Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

First Measurement of High-Energy Reactor Antineutrinos at Daya Bay

This Letter reports the first measurement of high-energy reactor antineutrinos at Daya Bay, with nearly 9000 inverse beta decay candidates in the prompt energy region of 8-12 MeV observed over 1958 days of data collection. A multivariate analysis is used to separate 2500 signal events from background statistically. The hypothesis of no reactor antineutrinos with neutrino energy above 10 MeV is rejected with a significance of 6.2 standard deviations. A 29% antineutrino flux deficit in the prompt energy region of 8-11 MeV is observed compared to a recent model prediction. We provide the unfolded antineutrino spectrum above 7 MeV as a data-based reference for other experiments. This result provides the first direct observation of the production of antineutrinos from several high-Q_{β} isotopes in commercial reactors.

Sampling, storage and laboratory approaches for dissolved organic matter characterisation in freshwaters: Moving from nutrient fraction to molecular-scale characterisation

Recent research has highlighted the importance of dissolved organic matter (DOM) for ecosystem function and because of this paradigm shift, it has become crucial to not only quantify its contribution to river nutrient loads but also to characterise its composition. There has been a significant research effort utilising optical methods, such as fluorescence and UV-Vis spectrophotometry, in order to start exploring DOM character. However, these methods still lack the granularity to understand the chemical composition at the molecular level, which is vital to properly understanding its functional role in freshwater ecosystems. As a direct result, there has been a shift towards including molecular-scale analyses to investigate the in-stream processing of the material. Alongside this, recent methodological advancements, particularly in mass spectrometry are opening new opportunities for probing one of the most complex environmental mixtures. However, in order to fully exploit these opportunities, it is key that the way that samples are collected, processed and stored is considered carefully such that sample integrity is maintained. There are additional challenges when collecting water samples for analysis at molecular scale, for example the ultra-low concentrations of individual compounds within DOM means that the samples are sensitive to contamination. This paper discusses current sample collection, processing and storage protocols for this C, N and P quantification and characterisation in freshwaters, and proposes a new standardised protocol suitable for both nutrient fraction quantification and molecular scale analyses, based on method development and testing undertaken in our UK Natural Environment Research Council large grant programme, characterising the nature, origins and ecological significance of Dissolved Organic Matter IN freshwater Ecosystems (DOMAINE).

Head and Neck Merkel Cell Carcinoma: A 12-Year Single Institutional Experience

Background

Merkel cell carcinoma (MCC) is an aggressive malignancy of presumed neuroendocrine origin. Most case series of MCC are limited by low case numbers and are not specific to head and neck tumours. The purpose of this study was to provide a focused review of head and neck MCC diagnosis and management in a single Irish institution.

Methods

Patient's demographics, tumour characteristics, pathological diagnosis, surgical treatment, adjuvant treatment, subsequent management and clinical course were collected. Estimates of progression-free MCC survival rates were calculated by the Kaplan–Meier statistical model. A Pearson product-moment correlation coefficient examined the association between surgical margins and disease-free follow-up.

Results

In total, 11 patients were treated for head and neck MCC with a mean age of 79.6 years (range = 69–91 years). The mean average follow-up duration of patients was 18.3 months. Of the cohort, 18% (n=2) had a sentinel node biopsy (SLNB). A selective neck dissection was subsequently performed in 18% (n=2). In total, 72% (n=8) of patients received adjuvant radiotherapy. Median disease-specific survival was 15 months for the SLNB group and 17 months for the non-SLNB group, not statistically significant (p=0.23). There was no significant association between surgical margins and disease-free follow (p=0.65).

Conclusions

Our case series adds to a limited body of evidence of head and neck MCC. Surgery remains the treatment priority in localized disease, with an increasing role of SLNB for accurate prognostication and staging. Early management of stage I disease results in moderate long-term disease-free survivability.

Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group

BACKGROUND & AIMS

Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment.

METHODS

A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis.

RESULTS

The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'.

CONCLUSIONS

These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints.

LAY SUMMARY

Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.

A computational model of neurodegeneration in Alzheimer's disease

Disruption of mental functions in Alzheimer's disease (AD) and related disorders is accompanied by selective degeneration of brain regions. These regions comprise large-scale ensembles of cells organized into systems for mental functioning, however the relationship between clinical symptoms of dementia, patterns of neurodegeneration, and functional systems is not clear. Here we present a model of the association between dementia symptoms and degenerative brain anatomy using F18-fluorodeoxyglucose PET and dimensionality reduction techniques in two cohorts of patients with AD. This reflected a simple information processing-based functional description of macroscale brain anatomy which we link to AD physiology, functional networks, and mental abilities. We further apply the model to normal aging and seven degenerative diseases of mental functions. We propose a global information processing model for mental functions that links neuroanatomy, cognitive neuroscience and clinical neurology.

Do people change their eating habits after a diagnosis of cancer? A systematic review

INTRODUCTION

People who live with and beyond cancer are thought to be motivated to change their diet. However, there is a lack of reviews conducted on what specific dietary changes people make and further evaluation may inform future interventional studies. Hence, we aim to summarise the evidence on dietary changes in observational studies before and after a cancer diagnosis.

METHODS

This systematic review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Electronic searches were conducted in four databases to identify cohort and cross-sectional studies on dietary changes before and after a cancer diagnosis, excluding studies that evaluated an intervention. Quality assessment was undertaken, and meta-analyses were conducted where suitable.

RESULTS

We identified 14 studies with 16,443 participants diagnosed with cancer, age range 18-75 years. Dietary change was assessed <1-5 years before diagnosis and up to 12-years post-diagnosis. Meta-analyses showed that the standard mean difference (SMD) for energy (SMD-0.32, 95% CI -0.46 to -0.17) and carbohydrate consumption (SMD 0.20, 95% CI -0.27 to -0.14). Studies showed inconsistent findings for fat, protein, and fibre, most food groups, and supplement intake. A small decrease in red and processed meat consumption was consistently reported.

CONCLUSION

All studies reported some positive changes in dietary intake and supplement consumption after receiving a cancer diagnosis without any intervention. However, differences for food groups and nutrients were mainly small and not necessarily clinically meaningful. Evidence demonstrates that a cancer diagnosis alone is insufficient to motivate people to change their dietary intake, indicating that most people would benefit from a dietary intervention to facilitate change. This article is protected by copyright. All rights reserved.

A209 EXPERT CONSENSUS CRITERIA AND PRACTICAL RECOMMENDATIONS FOR PBC CARE IN THE COVID-19 ERA AND BEYOND

Background

Primary biliary cholangitis (PBC) is a chronic autoimmune cholestatic liver disease that can progress to liver fibrosis and cirrhosis, and requires timely diagnosis, optimal treatment, and risk stratification. Several guidelines for the management of PBC have been published, including the American Association for the Study of Liver Disease (AASLD) and European Association for the Study of the Liver (EASL) Clinical Practice Guidelines, which include goals for standards of PBC care. However, recent audits have identified deficiencies in real-world PBC care. In addition, the global coronavirus (COVID-19) pandemic has generally reduced access to care, diminished healthcare resources and accelerated the use of remote patient management. There is therefore a need for simple, actionable guidance that physicians can implement in order to maintain standards of care in PBC in the new environment.

Aims

A working group of ten PBC specialists from Europe and Canada were convened by Intercept Pharmaceuticals in January 2020 with the aim of defining key criteria for the care of patients with PBC.

Methods

Following the outbreak of the COVID-19 pandemic, based on these criteria, a smaller working group of six PBC specialists developed practical recommendations to assist physicians in maintaining standards of care and to guide remote management of patients.

Results

The working group defined five key criteria for care in PBC, encompassing PBC diagnosis, initiation of first line therapy with ursodeoxycholic acid (UDCA), risk stratification on UDCA, symptom management, and initiation of 2L therapy. The group developed 21 practical recommendations for the management of patients with PBC in the COVID-19 environment including modality, frequency and timing of investigations and monitoring. (Figure 1).

Conclusions

The delivery of PBC care during the COVID-19 pandemic carries significant challenges. These consensus criteria and practical recommendations provide guidance for the management of PBC during the pandemic era and beyond.

Funding Agencies

NoneIntercept Pharmaceutical

Alcohol packaging as a promotional tool: A focus group study with young adult drinkers in Scotland

Background

Given the dearth of research on consumer perceptions of alcohol packaging as a marketing tool, with existing studies focused on children and adolescents, our aim was to explore how young adults view and engage with alcohol packaging.

Methods

Eight focus groups were conducted in Glasgow (Scotland) in September 2019 with young adult drinkers (n = 50), segmented by age (18-24, 25-35), gender (female, male) and social grade (ABC1, C2DE). Participants were shown, allowed to handle, and asked about, a range of alcoholic products. Data were analysed thematically using an inductive approach.

Results

Five main themes emerged from the data. The first was the ubiquity of alcohol packaging, with frequent exposure reported in different settings, such as shops and drinking venues, and via marketing. The second was appeal, with pack graphics (e.g. colour), structure (e.g. shape, size) and promotions (e.g. gifts, limited-editions) allowing alcohol packs to capture attention, enable products to stand out on shelves, and help create product and brand liking, interest and choice. Third, alcohol packaging was frequently associated with specific occasions and activities. Fourth, alcohol packaging informed perceptions of product-consumer targeting, suitability, and intended drinker profiles. Fifth, alcohol packaging also engaged non-visual senses, guiding expectations of product taste and palatability.

Conclusions

For young adult drinkers in Scotland, alcohol packaging can capture attention, create appeal, and help shape perceptions of the product, drinker and drinking experience.

Key messages

Alcohol packaging is a key marketing communications vehicle, which can attract attention, create product and brand liking, interest and choice, guide expectations, and influence purchasing decisions. Alcohol packaging conveys messages of consumer-product suitability and acceptability, helping to reinforce perceptions that alcohol is a desirable product via pack structure, graphics, and promotions.

P07.04 Rapid-CNS2: Rapid comprehensive adaptive nanopore-sequencing of CNS tumors, a proof of concept study

BACKGROUND

The WHO classification 2021 includes multiple molecular markers for routine diagnostics in addition to histology. Sequencing setup for complete molecular profiling requires considerable investment, while batching samples for sequencing and methylation profiling can delay turnaround time. We introduce RAPID-CNS2, a nanopore adaptive sequencing pipeline that enables comprehensive mutational, methylation and copy number profiling of CNS tumours with a single third generation sequencing assay. It can be run for single samples and offers highly flexible target selection requiring no additional library preparation.

MATERIAL AND METHODS

Utilising ReadFish, a toolkit enabling targeted nanopore sequencing, we sequenced DNA from 22 diffuse glioma patient samples on a MinION device. Target regions comprised our Heidelberg brain tumour NGS panel and pre-selected CpG sites for methylation classification by an adapted random forest classifier. Pathognomonic alterations, copy number profiles, and methylation classes were called using a custom bioinformatics pipeline. Results were compared to their corresponding NGS panel-seq and EPIC array outputs.

RESULTS

Complete concordance with the EPIC array was found for copy number profiles from RAPID-CNS2. 94% pathognomonic mutations were congruent with NGS panel-seq. MGMT promoter status was correctly identified in all samples. Methylation families were detected with 96% congruence. Among the alterations decisive for rendering a classification-compatible integrated diagnosis, 97% of the alterations were consistent over the entire cohort (completely congruent in 19/22 cases and sufficient for unequivocal diagnosis in all).

CONCLUSION

RAPID-CNS2 provides a swift and highly flexible alternative to conventional NGS and array-based methods for SNV/Indel analysis, detection of copy number alterations and methylation classification. The turnaround time of ~4 days can be further shortened to &lt;12h by altering target sizes. It offers a low-capital approach that would be cost-efficient for low throughput settings and invaluable in cases requiring immediate diagnoses.

The LeVe CPAP System for Oxygen-Efficient CPAP Respiratory Support: Development and Pilot Evaluation

Background: The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed a significant demand on healthcare providers (HCPs) to provide respiratory support for patients with moderate to severe symptoms. Continuous Positive Airway Pressure (CPAP) non-invasive ventilation can help patients with moderate symptoms to avoid the need for invasive ventilation in intensive care. However, existing CPAP systems can be complex (and thus expensive) or require high levels of oxygen, limiting their use in resource-stretched environments. Technical Development + Testing: The LeVe ("Light") CPAP system was developed using principles of frugal innovation to produce a solution of low complexity and high resource efficiency. The LeVe system exploits the air flow dynamics of electric fan blowers which are inherently suited to delivery of positive pressure at appropriate flow rates for CPAP. Laboratory evaluation demonstrated that performance of the LeVe system was equivalent to other commercially available systems used to deliver CPAP, achieving a 10 cm H2O target pressure within 2.4% RMS error and 50-70% FiO2 dependent with 10 L/min oxygen from a commercial concentrator. Pilot Evaluation: The LeVe CPAP system was tested to evaluate safety and acceptability in a group of ten healthy volunteers at Mengo Hospital in Kampala, Uganda. The study demonstrated that the system can be used safely without inducing hypoxia or hypercapnia and that its use was well-tolerated by users, with no adverse events reported. Conclusions: To provide respiratory support for the high patient numbers associated with the COVID-19 pandemic, healthcare providers require resource efficient solutions. We have shown that this can be achieved through frugal engineering of a CPAP ventilation system, in a system which is safe for use and well-tolerated in healthy volunteers. This approach may also benefit other respiratory conditions which often go unaddressed in Low and Middle Income Countries (LMICs) for want of context-appropriate technology designed for the limited oxygen resources available.

A cost analysis of cardiac magnetic resonance imaging in the diagnostic pathway of a population with unexplained acute myocardial injury and normal coronary angiography

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health Research (NIHR) Biomedical Research Centre at St Bartholomew"s Hospital London. Irish Cardiac Society

OnBehalf

European Association of Cardiovascular Imaging (EACVI) -Task Force for Cost Effectiveness.

Background

Acute presentations with myocardial injury that occur despite culprit-free coronary angiography were first reported over 70 years ago, with a prevalence between 5-9%.  1-3 There is increasing evidence that a more accurate diagnosis is available and that CMR is a key tool to determine the underlying pathology. This is reflected with the most recent international guidelines advocating for the use of CMR in the diagnostic pathways of this heterogeneous population.  However, to date there is no formal assessment of the financial implications of adopting these new guidelines.

Purpose

To determine the financial impact of implementing cardiac magnetic resonance imaging in the diagnostic pathway of a population with unexplained acute myocardial injury and normal coronary angiography in comparison to existing clinical practice.

Methods

We performed a focused cost-benefit analysis using a hypothetical population of 2,000 patients with unexplained acute myocardial injury and normal coronary angiography.  The population was split evenly into two groups of either standard, or CMR guided management, and extrapolated over a ten-year period. Standard management was defined as 66% of the population receiving dual antiplatelet therapy (ticagrelor and aspirin) for one year followed by aspirin for life, and the remaining 34% of the population receiving aspirin for life. CMR guided management determined antiplatelet therapy according to the imaging findings. This analysis focused on CMR’s ability to accurately identify those patients who may have had an MI and facilitate tailored treatment with evidence based dual antiplatelet therapy. Costs and rates were defined in Table 1. A one-way sensitivity analysis was also performed to determine the variables with largest impact on the costs. Each variable was varied by +/- 20% and the change in cost determined at year 10.

Results

Using CMR in the diagnostic pathway resulted in an increased cost of £72,656 in the first year. After year 7, CMR guided practice becomes cost neutral, resulting in cost saving of £24,054 over a ten-year period in a population of 1000 patients. Figure 1. Utilizing CMR in this population also resulted in 7 fewer myocardial infarctions and 14 fewer major bleeding events over a ten-year time horizon.

The three most sensitive variables were, in decreasing order, the cost of CMR, the cost of ticagrelor and the percentage of the population with MI requiring DAPT. A 20% change from baseline resulted in a 320%, 247% and 162% change in costs at 10 years, respectively.

Conclusion

Utilizing CMR in this population may be associated with reduced costs in the medium to long term. The initial increased cost of CMR is offset over time, by delivering a more personalised, higher quality level of care to patients.