique for creation of a neovagina in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) or vaginal agenesis. Herein we report its use in creating a neovagina after failure of a previous surgical attempt in a patient with a pelvic kidney, which has not been described to date. The patient, a 28-year-old woman with MRKH in whom creation of a neovagina using bilateral gracilis flaps had been attempted, was unable to have intercourse because of a shortened and scarred vagina. We successfully used the laparoscopic Davydov procedure to create a functional neovagina despite the previous surgery and the presence of a pelvic kidney. The Davydov procedure is an option for use in patients with MRKH with history of unsuccessful neovaginal surgery and can be performed in the presence of a pelvic kidney.