Effects of a personalized nutrition program on cardiometabolic health: a randomized controlled trial

Large variability exists in people's responses to foods. However, the efficacy of personalized dietary advice for health remains understudied. We compared a personalized dietary program (PDP) versus general advice (control) on cardiometabolic health using a randomized clinical trial. The PDP used food characteristics, individual postprandial glucose and triglyceride (TG) responses to foods, microbiomes and health history, to produce personalized food scores in an 18-week app-based program. The control group received standard care dietary advice (US Department of Agriculture Guidelines for Americans, 2020-2025) using online resources, check-ins, video lessons and a leaflet. Primary outcomes were serum low-density lipoprotein cholesterol and TG concentrations at baseline and at 18 weeks. Participants (n = 347), aged 41-70 years and generally representative of the average US population, were randomized to the PDP (n = 177) or control (n = 170). Intention-to-treat analysis (n = 347) between groups showed significant reduction in TGs (mean difference = -0.13 mmol l-1; log-transformed 95% confidence interval = -0.07 to -0.01, P = 0.016). Changes in low-density lipoprotein cholesterol were not significant. There were improvements in secondary outcomes, including body weight, waist circumference, HbA1c, diet quality and microbiome (beta-diversity) (P < 0.05), particularly in highly adherent PDP participants. However, blood pressure, insulin, glucose, C-peptide, apolipoprotein A1 and B, and postprandial TGs did not differ between groups. No serious intervention-related adverse events were reported. Following a personalized diet led to some improvements in cardiometabolic health compared to standard dietary advice. ClinicalTrials.gov registration: NCT05273268 .

Symptoms before and after COVID-19: a population and case-control study using prospective data

BACKGROUND

Some individuals experience prolonged illness after acute COVID-19. We assessed whether pre-infection symptoms affected post-COVID illness duration.

METHODS

Survival analysis was performed in adults (n=23 452) with community-managed SARC-CoV-2 infection prospectively self-logging data through the ZOE COVID Symptom Study app, at least weekly, from 8 weeks before to 12 weeks after COVID-19 onset, conditioned on presence versus absence of baseline symptoms (4-8 weeks before COVID-19). A case-control study was performed in 1350 individuals with long illness (≥8 weeks, 906 [67.1%] with illness ≥12 weeks), matched 1:1 (for age, sex, body mass index, testing week, prior infection, vaccination, smoking, index of multiple deprivation) with 1350 individuals with short illness (<4 weeks). Baseline symptoms were compared between the two groups; and against post-COVID symptoms.

RESULTS

Individuals reporting baseline symptoms had longer post-COVID symptom duration (from 10 to 15 days) with baseline fatigue nearly doubling duration. Two-thirds (910 of 1350 [67.4%]) of individuals with long illness were asymptomatic beforehand. However, 440 (32.6%) had baseline symptoms, versus 255 (18.9%) of 1350 individuals with short illness (p<0.0001). Baseline symptoms increased the odds ratio for long illness (2.14 [CI: 1.78; 2.57]). Prior comorbidities were more common in individuals with long versus short illness. In individuals with long illness, baseline symptomatic (versus asymptomatic) individuals were more likely to be female, younger, and have prior comorbidities; and baseline and post-acute symptoms and symptom burden correlated strongly.

CONCLUSIONS

Individuals experiencing symptoms before COVID-19 have longer illness duration and increased odds of long illness. However, many individuals with long illness are well before SARS-CoV-2 infection.

The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against.

METHODS

Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed.

RECOMMENDATIONS

The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

Overall survival and central nervous system activity of crizotinib in ROS1-rearranged lung cancer-final results of the EUCROSS trial

BACKGROUND

In 2019, we reported the first efficacy and safety analysis of EUCROSS, a phase II trial investigating crizotinib in ROS1 fusion-positive lung cancer. At that time, overall survival (OS) was immature and the effect of crizotinib on intracranial disease control remained unclear. Here, we present the final analysis of OS, systemic and intracranial activity, and the impact of co-occurring aberrations.

MATERIALS AND METHODS

EUCROSS was a prospective, single-arm, phase II trial. The primary endpoint was best overall response rate (ORR) using RECIST 1.1. Secondary and exploratory endpoints were progression-free survival (PFS), OS, and efficacy in pre-defined subgroups.

RESULTS

Median OS of the intention-to-treat population (N = 34) was 54.8 months [95% confidence interval (CI) 20.3 months-not reached (NR); median follow-up 81.4 months] and median all-cause PFS of the response-evaluable population (N = 30) was 19.4 months (95% CI 10.1-32.2 months). Time on treatment was significantly correlated with OS (R = 0.82; P < 0.0001). Patients with co-occurring TP53 aberrations (28%) had a significantly shorter OS [hazard ratio (HR) 11; 95% CI 2.0-56.0; P = 0.006] and all-cause PFS (HR 4.2; 95% CI 1.2-15; P = 0.025). Patients with central nervous system (CNS) involvement at baseline (N = 6; 20%) had a numerically shorter median OS and all-cause PFS. Median intracranial PFS was 32.2 months (95% CI 23.7 months-NR) and the rate of isolated CNS progression was 24%.

CONCLUSIONS

Our final analysis proves the efficacy of crizotinib in ROS1-positive lung cancer, but also highlights the devastating impact of TP53 mutations on survival and treatment efficacy. Additionally, our data show that CNS disease control is durable and the risk of CNS progression while on crizotinib treatment is low.

Snack quality and snack timing are associated with cardiometabolic blood markers: the ZOE PREDICT study

BACKGROUND

Snacking is a common diet behaviour which accounts for a large proportion of daily energy intake, making it a key determinant of diet quality. However, the relationship between snacking frequency, quality and timing with cardiometabolic health remains unclear.

DESIGN

Demography, diet, health (fasting and postprandial cardiometabolic blood and anthropometrics markers) and stool metagenomics data were assessed in the UK PREDICT 1 cohort (N = 1002) (NCT03479866). Snacks (foods or drinks consumed between main meals) were self-reported (weighed records) across 2-4 days. Average snacking frequency and quality [snack diet index (SDI)] were determined (N = 854 after exclusions). Associations between snacking frequency, quality and timing with cardiometabolic blood and anthropometric markers were assessed using regression models (adjusted for age, sex, BMI, education, physical activity level and main meal quality).

RESULTS

Participants were aged (mean, SD) 46.1 ± 11.9 years, had a mean BMI of 25.6 ± 4.88 kg/m2 and were predominantly female (73%). 95% of participants were snackers (≥ 1 snack/day; n = 813); mean daily snack intake was 2.28 snacks/day (24 ± 16% of daily calories; 203 ± 170 kcal); and 44% of participants were discordant for meal and snack quality. In snackers, overall snacking frequency and quantity of snack energy were not associated with cardiometabolic risk markers. However, lower snack quality (SDI range 1-11) was associated with higher blood markers, including elevated fasting triglycerides (TG (mmol/L) β; - 0.02, P = 0.02), postprandial TGs (6hiAUC (mmol/L.s); β; - 400, P = 0.01), fasting insulin (mIU/L) (β; - 0.15, P = 0.04), insulin resistance (HOMA-IR; β; - 0.04, P = 0.04) and hunger (scale 0-100) (β; - 0.52, P = 0.02) (P values non-significant after multiple testing adjustments). Late-evening snacking (≥ 9 pm; 31%) was associated with lower blood markers (HbA1c; 5.54 ± 0.42% vs 5.46 ± 0.28%, glucose 2hiAUC; 8212 ± 5559 vs 7321 ± 4928 mmol/L.s, P = 0.01 and TG 6hiAUC; 11,638 ± 8166 vs 9781 ± 6997 mmol/L.s, P = 0.01) compared to all other snacking times (HbA1c remained significant after multiple testing).

CONCLUSION

Snack quality and timing of consumption are simple diet features which may be targeted to improve diet quality, with potential health benefits.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

NCT03479866, https://clinicaltrials.gov/ct2/show/NCT03479866?term=NCT03479866&draw=2&rank=1.

SARS-CoV-2 infection following booster vaccination: Illness and symptom profile in a prospective, observational community-based case-control study

BACKGROUND

Booster COVID-19 vaccines have shown efficacy in clinical trials and effectiveness in real-world data against symptomatic and severe illness. However, some people still become infected with SARS-CoV-2 following a third (booster) vaccination. This study describes the characteristics of SARS-CoV-2 illness following a third vaccination and assesses the risk of progression to symptomatic disease in SARS-CoV-2 infected individuals with time since vaccination.

METHODS

This prospective, community-based, case-control study used data from UK-based, adult (≥18 years) users of the COVID Symptom Study mobile application, self-reporting a first positive COVID-19 test between June 1, 2021 and April 1, 2022. To describe the characteristics of SARS-CoV-2 illness following a third vaccination, we selected cases and controls who had received a third and second dose of monovalent vaccination against COVID-19, respectively, and reported a first positive SARS-CoV-2 test at least 7 days after most recent vaccination. Cases and controls were matched (1:1) based on age, sex, BMI, time between first vaccination and infection, and week of testing. We used logistic regression models (adjusted for age, sex, BMI, level of social deprivation and frailty) to analyse associations of disease severity, overall disease duration, and individual symptoms with booster vaccination status. To assess for potential waning of vaccine effectiveness, we compared disease severity, duration, and symptom profiles of individuals testing positive within 3 months of most recent vaccination (reference group) to profiles of individuals infected between 3 and 4, 4-5, and 5-6 months, for both third and second dose. All analyses were stratified by time period, based on the predominant SARS-CoV-2 variant at time of infection (Delta: June 1, 2021-27 Nov, 2021; Omicron: 20 Dec, 2021-Apr 1, 2022).

FINDINGS

During the study period, 50,162 (Delta period) and 162,041 (Omicron) participants reported a positive SARS-CoV-2 test. During the Delta period, infection following three vaccination doses was associated with lower odds of long COVID (symptoms≥ 4 weeks) (OR=0.83, CI[0.50-1.36], p < 0.0001), hospitalisation (OR=0.55, CI[0.39-0.75], p < 0.0001) and severe symptoms (OR=0.36, CI[0.27-0.49], p < 0.0001), and higher odds of asymptomatic infection (OR=3.45, CI[2.86-4.16], p < 0.0001), compared to infection following only two vaccination doses. During the Omicron period, infection following three vaccination doses was associated with lower odds of severe symptoms (OR=0.48, CI[0.42-0.55], p < 0.0001). During the Delta period, infected individuals were less likely to report almost all individual symptoms after a third vaccination. During the Omicron period, individuals were less likely to report most symptoms after a third vaccination, except for upper respiratory symptoms e.g. sneezing (OR=1.40, CI[1.18-1.35], p < 0.0001), runny nose (OR=1.26, CI[1.18-1.35], p < 0.0001), sore throat (OR=1.17, CI[1.10-1.25], p < 0.0001), and hoarse voice (OR=1.13, CI[1.06-1.21], p < 0.0001), which were more likely to be reported. There was evidence of reduced vaccine effectiveness during both Delta and Omicron periods in those infected more than 3 months after their most recent vaccination, with increased reporting of severe symptoms, long duration illness, and most individual symptoms.

INTERPRETATION

This study suggests that a third dose of monovalent vaccine may reduce symptoms, severity and duration of SARS-CoV-2 infection following vaccination. For Omicron variants, the third vaccination appears to reduce overall symptom burden but may increase upper respiratory symptoms, potentially due to immunological priming. There is evidence of waning vaccine effectiveness against progression to symptomatic and severe disease and long COVID after three months. Our findings support ongoing booster vaccination promotion amongst individuals at high risk from COVID-19, to reduce severe symptoms and duration of illness, and health system burden. Disseminating knowledge on expected symptoms following booster vaccination may encourage vaccine uptake.

Exploring the relationship between social jetlag with gut microbial composition, diet and cardiometabolic health, in the ZOE PREDICT 1 cohort

PURPOSE

In this study, we explore the relationship between social jetlag (SJL), a parameter of circadian misalignment, and gut microbial composition, diet and cardiometabolic health in the ZOE PREDICT 1 cohort (NCT03479866).

METHODS

We assessed demographic, diet, cardiometabolic, stool metagenomics and postprandial metabolic measures (n = 1002). We used self-reported habitual sleep (n = 934) to calculate SJL (difference in mid-sleep time point of ≥ 1.5 h on week versus weekend days). We tested group differences (SJL vs no-SJL) in cardiometabolic markers and diet (ANCOVA) adjusting for sex, age, BMI, ethnicity, and socio-economic status. We performed comparisons of gut microbial composition using machine learning and association analyses on the species level genome bins present in at least 20% of the samples.

RESULTS

The SJL group (16%, n = 145) had a greater proportion of males (39% vs 25%), shorter sleepers (average sleep < 7 h; 5% vs 3%), and were younger (38.4 ± 11.3y vs 46.8 ± 11.7y) compared to the no-SJL group. SJL was associated with a higher relative abundance of 9 gut bacteria and lower abundance of 8 gut bacteria (q < 0.2 and absolute Cohen's effect size > 0.2), in part mediated by diet. SJL was associated with unfavourable diet quality (less healthful Plant-based Diet Index), higher intakes of potatoes and sugar-sweetened beverages, and lower intakes of fruits, and nuts, and slightly higher markers of inflammation (GlycA and IL-6) compared with no-SJL (P < 0.05 adjusted for covariates); rendered non-significant after multiple testing adjustments.

CONCLUSIONS

Novel associations between SJL and a more disadvantageous gut microbiome in a cohort of predominantly adequate sleepers highlight the potential implications of SJL for health.

Diet and gut microbial associations in irritable bowel syndrome according to disease subtype

The role of diet and the gut microbiome in the etiopathogenesis of irritable bowel syndrome (IBS) is not fully understood. Therefore, we investigated the interplay between dietary risk factors and gut microbiota in IBS subtypes using a food frequency questionnaire and stool metagenome data from 969 participants aged 18-65 years in the ZOE PREDICT 1 study, an intervention study designed to predict postprandial metabolic responses. We identified individuals with IBS subtype according to the Rome III criteria based on predominant bowel habits during symptom onset: diarrhea (i.e. looser), constipation (i.e. harder), and mixed. Participants with IBS-D (n = 59) consumed more healthy plant-based foods (e.g. whole grains, leafy vegetables) and fiber, while those with IBS-C (n = 49) tended to consume more unhealthy plant-based foods (e.g. refined grains, fruit juice) than participants without IBS (n = 797). Microbial diversity was nominally lower in patients with IBS-D than in participants without IBS or with IBS-C. Using multivariable-adjusted linear regression, we identified specific microbiota variations in IBS subtypes, including slight increases in pro-inflammatory taxa in IBS-C (e.g. Escherichia coli) and loss of strict anaerobes in IBS-D (e.g. Faecalibacterium prausnitzii). Our analysis also revealed intriguing evidence of interactions between diet and Faecalibacterium prausnitzii. The positive associations between fiber and iron intake and IBS-diarrhea were stronger among individuals with a higher relative abundance of Faecalibacterium prausnitzii, potentially driven by carbohydrate metabolic pathways, including the superpathway of β-D-glucuronide and D-glucuronate degradation. In conclusion, our findings suggest subtype-specific variations in dietary habits, gut microbial composition and function, and diet-microbiota interactions in IBS, providing insights into potential microbiome-informed dietary interventions.

Extension of the Segatella copri complex to 13 species with distinct large extrachromosomal elements and associations with host conditions

The Segatella copri (formerly Prevotella copri) complex (ScC) comprises taxa that are key members of the human gut microbiome. It was previously described to contain four distinct phylogenetic clades. Combining targeted isolation with large-scale metagenomic analysis, we defined 13 distinct Segatella copri-related species, expanding the ScC complex beyond four clades. Complete genome reconstruction of thirteen strains from seven species unveiled the presence of genetically diverse large circular extrachromosomal elements. These elements are consistently present in most ScC species, contributing to intra- and inter-species diversities. The nine species-level clades present in humans display striking differences in prevalence and intra-species genetic makeup across human populations. Based on a meta-analysis, we found reproducible associations between members of ScC and the male sex and positive correlations with lower visceral fat and favorable markers of cardiometabolic health. Our work uncovers genomic diversity within ScC, facilitating a better characterization of the human microbiome.

Extending and improving metagenomic taxonomic profiling with uncharacterized species using MetaPhlAn 4

Metagenomic assembly enables new organism discovery from microbial communities, but it can only capture few abundant organisms from most metagenomes. Here we present MetaPhlAn 4, which integrates information from metagenome assemblies and microbial isolate genomes for more comprehensive metagenomic taxonomic profiling. From a curated collection of 1.01 M prokaryotic reference and metagenome-assembled genomes, we define unique marker genes for 26,970 species-level genome bins, 4,992 of them taxonomically unidentified at the species level. MetaPhlAn 4 explains ~20% more reads in most international human gut microbiomes and >40% in less-characterized environments such as the rumen microbiome and proves more accurate than available alternatives on synthetic evaluations while also reliably quantifying organisms with no cultured isolates. Application of the method to >24,500 metagenomes highlights previously undetected species to be strong biomarkers for host conditions and lifestyles in human and mouse microbiomes and shows that even previously uncharacterized species can be genetically profiled at the resolution of single microbial strains.

Glycaemic variability, assessed with continuous glucose monitors, is associated with diet, lifestyle and health in people without diabetes

Background

Continuous glucose monitors (CGMs) provide high-frequency information regarding daily glucose variation and are recognised as effective for improving glycaemic control in individuals living with diabetes. Despite increased use in individuals with non-diabetic blood glucose concentrations (euglycemia), their utility as a health tool in this population remains unclear.

Objectives

To characterise variation in time in range (TIR) and glycaemic variability in large populations without diabetes or impaired glucose tolerance; describe associations between CGM-derived glycaemic metrics and metabolic and cardiometabolic health traits; identify key diet and lifestyle factors associated with TIR and glycaemic variability.

Design

Glycaemic variability (coefficient of variation) and time spent in both the ADA secondary target range (TIRADA; 3.9-7.8 mmol/L) and a more stringent range (TIR3.9-5.6; 3.9-5.6 mmol/L) were calculated during free-living in PREDICT 1, PREDICT 2, and PREDICT 3 euglycaemic community-based volunteer cohorts. Associations between CGM derived glycaemic metrics, markers of cardiometabolic health, diet (food frequency questionnaire and logged diet records), diet-habits, and lifestyle were explored.

Results

Data from N=4135 participants (Mean SD; Age: 47 12 y; Sex: 83% Female, BMI: 27 6 kg/m2). Median glycaemic variability was 14.8% (IQR 12.6-17.6%), median TIRADA was 95.8% (IQR 89.6-98.6%) and TIR3.9-5.6 was 75.0% (IQR 64.6-82.8%). Greater TIR3.9-5.6 was associated with lower HbA1c, ASCVD 10y risk and HOMA-IR (all p < 0.05). Lower glycaemic variability was associated with lower % energy derived from carbohydrate (rs: 0.17, p < 0.01), ultra-processed foods (NOVA 4, % EI; rs: 0.12, p = 0.01) and a longer overnight fasting duration (rs: -0.10, p = 0.01).

Conclusions

A stringent TIR target provides sensitivity to detect changes in HOMA-IR, ASCVD 10 y risk and HbA1c that were not detected using ADA secondary targets. Associations among TIR, glycaemic variability, dietary intake (e.g. carbohydrate and protein) and habits (e.g. nocturnal fasting duration) highlight potential strategic targets to improve glycaemic metrics derived from continuous glucose monitors.

Outcomes of Patients Treated with Re-Irradiation for Recurrent Head and Neck Cancer Using Pencil Beam Scanning Proton Therapy

PURPOSE/OBJECTIVE(S)

Re-irradiation (re-RT) for recurrent head and neck cancer (HNC) after prior HNC radiation therapy (RT) is clinically challenging given prior radiation of nearby organs at risk (OARs). We describe clinical outcomes and toxicity of pencil beam scanning proton therapy (PBS-PT) for recurrent HNC.

MATERIALS/METHODS

We performed a retrospective analysis of recurrent HNC patients treated at a single institution with PBS-PT. Baseline demographic, disease and treatment characteristics were recorded. Local control (LC), locoregional control (LRC), progression free survival (PFS), distant metastasis free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method. UVA was completed using logistic regression, and MVA was performed using a backward elimination model. We also report acute and late grade 3+ toxicity outcomes, graded per CTCAE v5.0.

RESULTS

A total of 89 patients treated with PBS-PT for recurrent HNC between 2016 and 2022 were included. Primary sites included oropharynx (30.0%), oral cavity (22.5%), sinonasal cavity (15.7%), larynx (12.4%) and nasopharynx (6.7%). The most common tumor histology was SCC (73.0%). Median time to re-RT was 47 months. Median dose of PBS-PT was 60 Gy (range: 40-72) with 50.6% receiving BID treatment. Median GTV volume was 30cc (range 4.8-1083cc). 24% of patients received concurrent systemic therapy (46% cytotoxic, 4.5% immunotherapy). Median follow-up after PBS-PT was 8 months (range: 0-71), and median OS was 13 months (95% CI: 9.3-16.7). The median PFS and DMFS were 7 months (95% CI 5.0-9.0) and 9 months (95% CI 5.3-12.7) respectively. The 1- and 2-year LC rates were 80.8% (95% CI: 70.8-90.8) and 66.2% (95% CI: 50.7-81.7). The 1- and 2-year DMFS were 41.0% (95% CI: 30.0-52.0) and 26.3% (95% CI: 15.7-36.9). On UVA and MVA, smaller GTV volume was associated with improved OS (HR 1.002, p = .004), DMFS (HR 1.002, p = 0.004) and PFS (HR 1.002, p = 0.014). In addition, shorter time to re-RT was associated with worse LRC (HR 1.003, p = 0.002), and higher KPS was associated with improved PFS (HR 0.57, p = 0.04). There were 31 acute grade 3 toxicity events (21 patients), the most common being odynophagia (9.0%) followed mucositis (5.6%), dehydration and dermatitis (both 4.5%). One patient had grade 4 toxicity, laryngeal edema requiring intubation 40 days after completion of re-RT. One patient had acute grade 5 toxicity, an oropharyngeal bleed 74 days after completion of re-RT. There were 35 late toxicity events (n = 27), the most common being dysphagia (n = 7, 7.9%). One patient suffered late grade 5 osteoradionecrosis, which resulted in sepsis.

CONCLUSION

PBS-PT for recurrent HNC results in effective disease control and favorable toxicity. Patients with smaller GTV volume appear to have improved OS, PFS and DMFS, and may be better candidates. Those with shorter time to re-RT also have worse LRC. However, distant failure (DF) comprises a major failure pattern, and biomarkers to identify patients at risk for DF may improve clinical decision making.

Evaluating Pareto optimal tradeoffs for hippocampal avoidance whole brain radiotherapy with knowledge-based multicriteria optimization

The goal of this study is to investigate the Pareto optimal tradeoffs between target coverage and hippocampal sparing using knowledge-based multicriteria optimization (MCO). Ten prior clinical cases were selected that were treated with hippocampal avoidance whole brain radiotherapy (HA-WBRT) using VMAT. A new, balanced plan was generated for each case using an in-house RapidPlan model in the Eclipse V16.1 treatment planning system. The MCO decision support tool was used to create 4 Pareto optimal plans. The Pareto optimal plans were created using PTV Dmin and hippocampus Dmax as tradeoff criteria. The tradeoff plans were generated for each patient by adjusting PTV Dmin from the value achieved by the corresponding balanced plan in fixed intervals as follows: -4 Gy, -2 Gy, +2 Gy, and +4 Gy. All plans were normalized so that 95% of the PTV was covered by the prescription dose. A 1-way ANOVA, with Geisser-Greenhouse correction, was used for statistical analysis. When evaluating the achieved PTV Dmin and D98%, the results showed the dose to the hippocampus decreased as coverage lowered and in comparison, D98% was higher when the PTV coverage was increased. When comparing multiple tradeoffs, the p-value for PTV D98% was 0.0026, and the p-values for PTV D2%, PTV Dmin, Hippocampus Dmax, Dmin, and Dmean were all less than 0.0001, indicating that the tradeoff plans achieved statistically significant differences. The results also showed that Pareto optimal plans failed to reduce hippocampal dose beyond a certain point, indicating more limited achievability of the MCO-navigated plans than the interface suggested. This study presents valuable data for planning results for HA-WBRT using MCO. MCO has shown to be mostly effective in adjusting the tradeoff between PTV coverage and hippocampal dose.

Plasma protein N-glycome composition associates with postprandial lipaemic response

BACKGROUND

A dysregulated postprandial metabolic response is a risk factor for chronic diseases, including type 2 diabetes mellitus (T2DM). The plasma protein N-glycome is implicated in both lipid metabolism and T2DM risk. Hence, we first investigate the relationship between the N-glycome and postprandial metabolism and then explore the mediatory role of the plasma N-glycome in the relationship between postprandial lipaemia and T2DM.

METHODS

We included 995 individuals from the ZOE-PREDICT 1 study with plasma N-glycans measured by ultra-performance liquid chromatography at fasting and triglyceride, insulin, and glucose levels measured at fasting and following a mixed-meal challenge. Linear mixed models were used to investigate the associations between plasma protein N-glycosylation and metabolic response (fasting, postprandial (Cmax), or change from fasting). A mediation analysis was used to further explore the relationship of the N-glycome in the prediabetes (HbA1c = 39-47 mmol/mol (5.7-6.5%))-postprandial lipaemia association.

RESULTS

We identified 36 out of 55 glycans significantly associated with postprandial triglycerides (Cmax β ranging from -0.28 for low-branched glycans to 0.30 for GP26) after adjusting for covariates and multiple testing (padjusted < 0.05). N-glycome composition explained 12.6% of the variance in postprandial triglycerides not already explained by traditional risk factors. Twenty-seven glycans were also associated with postprandial glucose and 12 with postprandial insulin. Additionally, 3 of the postprandial triglyceride-associated glycans (GP9, GP11, and GP32) also correlate with prediabetes and partially mediate the relationship between prediabetes and postprandial triglycerides.

CONCLUSIONS

This study provides a comprehensive overview of the interconnections between plasma protein N-glycosylation and postprandial responses, demonstrating the incremental predictive benefit of N-glycans. We also suggest a considerable proportion of the effect of prediabetes on postprandial triglycerides is mediated by some plasma N-glycans.

Metabolomic and gut microbiome profiles across the spectrum of community-based COVID and non-COVID disease

Whilst most individuals with SARS-CoV-2 infection have relatively mild disease, managed in the community, it was noted early in the pandemic that individuals with cardiovascular risk factors were more likely to experience severe acute disease, requiring hospitalisation. As the pandemic has progressed, increasing concern has also developed over long symptom duration in many individuals after SARS-CoV-2 infection, including among the majority who are managed acutely in the community. Risk factors for long symptom duration, including biological variables, are still poorly defined. Here, we examine post-illness metabolomic profiles, using nuclear magnetic resonance (Nightingale Health Oyj), and gut-microbiome profiles, using shotgun metagenomic sequencing (Illumina Inc), in 2561 community-dwelling participants with SARS-CoV-2. Illness duration ranged from asymptomatic (n = 307) to Post-COVID Syndrome (n = 180), and included participants with prolonged non-COVID-19 illnesses (n = 287). We also assess a pre-established metabolomic biomarker score, previously associated with hospitalisation for both acute pneumonia and severe acute COVID-19 illness, for its association with illness duration. We found an atherogenic-dyslipidaemic metabolic profile, including biomarkers such as fatty acids and cholesterol, was associated with longer duration of illness, both in individuals with and without SARS-CoV-2 infection. Greater values of a pre-existing metabolomic biomarker score also associated with longer duration of illness, regardless of SARS-CoV-2 infection. We found no association between illness duration and gut microbiome profiles in convalescence. This highlights the potential role of cardiometabolic dysfunction in relation to the experience of long duration symptoms after symptoms of acute infection, both COVID-19 as well as other illnesses.

Characterisation of Fasting and Postprandial NMR Metabolites: Insights from the ZOE PREDICT 1 Study

BACKGROUND

Postprandial metabolomic profiles and their inter-individual variability are not well characterised. Here, we describe postprandial metabolite changes, their correlations with fasting values and their inter- and intra-individual variability, following a standardised meal in the ZOE PREDICT 1 cohort.

METHODS

In the ZOE PREDICT 1 study (n = 1002 (NCT03479866)), 250 metabolites, mainly lipids, were measured by a Nightingale NMR panel in fasting and postprandial (4 and 6 h after a 3.7 MJ mixed nutrient meal, with a second 2.2 MJ mixed nutrient meal at 4 h) serum samples. For each metabolite, inter- and intra-individual variability over time was evaluated using linear mixed modelling and intraclass correlation coefficients (ICC) were calculated.

RESULTS

Postprandially, 85% (of 250 metabolites) significantly changed from fasting at 6 h (47% increased, 53% decreased; Kruskal-Wallis), with 37 measures increasing by >25% and 14 increasing by >50%. The largest changes were observed in very large lipoprotein particles and ketone bodies. Seventy-one percent of circulating metabolites were strongly correlated (Spearman's rho >0.80) between fasting and postprandial timepoints, and 5% were weakly correlated (rho <0.50). The median ICC of the 250 metabolites was 0.91 (range 0.08-0.99). The lowest ICCs (ICC <0.40, 4% of measures) were found for glucose, pyruvate, ketone bodies (β-hydroxybutyrate, acetoacetate, acetate) and lactate.

CONCLUSIONS

In this large-scale postprandial metabolomic study, circulating metabolites were highly variable between individuals following sequential mixed meals. Findings suggest that a meal challenge may yield postprandial responses divergent from fasting measures, specifically for glycolysis, essential amino acid, ketone body and lipoprotein size metabolites.

The secondary bile acid isoursodeoxycholate correlates with post-prandial lipemia, inflammation, and appetite and changes post-bariatric surgery

Primary and secondary bile acids (BAs) influence metabolism and inflammation, and the gut microbiome modulates levels of BAs. We systematically explore the host genetic, gut microbial, and habitual dietary contribution to a panel of 19 serum and 15 stool BAs in two population-based cohorts (TwinsUK, n = 2,382; ZOE PREDICT-1, n = 327) and assess changes post-bariatric surgery and after nutritional interventions. We report that BAs have a moderately heritable genetic component, and the gut microbiome accurately predicts their levels in serum and stool. The secondary BA isoursodeoxycholate (isoUDCA) can be explained mostly by gut microbes (area under the receiver operating characteristic curve [AUC] = ∼80%) and associates with post-prandial lipemia and inflammation (GlycA). Furthermore, circulating isoUDCA decreases significantly 1 year after bariatric surgery (β = -0.72, p = 1 × 10-5) and in response to fiber supplementation (β = -0.37, p < 0.03) but not omega-3 supplementation. In healthy individuals, isoUDCA fasting levels correlate with pre-meal appetite (p < 1 × 10-4). Our findings indicate an important role for isoUDCA in lipid metabolism, appetite, and, potentially, cardiometabolic risk.

Associations between greenness and predicted COVID-19-like illness incidence in the United States and the United Kingdom

Green spaces may be protective against COVID-19 incidence. They may provide outdoor, ventilated, settings for physical and social activities and therefore decrease transmission risk. We examined the association between neighborhood greenness and COVID-19-like illness incidence using individual-level data.

Methods

The study population includes participants enrolled in the COVID Symptom Study smartphone application in the United Kingdom and the United States (March-November 2020). All participants were encouraged to report their current health condition and suspected risk factors for COVID-19. We used a validated symptom-based classifier that predicts COVID-19-like illness. We estimated the Normalized Difference Vegetation Index (NDVI), for each participant's reported neighborhood of residence for each month, using images from Landsat 8 (30 m2). We used time-varying Cox proportional hazards models stratified by age, country, and calendar month at study entry and adjusted for the individual- and neighborhood-level risk factors.

Results

We observed 143,340 cases of predicted COVID-19-like illness among 2,794,029 participants. Neighborhood NDVI was associated with a decreased risk of predicted COVID-19-like illness incidence in the fully adjusted model (hazard ratio = 0.965, 95% confidence interval = 0.960, 0.970, per 0.1 NDVI increase). Stratified analyses showed protective associations among U.K. participants but not among U.S. participants. Associations were slightly stronger for White individuals, for individuals living in rural neighborhoods, and for individuals living in high-income neighborhoods compared to individuals living in low-income neighborhoods.

Conclusions

Higher levels of greenness may reduce the risk of predicted COVID-19-like illness incidence, but these associations were not observed in all populations.

Characterization data of reference materials used for phase II of the priority program DFG SPP 2005 "Opus Fluidum Futurum - Rheology of reactive, multiscale, multiphase construction materials"

A thorough characterization of base materials is the prerequisite for further research. In this paper, the characterization data of the reference materials (CEM I 42.5 R, limestone powder, calcined clay and a mixture of these three components) used in the second funding phase of the priority program 2005 of the German Research Foundation (DFG SPP 2005) are presented under the aspects of chemical and mineralogical composition as well as physical and chemical properties. The data were collected based on tests performed by up to eleven research groups involved in this cooperative program.

Genetic and gut microbiome determinants of SCFA circulating and fecal levels, postprandial responses and links to chronic and acute inflammation

Short-chain fatty acids (SCFA) are involved in immune system and inflammatory responses. We comprehensively assessed the host genetic and gut microbial contribution to a panel of eight serum and stool SCFAs in two cohorts (TwinsUK, n = 2507; ZOE PREDICT-1, n = 328), examined their postprandial changes and explored their links with chronic and acute inflammatory responses in healthy individuals and trauma patients. We report low concordance between circulating and fecal SCFAs, significant postprandial changes in most circulating SCFAs, and a heritable genetic component (average h2: serum = 14%(SD = 14%); stool = 12%(SD = 6%)). Furthermore, we find that gut microbiome can accurately predict their fecal levels (AUC>0.71) while presenting weaker associations with serum. Finally, we report different correlation patterns with inflammatory markers depending on the type of inflammatory response (chronic or acute trauma). Our results illustrate the breadth of the physiological relevance of SCFAs on human inflammatory and metabolic responses highlighting the need for a deeper understanding of this important class of molecules.

Enhanced cardiac substructure sparing through knowledge-based treatment planning for non-small cell lung cancer radiotherapy

Radiotherapy (RT) doses to cardiac substructures from the definitive treatment of locally advanced non-small cell lung cancers (NSCLC) have been linked to post-RT cardiac toxicities. With modern treatment delivery techniques, it is possible to focus radiation doses to the planning target volume while reducing cardiac substructure doses. However, it is often challenging to design such treatment plans due to complex tradeoffs involving numerous cardiac substructures. Here, we built a cardiac-substructure-based knowledge-based planning (CS-KBP) model and retrospectively evaluated its performance against a cardiac-based KBP (C-KBP) model and manually optimized patient treatment plans. CS-KBP/C-KBP models were built with 27 previously-treated plans that preferentially spare the heart. While the C-KBP training plans were created with whole heart structures, the CS-KBP model training plans each have 15 cardiac substructures (coronary arteries, valves, great vessels, and chambers of the heart). CS-KBP training plans reflect cardiac-substructure sparing preferences. We evaluated both models on 28 additional patients. Three sets of treatment plans were compared: (1) manually optimized, (2) C-KBP model-generated, and (3) CS-KBP model-generated. Plans were normalized to receive the prescribed dose to at least 95% of the PTV. A two-tailed paired-sample t-test was performed for clinically relevant dose-volume metrics to evaluate the performance of the CS-KBP model against the C-KBP model and clinical plans, respectively. Overall results show significantly improved cardiac substructure sparing by CS-KBP in comparison to C-KBP and the clinical plans. For instance, the average left anterior descending artery volume receiving 15 Gy (V15 Gy) was significantly lower (p &lt; 0.01) for CS-KBP (0.69 ± 1.57 cc) compared to the clinical plans (1.23 ± 1.76 cc) and C-KBP plans (1.05 ± 1.68 cc). In conclusion, the CS-KBP model significantly improved cardiac-substructure sparing without exceeding the tolerances of other OARs or compromising PTV coverage.

External validation of a low fidelity dry-lab platform to enhance loupes surgical skills techniques for hypospadias repair

INTRODUCTION

Hypospadias repair is an index pediatric urology procedure that requires trainee familiarity with surgical loupes. A previous low-fidelity, 6-step curriculum was proposed that deconstructed the most important steps of loupe surgery. We expanded on this curriculum with an intermediate-fidelity silicone hypospadias model and designed an abbreviated version of the 6-step curriculum to precede the hypospadias repair simulation.

OBJECTIVE

To assess the validity of our prior, low-fidelity conceptual model using the metric of improved performance on the intermediate-fidelity silicone hypospadias model.

STUDY DESIGN

A silicone model was first prototyped with the design software Solidworks™, and then fabricated using a cast made of a mixture of silicone rubbers designed to function like skin and soft tissue (Mold Star 20T, Dragon skin FX-pro and Slacker). Casts were used to create the penile shaft model and the dorsal hooded foreskin model. The urethral plate was cast separately on a flat surface. The model was then assembled by hand. The model used for simulation included the penile shaft and urethral plate, while the dorsal-hooded foreskin was prepared to simulate the penile anatomy separately. Trainees were then divided into two groups. Group 1 practiced the low-fidelity curriculum (3 tasks) and then performed dissection of the urethral plate and suturing using the intermediate-fidelity hypospadias model. Group 2 practiced hypospadias repair prior to the low-fidelity curriculum. Both groups' models were scored by 3 blinded urologists. Trainees were then asked to complete a post simulation satisfaction survey. Data analysis was performed in IBM SPSS Statistics for Macintosh (Version 28.0 Armonk, NY: IBM Corp).

RESULTS

Twenty-two candidates across Wisconsin, USA, and Dublin, Ireland participated in the study. This included 7 s-year residents, 9 third-year residents, 2 fourth-year residents, and 3 fifth-year residents. Both Groups 1 and 2 had a similar distribution of trainees (p = 0.60). Group 1 outperformed group 2 in all tasks (p < 0.05, Table 1). Trainees reported that the platform was very useful (91%).

DISCUSSION

Our curriculum showed improvement in trainee ability and comfort to perform hypospadias repair. Advantages of such a simulated curriculum include improving current resident training in microsurgery, improving surgical ergonomics for trainees prior to real-time experience, and decreasing the learning curve for trainees pursuing pediatric urology.

CONCLUSION

An intermediate-fidelity hypospadias platform externally validates the conceptual model implemented in the low-fidelity loupes curriculum. This appears to lead to improvement in loupe surgical skills regardless of trainee level.

HepCCATT: a multilevel intervention for hepatitis C among vulnerable populations in Chicago

BACKGROUND

Hepatitis C infection could be eliminated. Underdiagnosis and lack of treatment are the barriers to cure, especially for vulnerable populations (i.e. unable to pay for health care).

METHODS

A multilevel intervention from September 2014 to September 2019 focused on the providers and organizations in 'the safety net' (providing health care to populations unable to pay), including: (i) public education, (ii) training for primary care providers (PCPs) and case managers, (iii) case management for high-risk populations, (iv) policy advice and (v) a registry (Registry) for 13 health centers contributing data. The project tracked the number of PCPs trained and, among Registry sites, the number of people screened, engaged in care (i.e. clinical follow-up after diagnosis), treated and/or cured.

RESULTS

In Chicago, 215 prescribing PCPs and 56 other health professionals, 86% of whom work in the safety net, were trained to manage hepatitis C. Among Registry sites, there was a 137% increase in antibody screening and a 32% increase in current hepatitis C diagnoses. Engagement in care rose by 18%.

CONCLUSIONS

Hepatitis C Community Alliance to Test and Treat (HepCCATT) successfully targeted safety net providers and organizations with a comprehensive care approach. While there were challenges, HepCCATT observed increased hepatitis C screening, diagnosis and engagement in care in the Chicago community.

Evaluating the plan quality of a general head-and-neck knowledge-based planning model versus separate unilateral/bilateral models

The implementation of knowledge-based planning (KBP) continues to grow in radiotherapy clinics. KBP guides radiation treatment design by generating clinically acceptable plans in a timely and resource-efficient manner. The role of multiple KBP models tailored for variations within a disease site remains undefined in part because of the substantial effort and number of training cases required to create a high-quality KBP model. In this study, our aim was to explore whether site-specific KBP models lead to clinically meaningful differences in plan quality for head-and-neck (HN) patients when compared to a general model. One KBP model was created from prior volumetric-modulated arc therapy (VMAT) cases that treated unilateral HN lymph nodes while another model was created from VMAT cases that treated bilateral HN nodes. Thirty cases from each model (60 cases total) were randomly selected to create a third, general model. These models were applied to 60 HN test cases - 30 unilateral and 30 bilateral - to generate 180 VMAT plans in Eclipse. Clinically relevant dose metrics were compared between models. Paired-sample t-tests were used for statistical analysis, with the threshold for statistical significance set a priori at 0.007, taking into consideration multiple hypothesis testing to avoid type I error. For unilateral test cases, the unilateral model-generated plans had significantly lower spinal cord maximum doses (12.1 Gy vs 19.3 Gy, p < 0.001) and oral cavity mean doses (20.8 Gy vs 23.0 Gy, p < 0.001), compared with the bilateral model-generated plans. The unilateral and general models generated comparable plans for unilateral HN test cases. For bilateral test cases, the bilateral model created plans had significantly lower brainstem maximum doses (10.8 Gy vs 12.2 Gy, p < 0.001) and parotid mean doses (24.0 Gy vs 25.5 Gy, p < 0.001) when compared to the unilateral model. Right parotid mean doses were lower for bilateral model plans compared to general model plans (23.8 Gy vs 24.4 Gy). The general model created plans with significantly lower brainstem maximum doses (10.3 Gy vs 10.8 Gy) and oral cavity mean doses (35.3 Gy vs 36.7 Gy) when compared with bilateral model-generated plans. The general model outperformed the bilateral model in several dose metrics but they were not deemed clinically significant. For both case sets, the unilateral and general model created plans had higher monitor units when compared to the bilateral model, likely due to more stringent constraint settings. All other dose metrics were comparable. This study demonstrates that a balanced general HN model created using carefully curated treatment plans can produce high quality plans comparable to dedicated unilateral and bilateral models.

Postprandial Responses to a Standardised Meal in Hypertension: The Mediatory Role of Visceral Fat Mass

Postprandial insulinaemia, triglyceridaemia and measures of inflammation are thought to be more closely associated with cardiovascular risk than fasting measures. Although hypertension is associated with altered fasting metabolism, it is unknown as to what extent postprandial lipaemic and inflammatory metabolic responses differ between hypertensive and normotensive individuals. Linear models adjusting for age, sex, body mass index (BMI), visceral fat mass (VFM) and multiple testing (false discovery rate), were used to investigate whether hypertensive cases and normotensive controls had different fasting and postprandial (in response to two standardised test meal challenges) lipaemic, glycaemic, insulinaemic, and inflammatory (glycoprotein acetylation (GlycA)) responses in 989 participants from the ZOE PREDICT-1 nutritional intervention study. Compared to normotensive controls, hypertensive individuals had significantly higher fasting and postprandial insulin, triglycerides, and markers of inflammation after adjusting for age, sex, and BMI (effect size: Beta (Standard Error) ranging from 0.17 (0.08), p = 0.04 for peak insulin to 0.29 (0.08), p = 4.4 × 10^-4 for peak GlycA). No difference was seen for postprandial glucose. When further adjusting for VFM effects were attenuated. Causal mediation analysis suggests that 36% of the variance in postprandial insulin response and 33.8% of variance in postprandial triglyceride response were mediated by VFM. Hypertensive individuals have different postprandial insulinaemic and lipaemic responses compared to normotensive controls and this is partially mediated by visceral fat mass. Consequently, reducing VFM should be a key focus of health interventions in hypertension. Trial registration: The ClinicalTrials.gov registration identifier is NCT03479866.

Menopause is associated with postprandial metabolism, metabolic health and lifestyle: The ZOE PREDICT study

BACKGROUND

The menopause transition is associated with unfavourable alterations in health. However, postprandial metabolic changes and their mediating factors are poorly understood.

METHODS

The PREDICT 1 UK cohort (n=1002; pre- n=366, peri- n=55, and post-menopausal females n=206) assessed phenotypic characteristics, anthropometric, diet and gut microbiome data, and fasting and postprandial (0-6 h) cardiometabolic blood measurements, including continuous glucose monitoring (CGM) data. Differences between menopausal groups were assessed in the cohort and in an age-matched subgroup, adjusting for age, BMI, menopausal hormone therapy (MHT) use, and smoking status.

FINDINGS

Post-menopausal females had higher fasting blood measures (glucose, HbA1c and inflammation (GlycA), 6%, 5% and 4% respectively), sugar intakes (12%) and poorer sleep (12%) compared with pre-menopausal females (p<0.05 for all). Postprandial metabolic responses for glucose_2hiauc and insulin_2hiauc were higher (42% and 4% respectively) and CGM measures (glycaemic variability and time in range) were unfavourable post- versus pre-menopause (p<0.05 for all). In age-matched subgroups (n=150), postprandial glucose responses remained higher post-menopause (peak_0-2h 4%). MHT was associated with favourable visceral fat, fasting (glucose and insulin) and postprandial (triglyceride_6hiauc) measures. Mediation analysis showed that associations between menopause and metabolic health indicators (visceral fat, GlycA_360mins and glycaemia (peak_0-2h)) were in part mediated by diet and gut bacterial species.

INTERPRETATION

Findings from this large scale, in-depth nutrition metabolic study of menopause, support the importance of monitoring risk factors for type-2 diabetes and cardiovascular disease in mid-life to older women to reduce morbidity and mortality associated with oestrogen decline.

FUNDING

Zoe Ltd.

A component method to delineate surgical spine implants for proton Monte Carlo dose calculation

PURPOSE

Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images.

METHODS

The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours.

RESULTS

For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm³ for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm³ , respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm³ for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt-chromium alloys by different vendors.

CONCLUSIONS

A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof-of-concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head-and-neck patients where tight margins are required to spare organs at risk.

The mental health burden of racial and ethnic minorities during the COVID-19 pandemic

Racial/ethnic minorities have been disproportionately impacted by COVID-19. The effects of COVID-19 on the long-term mental health of minorities remains unclear. To evaluate differences in odds of screening positive for depression and anxiety among various racial and ethnic groups during the latter phase of the COVID-19 pandemic, we performed a cross-sectional analysis of 691,473 participants nested within the prospective smartphone-based COVID Symptom Study in the United States (U.S.) and United Kingdom (U.K). from February 23, 2021 to June 9, 2021. In the U.S. (n=57,187), compared to White participants, the multivariable odds ratios (ORs) for screening positive for depression were 1·16 (95% CI: 1·02 to 1·31) for Black, 1·23 (1·11 to 1·36) for Hispanic, and 1·15 (1·02 to 1·30) for Asian participants, and 1·34 (1·13 to 1·59) for participants reporting more than one race/other even after accounting for personal factors such as prior history of a mental health disorder, COVID-19 infection status, and surrounding lockdown stringency. Rates of screening positive for anxiety were comparable. In the U.K. (n=643,286), racial/ethnic minorities had similarly elevated rates of positive screening for depression and anxiety. These disparities were not fully explained by changes in leisure time activities. Racial/ethnic minorities bore a disproportionate mental health burden during the COVID-19 pandemic. These differences will need to be considered as health care systems transition from prioritizing infection control to mitigating long-term consequences.

Post-vaccination infection rates and modification of COVID-19 symptoms in vaccinated UK school-aged children and adolescents: A prospective longitudinal cohort study

BACKGROUND

We aimed to explore the effectiveness of one-dose BNT162b2 vaccination upon SARS-CoV-2 infection, its effect on COVID-19 presentation, and post-vaccination symptoms in children and adolescents (CA) in the UK during periods of Delta and Omicron variant predominance.

METHODS

In this prospective longitudinal cohort study, we analysed data from 115,775 CA aged 12-17 years, proxy-reported through the Covid Symptom Study (CSS) smartphone application. We calculated post-vaccination infection risk after one dose of BNT162b2, and described the illness profile of CA with post-vaccination SARS-CoV-2 infection, compared to unvaccinated CA, and post-vaccination side-effects.

FINDINGS

Between August 5, 2021 and February 14, 2022, 25,971 UK CA aged 12-17 years received one dose of BNT162b2 vaccine. The probability of testing positive for infection diverged soon after vaccination, and was lower in CA with prior SARS-CoV-2 infection. Vaccination reduced proxy-reported infection risk (-80·4% (95% CI -0·82 -0·78) and -53·7% (95% CI -0·62 -0·43) at 14-30 days with Delta and Omicron variants respectively, and -61·5% (95% CI -0·74 -0·44) and -63·7% (95% CI -0·68 -0.59) after 61-90 days). Vaccinated CA who contracted SARS-CoV-2 during the Delta period had milder disease than unvaccinated CA; during the Omicron period this was only evident in children aged 12-15 years. Overall disease profile was similar in both vaccinated and unvaccinated CA. Post-vaccination local side-effects were common, systemic side-effects were uncommon, and both resolved within few days (3 days in most cases).

INTERPRETATION

One dose of BNT162b2 vaccine reduced risk of SARS-CoV-2 infection for at least 90 days in CA aged 12-17 years. Vaccine protection varied for SARS-CoV-2 variant type (lower for Omicron than Delta variant), and was enhanced by pre-vaccination SARS-CoV-2 infection. Severity of COVID-19 presentation after vaccination was generally milder, although unvaccinated CA also had generally mild disease. Overall, vaccination was well-tolerated.

FUNDING

UK Government Department of Health and Social Care, Chronic Disease Research Foundation, The Wellcome Trust, UK Engineering and Physical Sciences Research Council, UK Research and Innovation London Medical Imaging & Artificial Intelligence Centre for Value Based Healthcare, UK National Institute for Health Research, UK Medical Research Council, British Heart Foundation and Alzheimer's Society, and ZOE Limited.

Cutaneous manifestations of SARS-CoV-2 infection during the Delta and Omicron waves in 348 691 UK users of the UK ZOE COVID Study app

BACKGROUND

Symptoms of SARS-CoV-2 infection have differed during the different waves of the pandemic but little is known about how cutaneous manifestations have changed.

OBJECTIVES

To investigate the diagnostic value, frequency and duration of cutaneous manifestations of SARS-CoV-2 infection and to explore their variations between the Delta and Omicron waves of the pandemic.

METHODS

In this retrospective study, we used self-reported data from 348 691 UK users of the ZOE COVID Study app, matched 1 : 1 for age, sex, vaccination status and self-reported eczema diagnosis between the Delta and Omicron waves, to assess the diagnostic value, frequency and duration of five cutaneous manifestations of SARS-CoV-2 infection (acral, burning, erythematopapular and urticarial rash, and unusual hair loss), and how these changed between waves. We also investigated whether vaccination had any effect on symptom frequency.

RESULTS

We show a significant association between any cutaneous manifestations and a positive SARS-CoV-2 test result, with a diagnostic value higher in the Delta compared with the Omicron wave (odds ratio 2·29, 95% confidence interval 2·22-2·36, P < 0·001; and odds ratio 1·29, 95% confidence interval 1·26-1·33, P < 0·001, respectively). Cutaneous manifestations were also more common with Delta vs. Omicron (17·6% vs. 11·4%, respectively) and had a longer duration. During both waves, cutaneous symptoms clustered with other frequent symptoms and rarely (in < 2% of the users) as first or only clinical sign of SARS-CoV-2 infection. Finally, we observed that vaccinated and unvaccinated users showed similar odds of presenting with a cutaneous manifestation, apart from burning rash, where the odds were lower in vaccinated users.

CONCLUSIONS

Cutaneous manifestations are predictive of SARS-CoV-2 infection, and their frequency and duration have changed with different variants. Therefore, we advocate for their inclusion in the list of clinically relevant COVID-19 symptoms and suggest that their monitoring could help identify new variants. What is already known about this topic? Several studies during the wildtype COVID-19 wave reported that patients presented with common skin-related symptoms. It has been observed that COVID-19 symptoms differ among variants. No study has focused on how skin-related symptoms have changed across different variants. What does this study add? We showed, in a community-based retrospective study including over 348 000 individuals, that the presence of cutaneous symptoms is predictive of SARS-CoV-2 infection during the Delta and Omicron waves and that this diagnostic value, along with symptom frequency and duration, differs between variants. We showed that infected vaccinated and unvaccinated individuals reported similar skin-related symptoms during the Delta and Omicron waves, with only burning rashes being less common after vaccination.

New Constraint on the Local Relic Neutrino Background Overdensity with the First KATRIN Data Runs

We report on the direct search for cosmic relic neutrinos using data acquired during the first two science campaigns of the KATRIN experiment in 2019. Beta-decay electrons from a high-purity molecular tritium gas source are analyzed by a high-resolution MAC-E filter around the end point at 18.57 keV. The analysis is sensitive to a local relic neutrino overdensity ratio of η<9.7×10^{10}/α (1.1×10^{11}/α) at a 90% (95%) confidence level with α=1 (0.5) for Majorana (Dirac) neutrinos. A fit of the integrated electron spectrum over a narrow interval around the end point accounting for relic neutrino captures in the tritium source reveals no significant overdensity. This work improves the results obtained by the previous neutrino mass experiments at Los Alamos and Troitsk. We furthermore update the projected final sensitivity of the KATRIN experiment to η<1×10^{10}/α at 90% confidence level, by relying on updated operational conditions.

COVID-19 vaccine waning and effectiveness and side-effects of boosters: a prospective community study from the ZOE COVID Study

Background

With the surge of new SARS-CoV-2 variants, countries have begun offering COVID-19 vaccine booster doses to high-risk groups and, more recently, to the adult population in general. However, uncertainty remains over how long primary vaccination series remain effective, the ideal timing for booster doses, and the safety of heterologous booster regimens. We aimed to investigate COVID-19 primary vaccine series effectiveness and its waning, and the safety and effectiveness of booster doses, in a UK community setting.

Methods

We used SARS-CoV-2 positivity rates in individuals from a longitudinal, prospective, community-based study (ZOE COVID Study), in which data were self-reported through an app, to assess the effectiveness of three COVID-19 vaccines (ChAdOx1 nCov19 [Oxford-AstraZeneca], BNT162b2 [Pfizer-BioNtech], and mRNA1273 [Moderna]) against infection in the 8 months after completion of primary vaccination series. In individuals receiving boosters, we investigated vaccine effectiveness and reactogenicity, by assessing 16 self-reported systemic and localised side-effects. We used multivariate Poisson regression models adjusting for confounders to estimate vaccine effectiveness.

Findings

We included 620 793 participants who received two vaccine doses (204 731 [33·0%] received BNT162b2, 405 239 [65·3%] received ChAdOx1 nCoV-19, and 10 823 [1·7%] received mRNA-1273) and subsequently had a SARS-CoV-2 test result between May 23 (chosen to exclude the period of alpha [B.1.1.7] variant dominance) and Nov 23, 2021. 62 172 (10·0%) vaccinated individuals tested positive for SARS-CoV-2 and were compared with 40 345 unvaccinated controls (6726 [16·7%] of whom tested positive). Vaccine effectiveness waned after the second dose: at 5 months, BNT162b2 effectiveness was 82·1% (95% CI 81·3–82·9), ChAdOx1 nCoV-19 effectiveness was 75·7% (74·9–76·4), and mRNA-1273 effectiveness was 84·3% (81·2–86·9). Vaccine effectiveness decreased more among individuals aged 55 years or older and among those with comorbidities. 135 932 individuals aged 55 years or older received a booster (2123 [1·6%] of whom tested positive). Vaccine effectiveness for booster doses in 0–3 months after BNT162b2 primary vaccination was higher than 92·5%, and effectiveness for heterologous boosters after ChAdOx1 nCoV-19 was at least 88·8%. For the booster reactogenicity analysis, in 317 011 participants, the most common systemic symptom was fatigue (in 31 881 [10·1%] participants) and the most common local symptom was tenderness (in 187 767 [59·2%]). Systemic side-effects were more common for heterologous schedules (32 632 [17·9%] of 182 374) than for homologous schedules (17 707 [13·2%] of 134 637; odds ratio 1·5, 95% CI 1·5–1·6, p<0·0001).

Interpretation

After 5 months, vaccine effectiveness remained high among individuals younger than 55 years. Booster doses restore vaccine effectiveness. Adverse reactions after booster doses were similar to those after the second dose. Homologous booster schedules had fewer reported systemic side-effects than heterologous boosters.

Funding

Wellcome Trust, ZOE, National Institute for Health Research, Chronic Disease Research Foundation, National Institutes of Health, Medical Research Council

COVID-19 due to the B.1.617.2 (Delta) variant compared to B.1.1.7 (Alpha) variant of SARS-CoV-2: a prospective observational cohort study

The Delta (B.1.617.2) variant was the predominant UK circulating SARS-CoV-2 strain between May and December 2021. How Delta infection compares with previous variants is unknown. This prospective observational cohort study assessed symptomatic adults participating in the app-based COVID Symptom Study who tested positive for SARS-CoV-2 from May 26 to July 1, 2021 (Delta overwhelmingly the predominant circulating UK variant), compared (1:1, age- and sex-matched) with individuals presenting from December 28, 2020 to May 6, 2021 (Alpha (B.1.1.7) the predominant variant). We assessed illness (symptoms, duration, presentation to hospital) during Alpha- and Delta-predominant timeframes; and transmission, reinfection, and vaccine effectiveness during the Delta-predominant period. 3581 individuals (aged 18 to 100 years) from each timeframe were assessed. The seven most frequent symptoms were common to both variants. Within the first 28 days of illness, some symptoms were more common with Delta versus Alpha infection (including fever, sore throat, and headache) and some vice versa (dyspnoea). Symptom burden in the first week was higher with Delta versus Alpha infection; however, the odds of any given symptom lasting ≥ 7 days was either lower or unchanged. Illness duration ≥ 28 days was lower with Delta versus Alpha infection, though unchanged in unvaccinated individuals. Hospitalisation for COVID-19 was unchanged. The Delta variant appeared more (1.49) transmissible than Alpha. Re-infections were low in all UK regions. Vaccination markedly reduced the risk of Delta infection (by 69-84%). We conclude that COVID-19 from Delta or Alpha infections is similar. The Delta variant is more transmissible than Alpha; however, current vaccines showed good efficacy against disease. This research framework can be useful for future comparisons with new emerging variants.

A global ensemble of ocean wave climate statistics from contemporary wave reanalysis and hindcasts

There are numerous global ocean wave reanalysis and hindcast products currently being distributed and used across different scientific fields. However, there is not a consistent dataset that can sample across all existing products based on a standardized framework. Here, we present and describe the first coordinated multi-product ensemble of present-day global wave fields available to date. This dataset, produced through the Coordinated Ocean Wave Climate Project (COWCLIP) phase 2, includes general and extreme statistics of significant wave height (H_s), mean wave period (T_m) and mean wave direction (θ_m) computed across 1980–2014, at different frequency resolutions (monthly, seasonally, and annually). This coordinated global ensemble has been derived from fourteen state-of-the-science global wave products obtained from different atmospheric reanalysis forcing and downscaling methods. This data set has been processed, under a specific framework for consistency and quality, following standard Data Reference Syntax, Directory Structures and Metadata specifications. This new comprehensive dataset provides support to future broad-scale analysis of historical wave climatology and variability as well as coastal risk and vulnerability assessments across offshore and coastal engineering applications.

Measurement(s)	Significant wave height • Mean wave period • Mean wave direction
Technology Type(s)	Global wave reanalysis and hindcasts
Sample Characteristic - Environment	Wind-waves
Sample Characteristic - Location	Global

Menopause Is a Key Factor Influencing Postprandial Metabolism, Metabolic Health and Lifestyle: The ZOE PREDICT Study

Objectives

The menopause transition is associated with unfavourable alterations in metabolic and cardiovascular health. However, as an age-related biological event, it is difficult to untangle effects of age from menopause. Here, we investigate the impact of menopause on cardiometabolic health, lifestyle and diet in pre- and post-menopausal females and age-matched subgroups (including males) in the densely phenotyped ZOE PREDICT 1 cohort (NCT03479866).

Methods

Demographic information, diet, cardiometabolic blood biomarkers and postprandial responses (lipid and glucose) to standardized test meals in clinic and free-living settings were assessed (n = 1002). Self-reported pre- (n = 366), peri- (n = 55) and post-menopausal (n = 207) females (aged 18–65 y) and an age-matched subgroup (aged 47–56 y) of males (n = 76), pre- (n = 83) and post-menopausal females (n = 64) were identified. Linear regression analysis assessed differences in cardiometabolic health, anthropometry, lifestyle and diet (adjusted for sex, age, BMI, menopausal hormonal treatment and smoking status).

Results

Post-menopausal females had poorer fasting and postprandial blood measures (glucose, HbA1c, inflammation (GlycA), glucose_2hiauc and insulin_2hiauc; by 6, 5, 4, 42 and 4% respectively) and sleep quality (12%) and higher sugar intakes (12%) compared with pre-menopausal females (p < 0·05 for all). In age-matched females, postprandial glycemia was significantly higher in post- versus pre-menopausal females (p < 0·05), including clinic postprandial glucose peak0-2h (7·6 ± 1·2 vs 7·2 ± 1·0), glycemic variability (using a continuous glucose monitor (CGM)) (18 ± 4% vs 16 ± 4%) and glucose_2hiauc (CGM) following a standardized (typical UK/US nutrient composition) meal (13440 ± 5804 vs 12547 ± 5488). Compared to age-matched males, females (pre- and post-menopausal) had lower systolic blood pressure and ASCVD 10y risk (p < 0.05) and post-menopausal females only had worse glycemic variability (p < 0·001).

Conclusions

In the largest, in-depth nutrition metabolic study of menopause to date, we demonstrate unfavourable links between menopause transition and postprandial glycemic responses, sleep and diet. This emphasises the value of incorporating menopause as a factor in the delivery of nutrition advice.

Funding Sources

ZOE Ltd

Optimised Glucose “Time in Range” Using Continuous Glucose Monitors in 4,805 Non-Diabetic Individuals Is Associated With Favourable Diet and Health: The ZOE PREDICT Studies

Objectives

Continuous glucose monitoring (CGM) enables the dynamic measurement of glycemic control. In diabetic cohorts, time in range (TIR), measured by CGM, is discriminatory of future disease development. However, the value of CGM metrics in non-diabetic populations and their relationship with health outcomes is unclear. This research developed ‘optimised’ TIR targets specific to healthy populations and explored their relationship with diet and health.

Methods

The ZOE PREDICT studies, one (n = 1002, UK), two (n = 987, US) and three (n = 4,500, US) collected demographic information, habitual and free-living diet data, cardiometabolic blood biomarkers and postprandial responses to standardized meals in clinic and free-living settings. TIR was calculated from CGMs (2–4 days free-living) using 1) the American Diabetes Association (ADA); 70–140 mg/dL (TIR_ADA) and 2) a novel optimised; 70–100 mg/dL (TIR_optimised) target. Habitual diet quality (plant-based diet indices; PDI, healthy-PDI and unhealthy-PDI), and free-living nutrient intakes (% energy) were calculated. Associations (spearman's, adjusted for age, sex and BMI) between TIR and diet were examined, and differences in diet and health outcomes between quintile 1 (Q1) and 5 (Q5) of TIR targets were assessed.

Results

Mean fasting glucose was 91 ± 10 mg/dL, HbA1c 5.3 ± 0.4%, TIR_optimised 70 ± 17% and TIR_ADA 91 ± 13% (n = 4805 after exclusions, 78% females, mean age 46 ± 12y). Individuals with better glycemic control (TIR_optimised Q5 vs Q1) were younger (mean ± SD) (45 ± 11 vs 49 ± 12y), had lower HbA1c (5.2 ± 0.4 vs 5.5 ± 0.5) and fasting glucose (91 ± 14 vs 97 ± 23 mg/dL) and higher HDL-cholesterol (1.7 ± 0.4 vs 1.6 ± 0.5mmol/L) (P< 0.001 for all). TIR_optimised (PREDICT 1 n = 868) was associated with a favourable diet (lower unhealthy-PDI and carbohydrate intakes and higher protein intakes) and cardiometabolic risk profile (lower HbA1c and ASCVD) (P < 0.05 for all). However, TIR_ADA was not associated with diet or health outcomes.

Conclusions

We demonstrate that an optimised TIR target (70–100 mg/dL) is discriminatory of ASCVD risk despite normal fasting HbA1c. These findings demonstrate the utility of CGM's in non-diabetic populations and highlight the potential application of dietary strategies to improve TIR and subsequent metabolic complications.

Funding Sources

ZOE Ltd.

Social Jetlag Is Associated With Poor Diet and Increased Inflammation in the ZOE PREDICT 1 Cohort

Objectives

Social jetlag is a habitual pattern of short sleep on work days relative to longer, often later, ‘catch-up sleep’, on work-free days. This chronic pattern of inconsistent sleep times has been associated with poor dietary choices and unfavourable body weight and cardiometabolic health outcomes. We explored associations between social jetlag with dietary intake, body composition, and cardio-metabolic health in the densely phenotyped PREDICT 1 cohort.

Methods

Participants (n = 931) who self-reported habitual sleep on week-days and weekend days, (males, n = 258 and females, n = 673, aged 18–65 years) were identified from the ZOE PREDICT 1 study, a multi-centre dietary intervention study of 1002 healthy UK individuals (NCT03479866). Demographic information (age, gender, education level, ethnicity, menopausal status), habitual diet (FFQ), cardiometabolic blood biomarkers and postprandial responses to standardized test meals in clinic and free-living settings were collected. Social jetlag was calculated as a difference of ≥ 1.5 h in sleep midpoint on week versus weekend days. Differences in diet and cardiometabolic risk factors were tested (analysis of covariance) adjusting for sex, age, BMI, ethnicity and socio-economic status.

Results

Only 3% (n = 26) of participants were short sleepers (< 7 h), 25% (n = 237) were long sleepers (> 9 h) and 16% (n = 145) had social jetlag. The social jetlag group had a higher proportion of males (39% vs 25%) and were younger (mean ± SD) (38.4 ± 11.3 y vs 46.8 ± 11.7 y). Social jetlag was associated with less healthy diets (healthy plant based dietary index) and lower intakes of fruits, nuts and number of plants consumed, as well as higher intakes of sugar-sweetened beverages (p < 0.05 for all). Fasting concentrations of glycoprotein acetylation (GlycA), a composite marker of systemic inflammation, was slightly higher (1.35 ± 0.19 mmol/L vs 1.32 ± 0.18 mmol/L, p = 0.034) in participants with social jetlag.

Conclusions

Our findings support the complex relationship between sleep patterns, diet quality and markers of cardiometabolic health. Multi-factorial diet and lifestyle approaches are needed to improve health, now underpinned by emerging knowledge about the potential long-term impacts of modest circadian misalignments and low grade inflammation.

Funding Sources

ZOE Ltd.