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.

Impact of the introduction of an integrated multi-professional pathway for atrial fibrillation on long-term outcomes

Background

An integrated structured approach to atrial fibrillation (AF) management is recommended by ESC.1 However, limited data is available on its “real-world” impact on anticoagulation uptake and subsequent AF-related hospitalisation and stroke rates.

Purpose

To evaluate the long-term impact of the introduction of a community-wide integrated AF service based in a secondary care hospital.

Methods

In September 2017 we implemented a new integrated pathway for patients with newly diagnosed “symptomatic” atrial arrhythmias across two regions (population 450,000) in England in collaboration with primary care. All patients were seen in a one-stop multi-professional clinic (Arrhythmia nurse and Electrophysiologist with ECG and echocardiogram) within 2 weeks. They underwent standardised screening for modifiable risk factors, counselling regarding diagnosis/ anticoagulation and received an individualised AF management plan as well as access to a nurse-led telephone helpline. We followed up the first 126 consecutive patients for a period of 12 months.

Results

Baseline characteristics are shown in Table 1, showing a high incidence of modifiable risk factors (previously un-identified in the majority). After review in clinic, 30-day AF-related readmission rates to hospital were low (1.6%, n=2) as compared to historical local data (5.8%). This was sustained at 3 months (4.7%, n=6) and at 12 months (7.9%, n=10). 99% of 83 of eligible patients (CHA2DS2-VASc score of >2 with no major contra-indications) received oral anticoagulation. Over 12 months follow-up, rates of TIA/stroke was low (n=3, 2.4%). All-cause mortality was also low (n=1, 0.8%). NHS England region-wide data showed a marked reduction in percentage of total stroke admissions with history of AF not taking anticoagulation at stroke presentation in 2018/19 as compared to 2017/18 across our two regions; this was lower than the national average and the lowest within West Yorkshire (Figure 1).

Conclusions

An integrated service for AF management implemented community-wide was associated with high uptake of oral anticoagulation among eligible patients and low rates of AF-related hospitalisations and all-cause mortality. Across the community, among stroke admissions with AF at presentation, a lower percentage of patients without anticoagulation was observed in comparison with previous years and neighbouring regions.

Funding Acknowledgement

Type of funding sources: None.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

New developments in the evolution and application of the WHO/IPCS framework on mode of action/species concordance analysis

The World Health Organization/International Programme on Chemical Safety mode of action/human relevance framework has been updated to reflect the experience acquired in its application and extend its utility to emerging areas in toxicity testing and non-testing methods. The underlying principles have not changed, but the framework’s scope has been extended to enable integration of information at different levels of biological organization and reflect evolving experience in a much broader range of potential applications. Mode of action/species concordance analysis can also inform hypothesis-based data generation and research priorities in support of risk assessment.

The modified framework is incorporated within a roadmap, with feedback loops encouraging continuous refinement of fit-for-purpose testing strategies and risk assessment. Important in this construct is consideration of dose–response relationships and species concordance analysis in weight of evidence. The modified Bradford Hill considerations have been updated and additionally articulated to reflect increasing experience in application for cases where the toxicological outcome of chemical exposure is known.

The modified framework can be used as originally intended, where the toxicological effects of chemical exposure are known, or in hypothesizing effects resulting from chemical exposure, using information on putative key events in established modes of action from appropriate in vitro or in silico systems and other lines of evidence.

This modified mode of action framework and accompanying roadmap and case examples are expected to contribute to improving transparency in explicitly addressing weight of evidence considerations in mode of action/species concordance analysis based on both conventional data sources and evolving methods.

The Flask Combustion Technique in Pharmaceutical Analysis: Iodine-Containing Substances

The flask method for combustion of organic samples has been applied to a number of iodine-containing substances of pharmaceutical interest including the non-staining iodine ointments. The method is both rapid and simple and the accuracy and precision of the results obtained show that it is suitable for routine control purposes and possibly for consideration as an official assay procedure.

Burkitt's lymphoma associated with Helicobacter pylori

The association between Helicobacter pylori infection and low grade mucosa-associated lymphoid tissue lymphoma is now widely accepted. In this report, we describe the concurrent development of Burkitt's lymphoma in the stomach of a 53-year-old male with perforated duodenal ulcer and positive H. pylori serology. The temporal relationship between these two events raises the possibility of a causal link between H. pylori infection and this lymphoproliferative disease. In describing this rare case of gastric Burkitt's lymphoma, we consider the evidence that supports this possibility.

Prevention of rebleeding from oesophageal varices: two-year follow up of a prospective controlled trial of propranolol in addition to sclerotherapy

A prospective randomised trial comparing propranolol and sclerotherapy to sclerotherapy alone was conducted over a 2-year follow up in a district hospital setting of unselected patients. Rebleeding and survival were analysed. Thirty-nine patients were randomised to propranolol plus sclerotherapy and 34 to sclerotherapy alone. The two groups were clinically comparable. There was no significant difference in the cumulative percent of patients free of rebleeding; 54% of the sclerotherapy group rebled compared to 52% of the group treated with propranolol plus sclerotherapy (Hazard ratio 1.09 (0.54-2.22) and p = 0.81, NS). Two-year actuarial survival was also not significantly different, with 77% of the propanolol plus sclerotherapy group surviving, compared to 74% of sclerotherapy alone (Hazard ratio 1.08 (0.35-2.22) and p = 0.79, NS). The mean time to eradication of varices was not significantly different between the two groups (propranolol plus sclerotherapy 222 days, sclerotherapy alone 243 days), nor did the rate of variceal recurrence differ (72.7 vs 72 days). This study did not show long-term improvement in rebleeding or survival using propranolol in addition to a regular sclerotherapy programme.

Heat stroke following Rugby League football

OBJECTIVE

To present a case of severe heat stroke after Rugby League football.

CLINICAL FEATURES

A 29-year-old Rugby League forward with a mild infection of the upper respiratory tract collapsed while playing football in late March, when the ambient temperature was 24.1 degrees C and the relative humidity up to 73%. He was initially thought to have sustained a head injury and was markedly dehydrated. He suffered severe disseminated intravascular coagulation and gross neurological, renal and hepatic disturbances.

INTERVENTION AND OUTCOME

He required repeated haemodialysis, assisted ventilation and supportive therapy and remained unconscious for 10 days. He then recovered fully.

CONCLUSION

Heat stroke is potentially fatal and can be easily mistaken for head injury in contact sports. When players are dehydrated, have febrile illness and play in warm conditions, they may succumb to heat stroke.

Drug metabolism in end-stage liver disease. In vitro activities of some phase I and phase II enzymes

The activities of a number of drug metabolising enzymes were measured in liver samples obtained from three groups of subjects: normal donors, patients with primary biliary cirrhosis (PBC), and patients with other types of liver disease. In the latter group, all the enzyme activities determined were impaired relative to the normal group. In the PBC group, however, enzyme activities were altered more selectively. (a) Activities of the methyl cholanthrene-inducible forms of cytochrome P-450 were decreased compared to normal controls, whereas the activities of the phenobarbitone-inducible isozymes were relatively unaffected. (b) Sulfotransferase activities were decreased significantly compared to the normal group, whereas sulfatase activities remained unaltered.

Transplantation of the liver in adults and children with fulminant hepatic failure

Fulminant hepatic failure has a high mortality rate despite intensive medical treatment. Urgent hepatic transplantation was considered over a 3 year period in 26 (36%) of 73 patients with the worst prognostic features of fulminant hepatic failure. The criteria for patient selection were based on the duration of advanced hepatic coma and the deterioration of liver function. Sixteen patients were transplanted, and 9 (56%) are currently alive. The median duration of follow-up is 16 months and actuarial 1 year survival 55%. Six patients died because of the absence of offers of organ donation. Twenty-two (85%) of the 26 patients considered were referred with advanced encephalopathy or hepatorenal syndrome. Of the 57 patients not transplanted, 18 (95%) of 19 patients with grade I/II encephalopathy survived compared to 13 (34%) of 38 patients with grade III/IV encephalopathy. Transplantation does improve the chance of survival in selected patients with fulminant hepatic failure, early referral and availability or organ donation being important factors.

A case of lesser curve ulceration after combined highly selective vagotomy and abdominal aortic aneurysm resection

A 71 year old white male is reported in whom ischaemic ulceration of the lesser curve of the stomach, a variant of lesser curve necrosis, occurred after the combined procedures of highly selective vagotomy (HSV) and abdominal aortic aneurysmectomy. Other operations, particularly fundoplication and incidental splenectomy, have been implicated in the aetiology of lesser curve ischaemia, an otherwise rare complication of HSV. This case suggests that concomitant aortic surgery may also increase the risk of lesser curve ischaemia after HSV. Careful endoscopic monitoring of patients undergoing these combined procedures is therefore recommended to better define the risk.

Colectomy and ileostomy in the management of ulcerative colitis

For 30 years, colectomy with ileostomy has been the mainstay of the surgical treatment for ulcerative colitis. Between 1963 and 1985, 535 patients with inflammatory bowel disease were admitted to the Royal Prince Alfred Hospital in Sydney, Australia; 471 had ulcerative colitis and 64 Crohn's colitis. One hundred and eight-six of these patients underwent colonic resection. The proportion of patients who underwent surgery was the same for both disorders. There have been no deaths resulting from the surgical management of inflammatory bowel disease at our hospital since 1965. These patients should be treated safely by standard means before the more elaborate sphincter-saving procedures, currently recommended, are tried.

Two types of chronic lead treatment in C57BL/6 mice: interaction with behavioural determinants of pain

The male C57BL/6 mice used in this study were the offspring either of untreated or lead treated (0.1% lead acetate (PbAc) instead of drinking water) parents. Offspring of lead treated parents were reared on 0.1% PbAc until weaning, and also given 0.5% PbAc to drink for 3 weeks prior to testing (Pb2 group). Offspring of untreated parents were either given 0.5% PbAc to drink (Pb1 group) or maintained on tap water throughout (Control group). Control (C) and lead treated mice were subdivided according to single- or group-housing; no confrontation ("unfought") or confrontation with a trained aggressor mouse ("defeated"). All the mice were then given a hot-plate pain test, in which paw-lick and escape latencies were recorded. In untreated mice, latencies were reduced after defeat. This effect was not seen in lead treated animals. Lead treatment increased latencies in most instances relative to the appropriate control group. The paw-lick latencies were less consistently affected than the escape latencies. Escape latencies, with one exception, were longer in the Pb2 group than in the Pb1 group. Treatment with naloxone of single-housed C and Pb2 was without effect, except for Pb2 treated undefeated mice: here, naloxone abolished the analgesic effect of lead treatment. Lead-induced analgesia is discussed in terms of central mechanisms of pain reception.

Social behaviour in pairs of C57BL/6 mice of both sexes in the open field: effects of saline drinking and of naloxone

We have previously found that saline drinking increases fighting in male pairs and decided to test this treatment (0.9% NaCl for 24 hours before test day 1; SAL) on social behaviour of both males and females. Paired C57BL/6 mice (same-sex pairs) were observed in the open field in daily sessions for three days. One member of each pair (test mouse) was given either SAL treatment, a control injection of saline (SI), an injection of naloxone (1 mg/kg IP; NLX) or a combination of both treatments (NLX + SAL). NLX alone had previously been found to increase aggression in resident/intruder tests at the dose used. Open field testing is not associated with aggressive encounters in our experience. SAL had little effect on (unaggressive) social behaviour in males, but increased social contact seeking in females. The NLX and NLX + SAL treatments had essentially the same effects, irrespective of sex; the treated animals showed behavioural inhibition (reduced social and ambulatory behaviour), while their untreated partners showed significantly more than normal interest in the naloxone treated mice. The results are discussed in terms of opioid involvement in social behaviour.

Stimulation of aggression in male mice by alpha-MSH and its relation to light phase and to saline intake effects

The resident/intruder test was used to examine the social approach and aggressive behaviour of male albino mice. Digging, self-grooming and rearing were also recorded, as was the post-test response to hot-plate exposure. The resident mice were given either a single acute injection of MSH (MSH); 0.9% NaCl to drink (for 48 h prior to testing; SAL); a combination of both treatments (MSH + SAL) or an injection of 0.9% physiological saline (control group; CON). Testing was carried out at the midpoints of the light and dark phases of the 12:12 light cycle. Data on plasma ion levels and hypothalamic cAMP levels were collected after the hot-plate test. MSH stimulated fighting both in the light and dark, and SAL in the light. MSH + SAL reversed the effects of the single treatments in that fighting declined below CON levels in both light and dark. Social contact and other behaviours were much less affected by treatments. Pain responding and plasma ion levels were not changed. Effects on cAMP were largely inconclusive, but intruders had significantly lower levels than the aggressive resident animals.

Saline drinking and naloxone: Lightcycle dependent effects on social behaviour in male mice

Male mice (TO strain) were observed in the resident-intruder test and several behaviours monitored. Treatments were: isotonic saline drinking ad lib for 48 hours before testing (SAL), IP injections of 1 mg/kg naloxone 30 minutes before testing (NLX) or both treatments combined (NLX + SAL). The same sequence of tests were carried out both in the light and the dark phase of the 24-hour light cycle. The single treatments (SAL and NLX) both increased fighting (SAL, p less than 0.02) in the light phase. The combined treatment (NLX + SAL), which reduced behavioural activity overall, caused a marked increase in the proportion of behaviour time spent on aggression (p less than 0.002). These effects were either reversed (significant reductions in aggression with SAL and NLX, p less than 0.05) or cancelled (minor reduction, NLX + SAL) in the dark phase. Partner body sniffing showed a trend towards lower levels following treatments in the light, and higher levels in the dark. No other behaviour changed systematically with treatments. Plasma sodium levels were monitored: there was a trend of treatment group mean sodium levels changing in proportion to the aggressogenic effect of the treatment, but it was not confirmed by correlation tests on the plasma sodium and aggression levels of individuals. The data are discussed in terms of a possible interaction between opioid receptors and physiological sodium chloride loads.

Sex and strain related effects of melatonin and 5-methoxytryptophol on open field behaviour in paired mice

The effects of two methoxyindoles, melatonin (MEL) and 5-methoxytryptophol (5-MTL), on partner investigation and other aspects of pair behaviour in the open field, were observed on male and female mice of the albino TO, and the pigmented C57BL/6 strains. Both indole derivatives are major secretory products of rodent (and human) pineal glands. They were administered by i.p. injection (100 micrograms/kg) to both members of the pair 1 h before each 10 min open field exposure. The testing took place on 3 consecutive days. There were no significant differences in behaviour over days, and group means were used in subsequent data analysis (MANOVA and Dunnet's test). Males, more socially active than the females in both strains, responded to MEL by a reduction in contact time; 5-MTL had the same effect on C57 males (TO males showed no change). Females, on the other hand, did not respond to MEL, and increased their social contact seeking after 5-MTL. There was no consistent effect of either indole on locomotion, and erratic (TO strain only) effects on defaecation. The data are discussed in terms of possible actions of pineal indoles on determinants of social behaviour.