Background Vaccination prevents severe morbidity and mortality from COVID-19 in the general population. The immunogenicity and efficacy of SARS-CoV-2 vaccines in patients with antibody deficiency is poorly understood. Objectives COVID-19 in patients with antibody deficiency (COV-AD) is a multi-site UK study that aims to determine the immune response to SARS-CoV-2 infection and vaccination in patients with primary or secondary antibody deficiency, a population that suffers from severe and recurrent infection and does not respond well to vaccination. Methods Individuals on immunoglobulin replacement therapy or with an IgG less than 4 g/L receiving antibiotic prophylaxis were recruited from April 2021. Serological and cellular responses were determined using ELISA, live-virus neutralisation and interferon gamma release assays. SARS-CoV-2 infection and clearance were determined by PCR from serial nasopharyngeal swabs. Results A total of 5.6% (n = 320) of the cohort reported prior SARS-CoV-2 infection, but only 0.3% remained PCR positive on study entry. Seropositivity, following two doses of SARS-CoV-2 vaccination, was 54.8% (n = 168) compared with 100% of healthy controls (n = 205). The magnitude of the antibody response and its neutralising capacity were both significantly reduced compared to controls. Participants vaccinated with the Pfizer/BioNTech vaccine were more likely to be seropositive (65.7% vs. 48.0%, p = 0.03) and have higher antibody levels compared with the AstraZeneca vaccine (IgGAM ratio 3.73 vs. 2.39, p = 0.0003). T cell responses post vaccination was demonstrable in 46.2% of participants and were associated with better antibody responses but there was no difference between the two vaccines. Eleven vaccine-breakthrough infections have occurred to date, 10 of them in recipients of the AstraZeneca vaccine. Conclusion SARS-CoV-2 vaccines demonstrate reduced immunogenicity in patients with antibody deficiency with evidence of vaccine breakthrough infection.

A diagnosis of diabetes can require multiple changes in a person's behavior, diet, and lifestyle. Efforts to sustain these changes and manage this complex chronic disease can be difficult. Group visits, in which several patients meet together with a primary care provider and transdisciplinary team, have tremendous potential to improve health care quality, cost, and access. When group-based diabetes self-management education and a primary care visit occur within a single appointment, people with the disease can address multiple needs in one visit and take advantage of peer groups for support and motivation. A review of the literature demonstrates that the efficacy of group visits has a promising evidence base-but more needs to be learned about optimal group size and aspects of the model that should be standardized. An important first step is introducing a procedural code for group visits, so that providers and researchers can better track the efficacy of the group-visit model and develop best practices before the model is adopted systemwide.

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Psychological distress is common in palliative care patients and their families, and anger is a complex component of distress experienced by many patients at the end of life. Anger can be a form of tension release, as well as a coping mechanism for the patient and a way to disguise fear and anxiety. The interdisciplinary team are responsible for recognising psychological distress in patients, assessing their needs, and providing adequate psychological support. Although a certain level of psychological distress such as anger is expected in terminally ill patients owing to their situation, such responses may also be dysfunctional. This paper aims to highlight the challenges and complexities of adequately assessing and supporting palliative care patients who are presenting with psychological distress in the form of anger, in order to relieve their suffering and assist them in resolving their issues and improving their quality of life. Anger can be difficult to treat, and for some patients can be more distressing than some physical symptoms. Hence this paper also aims to offer anger management guidance to palliative care practitioners.