Humoral and cellular responses to SARS-CoV-2 in patients with B-cell haematological malignancies improve with successive vaccination

Patients with haematological malignancies are more likely to have poor responses to vaccination. Here we provide detailed analysis of the humoral and cellular responses to COVID-19 vaccination in 69 patients with B-cell malignancies. Measurement of anti-spike IgG in serum demonstrated a low seroconversion rate with 27.1% and 46.8% of patients seroconverting after the first and second doses of vaccine, respectively. In vitro pseudoneutralisation assays demonstrated a poor neutralising response, with 12.5% and 29.5% of patients producing a measurable neutralising titre after the first and second doses, respectively. A third dose increased seropositivity to 54.3% and neutralisation to 51.5%, while a fourth dose further increased both seropositivity and neutralisation to 87.9%. Neutralisation titres post-fourth dose showed a positive correlation with the size of the B-cell population measured by flow cytometry, suggesting an improved response correlating with recovery of the B-cell compartment after B-cell depletion treatments. In contrast, interferon gamma ELISpot analysis showed a largely intact T-cell response, with the percentage of patients producing a measurable response boosted by the second dose to 75.5%. This response was maintained thereafter, with only a small increase following the third and fourth doses, irrespective of the serological response at these timepoints

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Primary chronic lymphocytic leukemia cells can be maintained long-term in serum-free, cytokine-free 3D culture (Conference Abstract)

Chronic Lymphocytic Leukemia (CLL) cells undergo rapid and spontaneous apoptosis when cultured in vitro, challenging the study of disease biology. Conventional CLL culture platforms are dependent on addition of high concentrations of soluble molecules, animal- derived serum, adhesion proteins or allogeneic/xenogeneic stromal cells. We have hypothesized that a three-dimensional (3D) architecture may create a niche-like culture system, enabling CLL cell maintenance within a self-perpetuating microenvironment, in the absence of additional growth factors. In order to assess optimal culture parameters, several conditions were tested: (1) Initial seeding densities (2, 10 and 40 x 106 cells/scaffold); (2) Culture media (IMDM or RPMI + 10% FBS, StemSpan SFEM and Hybridoma SFM); (3) Oxygen tension (21% or 5% O2) and (4) Scaffold coating (uncoated, collagen, RGD). Primary mononuclear cells were seeded onto polyurethane scaffolds and complete media exchanges were performed every third day. The system has enabled successful culture for up to 54 days in 6 out of 7 primary patient samples, 5 of them isolated from peripheral blood (PB) and 1 from bone marrow (BM). Conventional cultures, set up in parallel, died out by day 7. On days 1, 7, 14 and 28, cultures were evaluated for viable cell expansion in the scaffold with Cell Titer Glo 3D (CTG), for morphological characteristics of CLL lymphocytes by May-Grunwald Giemsa (MGG) staining and for in situ niche-like structure formation with scanning electron microscopy (SEM) and fluorescence confocal microscopy. In both serum-containing media (RPMI and IMDM), cultures established with 2 x 106 cells/scaffold showed a reduction in CTG at day 28 compared with that at day 1 (p<0.01, N=2, n=2), whereas higher seeding densities maintained ATP content and metabolism in situ, suggesting improved maintenance of viable cells in scaffolds. For higher seeding densities, SEM images of scaffolds at day 28 show cells clustering in niches and MGG-stained cells show morphological characteristics of CLL, similar to those isolated from patients at day 0. Cultures with 1 x 107 cells/scaffold in hypoxia (5% O2) and in StemSpan SFEM also showed reduction in CTG from days 1 to 28 (p<0.01, N=3, n=2), suggesting lack of in situ proliferation in these conditions. Furthermore, functionalization of scaffolds with collagen or RGD coating did not improve culture dynamics, displaying no difference between conditions at days 1 or 28 with CTG and created more debris and cellular anomalies when visualised with MGG. In contrast, CLL cells morphologically identical to those isolated from the patient were retrieved from the uncoated scaffolds. When comparing RPMI + 10% FBS (FBS) and serum-free media Hybridoma SFM (SF), primary CLL cells were seeded at 1 x 107 cells/scaffold. Scaffold-extracted and supernatant cells were counted and analysed for viability with Guava Via Count assay and assessed for morphology with MGG at every medium exchange. At days 1, 14 and 28 of culture, cells extracted from scaffolds were also analysed with propidium iodide and Annexin V staining for detection of early apoptosis. In the first 8 days of culture, 10.2% of seeded cells egressed from FBS culture, compared with 5.9% in SF, both stabilizing thereafter with similar numbers of viable cells migrating into the supernatant. After 8 days, cells were more viable in SF than FBS in the supernatant (43.3% and 21.8%, respectively; p=0.0097) as well as when cells extracted from scaffolds on days 14 (61.9% and 32.6%, respectively; p<0.0001) and 28 (61% and 16%, respectively; p=0.0013). Consistent with these results, in situ proliferation was higher for SF than FBS (n=3, p<0.05). Using confocal microscopy, DAPI, and an amine reactive dye, widespread in situ scaffolddistribution of cells was observed in SF by day 28 with formation of cellular clusters inside the scaffold. Furthermore, lymphocytes and nurse-like cells (vimentin positive) were detected at day 28 in SF by confocal microscopy in niche-like structures. To the best of our knowledge, this work constitutes the first long-term culture (up to 8 weeks) of patient-derived primary CLL cells without cytokines, serum or feeder layers by using a 3D scaffold and high cell density. This platform may address an unmet need for a culture system which could represent the native disease environment, and a potential drug-testing platform

Efficacy and safety of two neutralising monoclonal antibody therapies, sotrovimab and BRII-196 plus BRII-198, for adults hospitalised with COVID-19 (TICO): a randomised controlled trial

We aimed to assess the efficacy and safety of two neutralising monoclonal antibody therapies (sotrovimab [Vir Biotechnology and GlaxoSmithKline] and BRII-196 plus BRII-198 [Brii Biosciences]) for adults admitted to hospital for COVID-19 (hereafter referred to as hospitalised) with COVID-19. In this multinational, double-blind, randomised, placebo-controlled, clinical trial (Therapeutics for Inpatients with COVID-19 [TICO]), adults (aged ≥18 years) hospitalised with COVID-19 at 43 hospitals in the USA, Denmark, Switzerland, and Poland were recruited. Patients were eligible if they had laboratory-confirmed SARS-CoV-2 infection and COVID-19 symptoms for up to 12 days. Using a web-based application, participants were randomly assigned (2:1:2:1), stratified by trial site pharmacy, to sotrovimab 500 mg, matching placebo for sotrovimab, BRII-196 1000 mg plus BRII-198 1000 mg, or matching placebo for BRII-196 plus BRII-198, in addition to standard of care. Each study product was administered as a single dose given intravenously over 60 min. The concurrent placebo groups were pooled for analyses. The primary outcome was time to sustained clinical recovery, defined as discharge from the hospital to home and remaining at home for 14 consecutive days, up to day 90 after randomisation. Interim futility analyses were based on two seven-category ordinal outcome scales on day 5 that measured pulmonary status and extrapulmonary complications of COVID-19. The safety outcome was a composite of death, serious adverse events, incident organ failure, and serious coinfection up to day 90 after randomisation. Efficacy and safety outcomes were assessed in the modified intention-to-treat population, defined as all patients randomly assigned to treatment who started the study infusion. This study is registered with ClinicalTrials.gov, NCT04501978. Between Dec 16, 2020, and March 1, 2021, 546 patients were enrolled and randomly assigned to sotrovimab (n=184), BRII-196 plus BRII-198 (n=183), or placebo (n=179), of whom 536 received part or all of their assigned study drug (sotrovimab n=182, BRII-196 plus BRII-198 n=176, or placebo n=178; median age of 60 years [IQR 50–72], 228 [43%] patients were female and 308 [57%] were male). At this point, enrolment was halted on the basis of the interim futility analysis. At day 5, neither the sotrovimab group nor the BRII-196 plus BRII-198 group had significantly higher odds of more favourable outcomes than the placebo group on either the pulmonary scale (adjusted odds ratio sotrovimab 1·07 [95% CI 0·74–1·56]; BRII-196 plus BRII-198 0·98 [95% CI 0·67–1·43]) or the pulmonary-plus complications scale (sotrovimab 1·08 [0·74–1·58]; BRII-196 plus BRII-198 1·00 [0·68–1·46]). By day 90, sustained clinical recovery was seen in 151 (85%) patients in the placebo group compared with 160 (88%) in the sotrovimab group (adjusted rate ratio 1·12 [95% CI 0·91–1·37]) and 155 (88%) in the BRII-196 plus BRII-198 group (1·08 [0·88–1·32]). The composite safety outcome up to day 90 was met by 48 (27%) patients in the placebo group, 42 (23%) in the sotrovimab group, and 45 (26%) in the BRII-196 plus BRII-198 group. 13 (7%) patients in the placebo group, 14 (8%) in the sotrovimab group, and 15 (9%) in the BRII-196 plus BRII-198 group died up to day 90. Neither sotrovimab nor BRII-196 plus BRII-198 showed efficacy for improving clinical outcomes among adults hospitalised with COVID-19. US National Institutes of Health and Operation Warp Spee