Notes From a Student

Serial SARS-CoV-2 Receptor-Binding Domain Antibody Responses in Patients Receiving Dialysis

Background: Assessing the evolution of SARS-CoV-2 immune response among patients receiving dialysis can define its durability in a highly clinically relevant context because patients receiving dialysis share the characteristics of persons most susceptible to SARS-CoV-2 infection. Objective: To evaluate the persistence of SARS-CoV-2 receptor-binding domain (RBD) IgG in seroprevalent patients receiving dialysis. Design: Prospective. Setting: Nationwide sample from dialysis facilities. Patients: 2215 patients receiving dialysis who had evidence of SARS-CoV-2 infection as of July 2020. Measurements: Remainder plasma from routine monthly laboratories was used to measure semiquantitative RBD IgG index value over 6 months. Results: A total of 2063 (93%) seroprevalent patients reached an assay detectable response (IgG index value ≥1). Most (n = 1323, 60%) had responses in July with index values classified as high (IgG ≥10); 1003 (76%) remained within this stratum. Adjusted median index values declined slowly but continuously (July vs. December values were 21 vs. 13; P < 0.001). The trajectory of the response did not vary by age group, sex, race/ethnicity, or diabetes status. Patients without an assay detectable response (n = 137) were more likely to be White and in the younger (18 to 44 years) or older (≥80 years) age groups and less likely to have diabetes and hypoalbuminemia. Limitation: Lack of data on symptoms or reverse transcriptase polymerase chain reaction diagnosis, cohort of persons who survived infection, and use of a semiquantitative assay. Conclusion: Despite impaired immunity, most seropositive patients receiving dialysis maintained RBD antibody levels over 6 months. A slow and continual decline in median antibody levels over time was seen, but no indication that subgroups with impaired immunity had a shorter-lived humoral response was found. Primary Funding Source: Ascend Clinical Laboratories.

Postdiagnosis Smoking Cessation and Reduced Risk for Lung Cancer Progression and Mortality: A Prospective Cohort Study: Annals of Internal Medicine: Vol 174, No 9

Background: Lung cancer is the leading cause of cancer death worldwide, and about one half of patients with lung cancer are active smokers at diagnosis. Objective: To determine whether quitting smoking after diagnosis of lung cancer affects the risk for disease progression and mortality. Design: Prospective study of patients with non–small cell lung cancer (NSCLC) who were recruited between 2007 and 2016 and followed annually through 2020. Setting: N.N. Blokhin National Medical Research Center of Oncology and City Clinical Oncological Hospital No. 1, Moscow, Russia. Patients: 517 current smokers who were diagnosed with early-stage (IA-IIIA) NSCLC. Measurements: Probabilities of overall survival, progression-free survival, and lung cancer–specific mortality and hazard ratios (HRs) for all-cause and cancer-specific mortality. Results: During an average of 7 years of follow-up, 327 (63.2%) deaths, 273 (52.8%) cancer-specific deaths, and 172 (33.7%) cases of tumor progression (local recurrence or metastasis) were recorded. The adjusted median overall survival time was 21.6 months higher among patients who had quit smoking than those who continued smoking (6.6 vs. 4.8 years, respectively; P = 0.001). Higher 5-year overall survival (60.6% vs. 48.6%; P = 0.001) and progression-free survival (54.4% vs. 43.8%; P = 0.004) were observed among patients who quit than those who continued smoking. After adjustments, smoking cessation remained associated with decreased risk for all-cause mortality (HR, 0.67 [95% CI, 0.53 to 0.85]), cancer-specific mortality (HR, 0.75 [CI, 0.58 to 0.98]), and disease progression (HR, 0.70 [CI, 0.56 to 0.89]). Similar effects were observed among mild to moderate and heavy smokers and patients with earlier and later cancer stages. Limitation: Exposure measurements were based on self-reported questionnaires. Conclusion: Smoking cessation after diagnosis materially improved overall and progression-free survival among current smokers with early-stage lung cancer. Primary Funding Source: International Agency for Research on Cancer.

Inclusion of Pregnant and Lactating Persons in COVID-19 Vaccination Efforts

SARS-CoV-2 Vaccines: Much Accomplished, Much to Learn

Recommended Adult Immunization Schedule, United States, 2021

Association Between Mortality and Levels of Autonomous Cortisol Secretion by Adrenal Incidentalomas: A Cohort Study: Annals of Internal Medicine: Vol 174, No 8

Background: Autonomous cortisol secretion in patients with adrenal incidentalomas is associated with increased mortality, but detailed information about the risk associated with specific levels of autonomous cortisol secretion is not available. Objective: To measure the association between mortality and levels of autonomous cortisol secretion in patients with adrenal incidentalomas. Design: Retrospective cohort study. (ClinicalTrials.gov: NCT03919734) Setting: Two hospitals in southern Sweden. Patients: Consecutive patients who had adrenal incidentalomas identified between 2005 and 2015 and were followed for up to 14 years. Outcome data were collected from national registers. Measurements: Patients were grouped according to plasma cortisol level after a 1-mg dexamethasone suppression test (cortisolDST; <50, 50 to 82, 83 to 137, or ≥138 nmol/L). Results: During a median follow-up of 6.4 years, 170 of 1048 patients died. Compared with a cortisolDST less than 50 nmol/L, a cortisolDST of 50 to 82 nmol/L was not associated with increased mortality (hazard ratio [HR], 1.15 [95% CI, 0.78 to 1.70]). However, a cortisolDST of 83 to 137 nmol/L (n = 119) had an HR of 2.30 (CI, 1.52 to 3.49), and a cortisolDST of 138 nmol/L or higher (n = 82) had an HR of 3.04 (CI, 1.86 to 4.98). Analyses using restricted cubic splines indicated that the association between cortisolDST and mortality was linear up to a cortisolDST of 200 nmol/L. Limitation: The results are not based on verified autonomous cortisol secretion; thus, the association may be underestimated. Conclusion: The association between mortality and cortisolDST increased linearly until cortisolDST reached 200 nmol/L. A cortisolDST of 83 to 137 nmol/L was associated with a 2-fold increase in mortality, and a cortisolDST of 138 nmol/L or higher was associated with a 3-fold increase in mortality. Additional studies should be done, and until those studies are completed some clinicians may consider these findings when deciding which patients to recommend for surgery. Primary Funding Source: Lisa and Johan Grönberg Foundation and Gyllenstiernska Krapperup Foundation.

Should You Recommend Cannabinoids for This Patient With Painful Neuropathy?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 2

Cannabis includes 140 active cannabinoid compounds, the most important of which are tetrahydrocannabinol and cannabidiol (CBD). Tetrahydrocannabinol is primarily responsible for the intoxicating effects of cannabis; CBD has potential therapeutic effects, including reduction in chronic pain. Recent legislative changes have resulted in the legal availability of cannabinoids in all 50 states, as well as a marked increase in patients' interest in their use. Despite an abundance of data, albeit of varied quality, clinicians may feel poorly prepared to counsel patients seeking advice on the suitability of CBD products for various indications, particularly chronic neuropathic pain. In 2018, on the basis of a systematic review of the literature, a Canadian Evidence Review Group published a guideline with recommendations for clinicians on prescribing cannabinoids in primary care practice. The overall quality of evidence was low to very low. In a meta-analysis of 15 randomized trials of medical cannabis for treating chronic pain, 39% of patients achieved at least a 30% reduction in pain. The corresponding value for placebo-treated patients was 30%; the number needed to treat was 11. More evidence exists for neuropathic pain than for other types of noncancer pain. Here, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature to make recommendations for a patient with painful diabetic neuropathy, including counseling on both potential benefits and harms.

Reported Adverse Drug Reactions Associated With the Use of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic

Clinical Practice Guidelines Registry: Toward Reducing Duplication, Improving Collaboration, and Increasing Transparency