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.

wEight chanGes, caRdio-mEtabolic risks and morTality in patients with hyperthyroidism (EGRET): a protocol for a CPRD-HES linked cohort study

INTRODUCTION

Hyperthyroidism is a common condition affecting up to 3% of the UK population. Treatment improves symptoms and reduces the risk of atrial fibrillation and stroke that contribute to increased mortality. The most common symptom is weight loss, which is reversed during treatment. However, the weight regain may be excessive, contributing to increased risk of obesity. Current treatment options include antithyroid drugs, radioiodine and thyroidectomy. Whether there are differences in either weight change or the long-term cardiometabolic risk between the three treatments is unclear.

METHODS AND ANALYSIS

The study will establish the natural history of weight change in hyperthyroidism, investigate the risk of obesity and risks of cardiometabolic conditions and death relative to the treatment. The data on patients diagnosed with hyperthyroidism between 1 January 1996 and 31 December 2015 will come from Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office of National Statistics Death Registry. The weight changes will be modelled using a flexible joint modelling, accounting for mortality. Obesity prevalence in the general population will be sourced from Health Survey for England and compared with the post-treatment prevalence of obesity in patients with hyperthyroidism. The incidence and time-to-event of major adverse cardiovascular events, other cardiometabolic outcomes and mortality will be compared between the treatments using the inverse propensity weighting model. Incidence rate ratios of outcomes will be modelled with Poisson regression. Time to event will be analysed using Cox proportional hazards model. A competing risks approach will be adopted to estimate comparative incidences to allow for the impact of mortality.

ETHICS AND DISSEMINATION

The study will bring new knowledge on the risk of developing obesity, cardiometabolic morbidity and mortality following treatment for hyperthyroidism to inform clinical practice and public health policies. The results will be disseminated via open-access peer-reviewed publications and directly to the patients and public groups (Independent Scientific Advisory Committee protocol approval #20_000185).

mRNA vaccination in people over 80 years of age induces strong humoral immune responses against SARS-CoV-2 with cross neutralization of P.1 Brazilian variant

Age is the major risk factor for mortality after SARS-CoV-2 infection and older people have received priority consideration for COVID-19 vaccination. However, vaccine responses are often suboptimal in this age group and few people over the age of 80 years were included in vaccine registration trials. We determined the serological and cellular response to spike protein in 100 people aged 80-96 years at 2 weeks after the second vaccination with the Pfizer BNT162b2 mRNA vaccine. Antibody responses were seen in every donor with high titers in 98%. Spike-specific cellular immune responses were detectable in only 63% and correlated with humoral response. Previous SARS-CoV-2 infection substantially increased antibody responses after one vaccine and antibody and cellular responses remained 28-fold and 3-fold higher, respectively, after dual vaccination. Post-vaccine sera mediated strong neutralization of live Victoria infection and although neutralization titers were reduced 14-fold against the P.1 variant first discovered in Brazil they remained largely effective. These data demonstrate that the mRNA vaccine platform delivers strong humoral immunity in people up to 96 years of age and retains broad efficacy against the P.1 variant of concern.

Clinical outcomes and cost analysis of one- versus two-stage bilateral hip arthroplasty. A retrospective study of a single surgeon experience

Purpose:

One in 10 patients presenting for total hip arthroplasty (THA) will have significant osteoarthritis in both hips. In appropriately selected individuals, one-stage bilateral THA is a treatment option. This study aims to compare outcomes of one-stage bilateral THA with two-stage procedure.

Methods:

A retrospective review of a single surgeon series was conducted comparing One-stage bilateral THA (n = 59) with two-stage bilateral THA (n = 50). The primary outcomes were post-operative complication and the Oxford Hip Score. The secondary outcome was a financial analysis.

Results:

Complications were infrequent and comparable between both groups. Oxford hip scores were slightly higher in the one-stage group. One-staged bilateral THA had a lower cost but hospital tariff is higher for two-stage bilateral THA.

Conclusion:

In appropriately selected patients with bilateral hip arthritis, one-stage bilateral THA gives good clinical outcomes. However, the current payment system in the NHS makes two-stage bilateral THA more financially viable to the hospital.

The Forgotten Dimension of Central-Local Relations: Theorising the ‘Regional State’

It is argued that the regional level of the state in Britain has been neglected in recent work on intrastate relations. The aim in this paper is to develop, through the application, development, and amendment of a ‘dual politics’ thesis, a middle-range theory of the political processes which characterise the regional state level. On the basis of a review and discussion of primary and secondary research materials relating to English Regional Water Authorities and Regional Health Authorities, it is suggested that the ‘politics of production’ at regional level are characterised by class domination organised through corporatist forms, whereas the ‘politics of consumption’ at this level tend towards a pattern of bureaucratic and professional closure. Explanations for such a divergence are put forward and the implications for democracy of a growth of state functions at a regional level are briefly explored.

Does gender or mode of HIV acquisition affect virological response to modern antiretroviral therapy (ART)?

OBJECTIVES

Previous UK studies have reported disparities in HIV treatment outcomes for women. We investigated whether these differences persist in the modern antiretroviral treatment (ART) era.

METHODS

A single-centre cohort analysis was carried out. We included in the study all previously ART-naïve individuals at our clinic starting triple ART from 1 January 2006 onwards with at least one follow-up viral load (VL). Time to viral suppression (VS; first viral load < 50 HIV-1 RNA copies/mL), virological failure (VF; first of two consecutive VLs > 200 copies/mL more than 6 months post-ART) and treatment modification were estimated using standard survival methods.

RESULTS

Of 1086 individuals, 563 (52%) were men whose risk for HIV acquisition was sex with other men (MSM), 207 (19%) were men whose risk for HIV acquisition was sex with women (MSW) and 316 (29%) were women. Median pre-ART CD4 count and time since HIV diagnosis in these groups were 298, 215 and 219 cells/μL, and 2.3, 0.3 and 0.3 years, respectively. Time to VS was comparable between groups, but women [adjusted hazard ratio (aHR) 2.32; 95% confidence interval (CI) 1.28-4.22] and MSW (aHR 3.28; 95% CI 1.91-5.64) were at considerably higher risk of VF than MSM. Treatment switches and complete discontinuation were also more common among MSW [aHR 1.38 (95% CI 1.04-1.81) and aHR 1.73 (95% CI 0.97-3.16), respectively] and women [aHR 1.87 (95% CI 1.43-2.46) and aHR 3.20 (95% CI 2.03-5.03), respectively] than MSM.

CONCLUSIONS

Although response rates were good in all groups, poorer virological outcomes for women and MSW have persisted into the modern ART era. Factors that might influence the differences include socioeconomic status and mental health disorders. Further interventions to ensure excellent response rates in women and MSW are required.

Microscopy outperformed in a comparison of five methods for detecting Trichomonas vaginalis in symptomatic women

In the UK, despite its low sensitivity, wet mount microscopy is often the only method of detecting Trichomonas vaginalis infection. A study was conducted in symptomatic women to compare the performance of five methods for detecting T. vaginalis: an in-house polymerase chain reaction (PCR); Aptima T. vaginalis kit; OSOM ®Trichomonas Rapid Test; culture and microscopy. Symptomatic women underwent routine testing; microscopy and further swabs were taken for molecular testing, OSOM and culture. A true positive was defined as a sample that was positive for T. vaginalis by two or more different methods. Two hundred and forty-six women were recruited: 24 patients were positive for T. vaginalis by two or more different methods. Of these 24 patients, 21 patients were detected by real-time PCR (sensitivity 88%); 22 patients were detected by the Aptima T. vaginalis kit (sensitivity 92%); 22 patients were detected by OSOM (sensitivity 92%); nine were detected by wet mount microscopy (sensitivity 38%); and 21 were detected by culture (sensitivity 88%). Two patients were positive by just one method and were not considered true positives. All the other detection methods had a sensitivity to detect T. vaginalis that was significantly greater than wet mount microscopy, highlighting the number of cases that are routinely missed even in symptomatic women if microscopy is the only diagnostic method available.

The mammalian target of rapamycin inhibitor RAD001 (everolimus) synergizes with chemotherapeutic agents, ionizing radiation and proteasome inhibitors in pre-B acute lymphocytic leukemia

BACKGROUND

Despite incremental improvements in outcomes for patients with acute lymphoblastic leukemia, significant numbers of patients still die from this disease. Mammalian target of rapamycin inhibitors have shown potential in vitro and in vivo as therapeutic agents against a range of tumors including acute lymphoblastic leukemia.

DESIGN AND METHODS

Flow cytometry was used to evaluate drug-induced cell death in acute lymphoblastic leukemia cell lines and patients' samples. Human xenografts in immunocompromised mice were used to assess the in vivo effects of selected combinations. Pharmacological inhibitors and lentiviral small interfering ribonucleic acid knock-down of p53 were used to investigate the mechanism of cell killing involved.

RESULTS

Synergistic interactions between RAD001 and cytotoxic agents were demonstrated in vitro and in vivo, with increased caspase-dependent killing. RAD001 suppressed p53 and p21 responses, while suppression of p53 did not prevent killing, indicating p53 independence. RAD001 and cytotoxic agents activated the JUN N-terminal kinase pathway and the combination further increased JUN N-terminal kinase activation. JUN N-terminal kinase inhibition reduced synergistic cell killing by cytotoxic agents and RAD001 in pre-B acute lymphoblastic leukemia cell lines and patients' samples. Bortezomib and MG132, which activate the JUN N-terminal kinase pathway, also synergized with RAD001 in killing pre-B acute lymphoblastic leukemia cells. Killing was greater when RAD001 was combined with proteasome inhibitors than with cytotoxic drugs.

CONCLUSIONS

These observations suggest that combining mammalian target of rapamycin inhibitors with conventional chemotherapy or selected novel agents has the potential to improve clinical responses in patients with pre-B acute lymphoblastic leukemia.

The prevalence of urethral and rectal Mycoplasma genitalium and its associations in men who have sex with men attending a genitourinary medicine clinic

OBJECTIVES

To determine the prevalence of rectal and urethral Mycoplasma genitalium (MG) in men who have sex with men (MSM) attending a genitourinary medicine clinic and to measure its associations with symptoms, clinical signs, sexual behaviour and concomitant sexually transmitted infections (STI).

METHODS

MSM attending for STI screening were tested for MG using a real-time PCR assay that targets the MgPa gene. Data were collected on demographics, sexual behaviour, past STI history and clinical symptoms and signs.

RESULTS

849 first-void urine and rectal specimens were collected from 438 MSM. The overall prevalence of MG in MSM was 6.6% with first-void urine positivity of 2.7% and rectal positivity of 4.4%. MG was significantly associated with HIV positivity (OR 7.6, 95% CI 3.2 to 18.7, p<0.001) in contrast to Chlamydia trachomatis (OR 1.5, 95% CI 0.5 to 4.1, p=0.4) and Neisseria gonorrhoeae (OR 1.7, 95% CI 0.7 to 3.8, p=0.194). MG was more prevalent than C trachomatis (p=0.15) and N gonorrhoeae (p=0.02) in this subgroup of HIV-positive MSM. Urethral infection was associated with dysuria (p<0.001) but there was no association between rectal infection and anorectal symptoms or signs.

CONCLUSION

Rates of MG are much higher in HIV-positive MSM than HIV-negative MSM at both urethral and rectal sites, and MG is more prevalent in HIV-positive MSM than other bacterial STI. Although the subclinical nature of MG in the rectum questions its significance, the high prevalence seen at this site could be a potential source of onward urethral transmission. Future work should assess the need for appropriate screening and treatment of MG infection in MSM, particularly those with HIV infection and high-risk sexual behaviour.

Mycoplasma genitalium in asymptomatic patients: implications for screening

OBJECTIVES

Mycoplasma genitalium is well established as a cause of urethritis and has also been associated with cervicitis, endometritis and pelvic infection. Low rates of infection suggest screening may be inappropriate in the general population, but it remains unclear whether asymptomatic patients attending a sexual-health clinic should be tested routinely. The objective of this study was to measure the positivity rate of M genitalium infection in asymptomatic individuals presenting to a sexual-health clinic to inform the need for screening in this population.

METHODS

Asymptomatic patients were identified using a structured questionnaire and tested for M genitalium from genital swabs or urine using two separate polymerase chain reaction (PCR) assays incorporating different primer sequences.

RESULTS

1304 patients were approached over a 6-month period. 743 (57%) patients were symptomatic, and 168 (13%) refused consent, leaving 394 (30%) patients who entered the study. Residual samples were available for 308 (79%) patients, 168 (54%) men and 140 (46%) women. 14/308 (4.5%, 95% CI 2.2 to 6.9%) asymptomatic patients were infected with M genitalium, and an additional 2 (0.6%, 95% CI 0.2 to 2.3%) patients had discrepant PCR results. No significant associations were found between M genitalium infection and age, gender, ethnicity or isolation site.

CONCLUSION

The positivity rate of M genitalium infection in asymptomatic sexual-health clinic attendees is comparable with that of gonorrhoea or chlamydia, and, if evidence of pathogenicity continues to accumulate, a further assessment of the role of routine screening in this setting would be appropriate.

Chemical incidents: are we ready in the West Midlands? Testing the communication arrangements of on-call public health doctors

Primary care trusts are responsible for handling major chemical hazards. This includes the testing and exercising of plans in a regular and routine manner. The Chemical Hazards and Poisons Division (Birmingham), which provides a 24-h, 365-day resource for the West Midlands region in the UK, undertook an audit to test the out-of-hours communication arrangements of public health doctors. The audit revealed that there is an urgent need to: (1) review contact details within on-call packs; (2) ensure that doctors performing on-call duties know, at the very least, the names of the primary care trusts/local authorities, county councils/other trusts in the area; and (3) ensure a failsafe method for contacting the person on call for public health.

Effect of ovariectomy on adipose tissue of mice in the absence of estrogen receptor alpha (ERalpha): a potential role for estrogen receptor beta (ERbeta)

Adipose tissue deposition is highly responsive to estrogen; ovariectomy increases adipose deposition, and estrogen replacement reverses this. Estrogen receptor alpha (ERalpha) plays a major role in adipose tissue. ERalpha knockout (alphaERKO) mice show an increase in adipose tissue of over a 100 % compared to wild-type mice. However, alphaERKO mice undergo a 10-fold increase in 17beta-estradiol (E2), and persistent or even increased signaling through ERbeta could be a factor in obesity of alphaERKO mice. To test the hypothesis that ERbeta plays a role in adipose tissue, adult female alphaERKO mice were ovariectomized or sham-ovariectomized and fed a phytoestrogen-free diet. Ovariectomized mice were treated with vehicle or E2, and bodyweights and food consumption were measured. Mice were killed after 28 days and inguinal and parametrial fat pads collected. Sham-ovariectomized alphaERKO mice had increased body weight, ovariectomized alphaERKO mice showed a 6 % decrease, and E2 replacement restored body weight to sham levels. Fat pads of ovariectomized alphaERKO mice showed 45 % and 16 % decreases in weight and adipocyte circumference, respectively, compared to sham-ovariectomized or E2-replaced ovariectomized alphaERKO mice. Ovariectomized alphaERKO mice showed a trend towards decreased feed consumption that did not reach significance. Blood glucose levels were lower both before and after glucose injection in ovariectomized compared to sham alphaERKO mice, and E2 treatment reversed this. Insulin levels following glucose challenge were lower in ovariectomized compared to sham-ovariectomized alphaERKO mice, indicating that ovariectomy ameliorated the glucose intolerance and insulin resistance in alphaERKO mice. Immunohistochemical analysis revealed strong staining for ERbeta in adipose tissue. These observations indicate that removing E2/ERbeta signaling in alphaERKO mice by ovariectomy decreases body and fat-pad weights and adipocyte size, while improving insulin and glucose metabolism. ERbeta mediated effects on adipose tissue are opposite those of ERalpha, although E2 effects on adipose tissue are predominately through ERalpha.

Identifying 'non-medical' datasets to monitor community health and well-being

BACKGROUND

The aim of the study was to identify 'non-medical' datasets holding routinely collected information that might be used to measure and monitor the wider determinants of community health and well-being.

METHODS

An expert panel discussion, involving public health and environmental health academics and professionals with expertise in a variety of backgrounds (including environmental health, housing, transport, community safety, public health, primary and secondary care), and interrogation of the Office for National Statistics database were carried out for the West Midlands region. The aim was to identify routinely collected 'non-medical' datasets containing information on the following factors: physical environment, crime, housing and homelessness, social services, socio-economic environment including employment, lifestyles, education, leisure and culture, transport and accidents.

RESULTS

Fifty-six datasets were identified. Although 43 (77 per cent) were collected at least annually, few (17; 30 per cent) held data that were disaggregated and routinely available at the sub-local authority level.

CONCLUSIONS

This study has identified a number of datasets that hold information relevant to health. However, no single dataset is likely to provide information on all dimensions of health and the determinants of health, and local agencies should consider carefully the strengths and weaknesses of each. Through the development of inter-sectoral working and multi-agency involvement at the local level there is now considerable scope to improve the quality of many of these datasets and to promote their use in the measurement and monitoring of community health.

Archetypes, complexes and self-organization

There has always been confusion and disagreement about the nature of the terms archetype and complex in Jungian circles, not to mention non-Jungian ones. Another ongoing concern is whether Jung's concept of the archetype and complex can be justified in terms of current scientific research, most notably that of neurophysiologists and others interested in the brain and consciousness. This paper proposes a theory of the formation of complexes, namely, that they are created through self-organization within the brain/mind. Self-organization is a process typical of large complex systems, and is generally accepted to operate within the brain and to be important in its functioning. Examples of self-organization in biology are related to the psychic processes that form the complexes. It is then natural to define the archetype in terms of the complex, and the authors propose a definition of the archetype as an equivalence class of complexes. On this view, the archetype is an emergent property of the activity of the brain/mind, and is, appropriately, defined at the level at which it emerges. This definition is in line with the original development of Jung's ideas, in that he derived the concept of the archetype from his earlier discovery of the feeling-toned complex.

Stress-induced decrease of the intestinal barrier function. The role of muscarinic receptor activation

Recently the breakdown of the barrier function of the intestinal epithelium after application of an experimental psychological and physical stress protocol in rats has been observed. Not only did smaller molecules pass from the luminal to the serosal side, but so also did larger proteins with the dimensions of luminal antigens and toxins. The increased permeability for macromolecules is primarily due to a decrease of the tightness of the zonula occludens, but an increased endocytotic uptake indicates that transcytosis is increased also. From studies of model systems it can be concluded that activation of the intracellular protein kinase C route by muscarinic receptor activation or histamine receptor activation can be one of the underlying cellular pathways. The physical pathway relaying the stress from the brain to the intestinal tract appears to be the parasympathetic branch of the autonomic nervous system. The difference in reaction of different strains suggests that coping style is an important determinant of the response of the intestinal barrier to stress.