CRISPR-Cas9 and beyond: identifying target genes for developing disease-resistant plants

Throughout the history of crop domestication, desirable traits have been selected in agricultural products. However, such selection often leads to crops and vegetables with weaker vitality and viability than their wild ancestors when exposed to adverse environmental conditions. Considering the increasing human population and climate change challenges, it is crucial to enhance crop quality and quantity. Accordingly, the identification and utilization of diverse genetic resources are imperative for developing disease-resistant plants that can withstand unexpected epidemics of plant diseases. In this review, we provide a brief overview of recent progress in genome-editing technologies, including zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and clustered regularly interspaced short palindromic repeats (CRISPR)-associated protein 9 (Cas9) technologies. In particular, we classify disease-resistant mutants of Arabidopsis thaliana and several crop plants based on the roles or functions of the mutated genes in plant immunity and suggest potential target genes for molecular breeding of genome-edited disease-resistant plants. Genome-editing technologies are resilient tools for sustainable development and promising solutions for coping with climate change and population increases.

Effect of bimatoprost sustained-release intracameral implant on intraocular pressure and medication burden in patients with prior glaucoma surgery

The present retrospective study evaluated intraocular pressure (IOP) and medication burden after bimatoprost sustained-release (bimatoprost SR, Durysta, Allergan) implantation in patients with glaucoma. A secondary objective was to examine an effect of bimatoprost SR in a subset of patients with prior minimally invasive and incisional glaucoma surgery. A retrospective chart review of 122 eyes that received bimatoprost SR by 6 glaucoma specialists at Wills Eye Hospital between March 2020 and September 2021 was performed. One hundred and eighteen eyes from 84 patients had a reduction in IOP (18.5±5.7mmHg vs. 16.0±5.4mmHg, P<0.01) and required fewer glaucoma medications (2.1±1.4 vs. 1.2±1.2, P<0.01) after bimatoprost SR implantation. In 41 eyes from 31 patients who previously underwent glaucoma surgery (including iStent, goniotomy, trabeculectomy, Xen Gel Stent, or tube shunt surgery), medication burden was decreased after bimatoprost SR implantation (1.9±1.3 vs. 1.0±1.0, P<0.001). These data suggest that bimatoprost SR is an efficacious treatment modality for glaucoma, even in post-surgical patients.

Fracture Resistance of Chairside CAD/CAM Lithium Disilicate-reinforced Ceramic Occlusal Veneers With and Without Margin and Full Coverage Crowns

OBJECTIVE

The aim of this investigation was to compare the fracture resistance of chairside computer-aided design and computer-aided manufacturing (CAD/CAM) lithium disilicate-reinforced ceramic occlusal veneers with and without margin and traditional full coverage premolar crowns.

METHODS AND MATERIALS

A total of 60 chairside CAD/CAM lithium disilicate-reinforced ceramic (Amber Mill, Hass Bio) restorations were designed and fabricated with a chairside CAD/CAM system (CEREC Dentsply Sirona). The restorations were divided into three groups (n=20): 1) occlusal veneer with 1.0-mm uniform occlusal thickness and with chamfer margin; 2) occlusal veneer with 1.0-mm uniform occlusal thickness and without margin; and 3) full coverage crown with uniform occlusal thickness and gingival margin. Occlusal veneers and crowns were cemented with dual cured resin luting cement (Multilink, Ivoclar Vivadent) to printed resin dies, load cycled (5 million load cycles at 1 Hz with 275 N force), and then loaded until fracture. Load at break (LB) and peak load (PL) until fracture were recorded. Scanning electron microscope images of the tested restorations on the abutments were obtained.

RESULTS

Fracture strengths were different depending on the design of the restoration. There was no significant difference in fracture strength between the two types of occlusal veneer (LB: 1132.45 N; PL: 1143.30 N for veneers with margin; LB: 1149.25 N; PL: 1219.05 N for veneers without margin). Full coverage crowns showed the lowest fracture resistance (LB: 936.26 N, PL: 976.42 N), which was significantly lower than both designs of occlusal veneer.

CONCLUSIONS

The fracture resistance of the CAD/CAM lithium disilicate-reinforced ceramic restorations was influenced by the design. Occlusal veneers with and without margin displayed higher fracture resistance than traditional crowns.

Decentralized clinical trial design using blood microsampling technology for serum bioanalysis

Background: Alternatives to phlebotomy in clinical trials increase options for patients and clinicians by simplifying and increasing accessibility to clinical trials. The authors investigated the technical and logistical considerations of one technology compared with phlebotomy. Methodology: Paired samples were collected from 16 donors via a second-generation serum gel microsampling device and conventional phlebotomy. Microsamples were subject to alternative sample handling conditions and were evaluated for quality, clinical testing and proteome profiling. Results: Timely centrifugation of blood serum microsamples largely preserved analyte stability. Conclusion: Centrifugation timing of serum microsamples impacts the quality of specific clinical chemistry and protein biomarkers. Microsampling devices with remote centrifugation and refrigerated shipping can decrease patient burden, expand clinical trial populations and aid clinical decisions.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

A Comparison of Treatment Plan Adaptation Methods on PTV Margin Coverage in MR-Linac Prostate SBRT

PURPOSE/OBJECTIVE(S)

MRI-Linac guided radiotherapy is a novel treatment modality allowing for daily online adaptation of contours and treatment planning. MRI-Linac prostate SBRT (MRL-SBRT) has recently been shown to provide a tangible benefit in decreasing both acute and late toxicity, due to the ability to evaluate soft tissue contrast, directly monitor organ motion, and anatomical changes during the entire treatment course. Multiple MRI-Linac platforms are available, which provide different advantages with regards to imaging and motion management. We undertook this study to assess coverage of the clinical target volume with use of a standard PTV margin in patients receiving either adapt-to-position (ATP) only treatment or a combination of adapt-to-position and adapt-to-shape (ATP+ATS) on the Elekta Unity MR-Linac.

MATERIALS/METHODS

Data was collected retrospectively in patients who underwent prostate SBRT using a 1.5 T MR-Linac (Unity, Elekta AB, Stockholm, Sweden). Prior to each fraction, determination of ATP or ATS planning was at the discretion of the treating physician. Prostate and organs at risk (OAR's) were contoured on the reference MRI and daily MR image sets acquired prior to each fraction. The prostate PTV consisted of a 5mm margin, except 3mm posteriorly. Contours were merged to account for target and OAR volumes during all fractions. Target volumes from the reference plan were then compared to the clinical target volume (CTV) on pre-treatment MR-Linac imaging as well as intersection with OAR's.

RESULTS

Nineteen men, median age 72 years (range 67-75), with prostate cancer underwent treatment from May 2021 to January 2023 with MRL-SBRT. The average time for ATP vs ATP+ATS was 45 minutes (range 35-60) and 60 minutes (range 50-80), respectively. The mean CTV treated was 43.4cc (range 31-60) for ATP and 51.8cc (range 36-67) for ATP+ATS. Prior to plan adaptation, target volumes in 92.6% of fractions were not covered completely by the PTV. In the ATP cohort, 89% of fractions had a portion of the CTV uncovered with an average of 2.9cc. In the ATP+ATS cohort, 96.4% had a portion of the CTV uncovered, with an average of 6.9cc. There was no difference in the amount of PTV intersection for ATP or ATP+ATS plans with the rectum (1.1cc vs. 1.5cc) and bladder (9.2cc vs. 12.6cc), respectively. All patients completed the planned course of treatment.

CONCLUSION

Adaptive radiation therapy for prostate cancer utilizing an MR-Linac based approach with the Elekta Unity was feasible for patients requiring either ATP only or ATP+ATS plans. As expected, ATS plans required longer treatment time, allowing for improved coverage of the target when deemed clinically necessary. Despite a larger overall volume treated in ATS plans, there was no difference in overlap with OARs between ATP and ATS plans. Adaption for each daily fraction and intrafraction motion monitoring improved CT coverage with our pre-specified PTV margin.

Assessment of Daily Target Motion to Optimize ITV Margins in Online Adaptive Plan for Liver and Pancreatic SBRT on MR-LINAC

PURPOSE/OBJECTIVE(S)

Accurate measurement of daily target motion on online plan adaptation is essential for re-optimizing the internal target volume (ITV) margins. In this study, by analyzing 2D cine MR images acquired in a 1.5T MR-Linac, we assessed daily target motion and its inter-fractional variations, which is then used to customize ITV margins for MR-based online adaptive plan of liver and pancreatic stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Twenty-threepatients, enrolled in this study, underwent MR-guided online adaptive SBRT on 1.5 T MR-Linac: liver (n = 12 without compression belt (CB), n = 2 with CB) and pancreas (n = 9 with CB). Target motion in a 2D coronal and sagittal MR images (> 200 cine images to cover multiple breathing cycles), as well as a set of 4D-CT images during the simulation, was analyzed to determine patient specific ITV margins for a reference plan. On every fraction of online adaptive SBRT, the 2D MR images were exported to commercially available software along with a planning MR images: a T1-wighted MR image set for pancreas and or a navigated T2-wighted MR image set for liver. Daily target motion was then measured by overlaying the orthogonal cine image set on the T1- or T2-wighted image set. The ITV margin was adjusted when required prior to online plan optimization RESULTS: Thisstudy successfully assessed the daily target motion and inter-fractional variations in 23 liver or pancreatic cancer patients. We found a discrepancy of daily target motion of orthogonal 2D cine MR images from that of 4D-CT, required to adjust the ITV margin for online plan adaptation. In liver SBRT without CB, 15 out of 45 fractions from 12 patients (33.3 %) went through adjusted ITV margin. The tumor motion was large up to a 2.2 cm along the inferior direction in a patient without CB and thus the patient was treated on a conventional Linac with the active breathing control (ABC) unit for breath-hold. On the other hand, no adjustments were necessary for 2 liver patients with CB. In 9 patients with pancreatic cancers, we found the inter-fractional ITV variations in 3 out of 45 fractions (6.7 %) adjusted the ITV margin. The daily target motion in the pancreatic patients with CB was more stable and relatively smaller than that of the liver patients.

CONCLUSION

Theorthogonal 2D cine MR images are evidently essential for assessing daily target motion to evaluate the inter-fractional variation and achieve daily ITV-customized liver and pancreatic SBRT in the 1.5 T MR-Linac. The customized ITV approach will improve the treatment outcome of the MR-guided online adaptive therapy.

Goals for girls: a cluster-randomized trial to investigate a school-based sexual health programme amongst female learners in South Africa

The delivery of comprehensive sexuality education to adolescents at school is recognized as a long-term strategy to support adolescent health. Suboptimal sexual and reproductive health (SRH) outcomes among South African adolescents necessitate the ongoing development and optimization of SRH education and promotion models. We conducted a cluster-randomized controlled trial amongst secondary schools (n = 38) in Cape Town, South Africa, to evaluate a sport-based, near-peer-led SRH curriculum, SKILLZ, amongst female learners (n = 2791). Biomedical (sexually transmitted infections [STIs], human immunodeficiency virus [HIV] and pregnancy) and socio-behavioural (social support, gender norms and self-concept) outcomes were assessed pre and post intervention. Attendance at SKILLZ was low and intervention participants did not show an improvement in SRH outcomes, with HIV and pregnancy incidence remaining stable and STI prevalence remaining high and increasing in both control and intervention arms. Although evidence of positive socio-behavioural measures was present at baseline, participants with high attendance showed further improvement in positive gender norms. SKILLZ did not demonstrate the capacity to significantly impact clinical SRH outcomes. Modest improvements in outcomes amongst high attenders suggest that the impact may be possible with improved attendance; however, in the absence of optimal attendance, alternative intervention strategies may be required to improve SRH outcomes amongst adolescents.

Experiences with Racism Among Asian American Medical Students

Importance

Asian American physicians have experienced a dual pandemic of racism and COVID-19 since 2020; understanding how racism has affected the learning environment of Asian American medical students is necessary to inform strategies to promoting a more inclusive medical school environment and a diverse and inclusive workforce. While prior research has explored the influence of anti-Asian racism on the experiences of Asian American health care workers, to our knowledge there are no studies investigating how racism has impacted the training experiences of Asian American medical students.

Objective

To characterize how Asian American medical students have experienced anti-Asian racism in a medical school learning environment.

Design, Setting, and Participants

This qualitative study included online video interviews of Asian American medical students performed between July 29, 2021, and August 22, 2022. Eligible participants were recruited through the Asian Pacific American Medical Students Association and snowball sampling, and the sample represented a disaggregated population of Asian Americans and all 4 medical school years.

Main Outcomes and Measures

The medical school experiences of Asian American medical students.

Results

Among 25 participants, Asian ethnicities included 8 Chinese American (32%), 5 Korean American (20%), 5 Indian American (20%), 3 Vietnamese American (12%), 2 Filipino American (8%), and 1 (4%) each Nepalese, Pakistani, and Desi American; 16 (64%) were female. Participants described 5 major themes concerning their experience with discrimination: (1) invisibility as racial aggression (eg, "It took them the whole first year to be able to tell me apart from the other Asian guy"); (2) visibility and racial aggression ("It transitioned from these series of microaggressions that every Asian person felt to actual aggression"); (3) absence of the Asian American experience in medical school ("They're not going to mention Asian Americans at all"); (4) ignored while seeking support ("I don't know what it means to have this part of my identity supported"); and (5) envisioning the future.

Conclusions and Relevance

In this qualitative study, Asian American medical students reported feeling invisible within medical school while a target of anti-Asian racism. Addressing these unique challenges related to anti-Asian racism is necessary to promote a more inclusive medical school learning environment.

How important is it to avoid indices of deprivation that include health variables in analyses of health inequalities?

OBJECTIVES

This study aimed to quantify the difference in mortality inequalities using the Scottish Index of Multiple Deprivation (SIMD) and the Income and Employment Index (IEI; a subindex of SIMD, which excludes health) as ranking measures in Scotland.

STUDY DESIGN

This ecological study was a cross-sectional analysis of routine administrative data.

METHODS

Data from the 2020 SIMD and the subindex using data from only the Income and Employment domains, the IEI, were obtained. The correlation between data zones, percentage of data zones that changed deprivation tenth and differences in the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) for Standardised Mortality Ratios (SMRs) across tenths were compared when data zones were ranked by SIMD and IEI.

RESULTS

There was a close correlation between data zones ranked by SIMD and IEI (R² = 0.96). When data zones were ranked by IEI, 18.7% of data zones moved to a lower deprivation tenth, and 20.8% of data zones moved to a higher deprivation tenth, compared with SIMD. However, only a negligible number of data zones moved two or more tenths. The SMRs across deprivation tenths were very similar between the SIMD and IEI, as were the summary health inequality measures of SII (87.3 compared with 85.7) and RII (0.88 and 0.86).

CONCLUSION

Although there is a logical problem in using deprivation indices that include health outcomes to rank areas to calculate the scale of health inequalities, the impact of using an alternative subindex containing only data from the income and employment domains is minimal. For population-wide analyses of health inequalities in Scotland, the SIMD does not introduce a substantial bias in the health inequalities summary measures despite substantial movement of small areas between ranked population tenths. Although not examined here, this is likely to be relevant to other similar indices across the United Kingdom.

A9 INTESTINAL ORGANOID TRANSPLANTATION REVERSED THE INTESTINAL EPITHELIUM DAMAGE IN EXPERIMENTAL NECROTIZING ENTEROCOLITIS

NOT PUBLISHED AT AUTHOR’S REQUEST

How well do area-based deprivation indices identify income- and employment-deprived individuals across Great Britain today?

BACKGROUND

Area-based deprivation indices are used in many countries to target interventions and policies to populations with the greatest needs. Analyses of the Carstairs deprivation index applied to postcode sectors in 2001 identified that less than half of all deprived individuals lived in the most deprived areas.

OBJECTIVE

This article examines the specificity and sensitivity of deprivation indices across Great Britain in identifying individuals claiming income- and employment-related social security benefits.

STUDY DESIGN

This was a descriptive analysis of cross-sectional administrative data.

METHODS

The data sets for the 2020 Scottish Index of Multiple Deprivation, Scottish Income and Employment Index, the 2019 English Index of Multiple Deprivation and the 2019 Welsh Index of Multiple Deprivation were obtained. For each data set, small areas were ranked by increasing overall deprivation, and the cumulative proportions of individuals who were income and employment deprived were calculated. Receiver operating characteristic curves were plotted to show the sensitivity and specificity of each index, and the percentages of income- and employment-deprived individuals captured at different overall deprivation thresholds were calculated.

RESULTS

Across all indices, the sensitivity and specificity for detecting income- and employment-deprived individuals were low, with less than half living in the most deprived 20% of areas. Between 55% and 62% of income-deprived people and between 56% and 63% of employment-deprived people were missed across the indices at the 20% deprivation threshold. The sensitivity and specificity were slightly higher for income deprivation than employment deprivation across indices and slightly higher for the Scottish Index of Multiple Deprivation and Scottish Income and Employment Index than for the English Index of Multiple Deprivation and Welsh Index of Multiple Deprivation.

CONCLUSION

Area-based deprivation measures in Great Britain have limited sensitivity and specificity for identifying individuals who are income or employment deprived. Place-based policies and interventions are unlikely to be effective at reducing inequalities as a result. Creation of individually linked data sets and interventions that recognise the social and economic relationships between social groups are likely to be more effective.

Blueprint for antibody biologics developability

Large-molecule antibody biologics have revolutionized medicine owing to their superior target specificity, pharmacokinetic and pharmacodynamic properties, safety and toxicity profiles, and amenability to versatile engineering. In this review, we focus on preclinical antibody developability, including its definition, scope, and key activities from hit to lead optimization and selection. This includes generation, computational and in silico approaches, molecular engineering, production, analytical and biophysical characterization, stability and forced degradation studies, and process and formulation assessments. More recently, it is apparent these activities not only affect lead selection and manufacturability, but ultimately correlate with clinical progression and success. Emerging developability workflows and strategies are explored as part of a blueprint for developability success that includes an overview of the four major molecular properties that affect all developability outcomes: 1) conformational, 2) chemical, 3) colloidal, and 4) other interactions. We also examine risk assessment and mitigation strategies that increase the likelihood of success for moving the right candidate into the clinic.

Patterns of anticoagulant prescribing and renal function changes in patients with atrial fibrillation

Background

The prevalence of atrial fibrillation (AF) is nearly three times higher in patients with chronic kidney disease (CKD) than the general population. These patients have an increased risk of stroke and systemic thromboembolism (SSE) as well as bleeding. The role for direct oral anticoagulants (DOACs) in those with advanced CKD and AF remains controversial. Studies show that patients on DOACs for AF with advanced CKD have similar risk of SSE and bleeding compared to those on warfarin, but these failed to account for changes in renal function over time.

Purpose

We sought to evaluate the pattern of oral anticoagulant prescribing, class switching, discontinuation and renal function trajectory in patients with AF in the last decade, coinciding with the development of DOACs.

Methods

Using linked administrative databases, we assessed patients 66 years of age and older with a new diagnosis of non-valvular AF between April 1, 2012 and March 31, 2020 who were started on oral anticoagulation within 90 days of diagnosis. Participants required a baseline serum creatinine (Cr) measurement in the year preceding AF diagnosis. Cr values were used to calculate the estimated glomerular filtration rate (eGFR) using the CKD Epidemiology Collaboration equation. Kidney function was tracked at baseline and longitudinally among patients prescribed DOACs versus warfarin using the Laboratories Information System. Anticoagulant class switching was tracked and discontinuation was defined if a new prescription for anticoagulation was not filled after 90 days of their last prescription ending.

Results

A total of 57,574 participants were included in the study; 48,662 were started on DOACs and 8,912 were started on warfarin. In April 2012, 83.8% of patients were prescribed warfarin; however, the proportion of first prescriptions significantly evolved over time to DOACs (Figure 1). Of those started on DOACs, 13,383 (27.5%) discontinued therapy, 34,918 (71.8%) remained on therapy and 361 (0.7%) switched to warfarin. The rate of discontinuation among those started on warfarin was higher with 4,144 (46.5%) stopping, 3,172 (35.6%) continuing therapy and 1,596 (17.9%) switching to DOACs. Most patients (75.6%) who switched to DOACs from warfarin remained on DOACs until the occurrence of dialysis, renal transplantation, death, or the last follow-up date (March 31, 2020). At baseline, the mean eGFR in the warfarin group was 56.2 compared with 66.3 mL/min/1.73 m2 in the DOAC group (p&lt;0.01). Over the course of study, more than half of the subjects in both groups had a 20% or more decline in eGFR (Figure 2).

Conclusion

Given the degree of renal function decline and frequency of anticoagulant class switching in our cohort, existing observational studies comparing DOACs to warfarin in patients with AF and CKD may be limited. In order to better compare DOACs to warfarin in this population, time-varying covariates like renal function should be included in modelling.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR Foundation Grant

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.

Post-fracture care programs for prevention of subsequent fragility fractures: a literature assessment of current trends

Post-fracture care (PFC) programs evaluate and manage patients with a minimal trauma or fragility fracture to prevent subsequent fractures. We conducted a literature review to understand current trends in PFC publications, evaluate key characteristics of PFC programs, and assess their clinical effectiveness, geographic variations, and cost-effectiveness. We performed a search for peer-reviewed articles published between January 2003 and December 2020 listed in PubMed or Google Scholar. We categorized identified articles into 4 non-mutually exclusive PFC subtopics based on keywords and abstract content: PFC Types, PFC Effectiveness/Success, PFC Geography, and PFC Economics. The literature search identified 784 eligible articles. Most articles fit into multiple PFC subtopics (PFC Types, 597; PFC Effectiveness/Success, 579; PFC Geography, 255; and PFC Economics, 98). The number of publications describing how PFC programs can improve osteoporosis treatment rates has markedly increased since 2003; however, publication gaps remain, including low numbers of publications from some countries with reported high rates of osteoporosis and/or hip fractures. Fracture liaison services and geriatric/orthogeriatric services were the most common models of PFC programs, and both were shown to be cost-effective. We identified a need to expand and refine PFC programs and to standardize patient identification and reporting on quality improvement measures. Although there is an increasing awareness of the importance of PFC programs, publication gaps remain in most countries. Improvements in established PFC programs and implementation of new PFC programs are still needed to enhance equitable patient care to prevent occurrence of subsequent fractures.

Pharmacokinetics and Macrophage Inhibitory Cytokine-1 Pharmacodynamics of the Murine Double Minute 2 Inhibitor, Navtemadlin (KRT-232) in Fed and Fasted Healthy Subjects

This single 60-mg dose, 4-period crossover study assessed the effect of food and formulation change on navtemadlin (KRT-232) pharmacokinetics (PK) and macrophage inhibitory cytokine-1 (MIC-1) pharmacodynamics. Healthy subjects (N = 30) were randomized to 3 treatment sequences, A: new tablet, fasted (reference, dosed twice); B: new tablet, 30 minutes after a high-fat meal (test 1); C: old tablet, fasted (test 2). PK/pharmacodynamic parameters were measured over 0 to 96 hours. Adverse events were mild without any discontinuations. No serious adverse events or deaths occurred. In treatment A, navtemadlin mean (coefficient of variation) maximum concentration (Cmax ) was 525 (66) ng/mL, at median time to maximum concentration (tmax ) of 2 hours. Mean (coefficient of variation) area under the plasma concentration-time curve from time 0 to time t (AUC0-t ) was 3392 (63.3) ng • h/mL, and arithmetic mean terminal half-life was 18.6 hours. Acyl glucuronide metabolite (M1)/navtemadlin AUC0-t ratio was 0.2, and urine excretion of navtemadlin was negligible. After a meal (B vs A), navtemadlin tmax was delayed by 1 hour. Geometric least squares means ratios (90%CI) for navtemadlin Cmax and AUC0-t were 102.7% (87.4-120.6) and 81.4% (76.2-86.9), respectively. Old vs new tablet fasted formulations (C vs A) had geometric least squares means ratios (90%CI) of 78.4% (72.0-85.3) for Cmax and 85.9% (80.5-91.7) for AUC0-t . MIC-1 Cmax and AUC were comparable across groups; tmax was delayed relative to navtemadlin tmax by ≈8 hours. Navtemadlin AUC0-t and MIC-1 AUC0-t correlated significantly. In conclusion, navtemadlin can be administered safely with or without food; the new formulation does not affect navtemadlin PK. The 60-mg navtemadlin dose elicited a reproducible and robust MIC-1 response that correlated well with navtemadlin exposure, indicating that murine double minute 2 target engagement leads to p53 activation.

Posttraumatic Stress, Anxiety, and Depression in COVID-19 Survivors

OBJECTIVES

This study aims to examine the rates of anxiety, depression, and posttraumatic stress disorder (PTSD) after hospital discharge among COVID-19 survivors and to determine the associated risk factors.

METHODS

Adult COVID-19 survivors discharged from hospitals between March 2020 and March 2021 were asked to complete a questionnaire at 4 weeks after discharge. The Chinese version of the 22-item Impact of Event Scale - Revised (IES-R) was used to measure symptoms of PTSD. The 9-item Patient Health Questionnaire (PHQ-9) was used to assess symptoms of major depressive disorder. The 7-item Generalised Anxiety Disorder Scale (GAD-7) was used to measure symptoms of generalised anxiety disorder. The rates of anxiety, depression, and PTSD among discharged patients were determined, as were associations between psychosocial factors and outcome measures and predictors for moderate-tosevere symptoms of anxiety, depression, and PTSD.

RESULTS

96 men and 103 women aged 18 to 81 years returned the completed questionnaire. 12.1% to 20.1% of them reported symptoms of PTSD, anxiety, or depression. Higher symptom severity was associated with higher perceived life threat, lower emotional support, lower disease severity upon admission, and longer hospital stay. Women had more PTSD symptoms than men, particularly when knowing someone under quarantine.

CONCLUSION

COVID-19 survivors with higher perceived life threat, lower emotional support, lower disease severity upon admission, and longer hospital stay were associated with higher severity of symptoms of PTSD, anxiety, and depression. Timely intervention should provide to at-risk survivors.

Suspected human intravenous immunoglobulin-induced acute haemolytic anaemia in a dog

A 2-year-old mixed breed dog presented with a 1-year history of crust and erosion on the nasal planum. Because histopathological examination revealed ruptured intraepidermal pustules and superficial dermal inflammation, the dog was diagnosed with pemphigus foliaceus. Human intravenous immunoglobulin was administered in two consecutive doses of 0.5 g/kg/day due to poor therapeutic response to previous immunosuppressive therapy. From Day 3 after the first dose of human intravenous immunoglobulin, tachypnoea, pale mucous membrane, haemoglobinuria and haemoglobinemia were observed, thus confirming haemolytic anaemia. Other drug-induced haemolytic anaemias were excluded because no additional drugs had been administered before the haemolysis occurred. Immune-mediated haemolytic anaemia was also excluded because the direct antiglobulin test was negative. Two transfusions were performed, and haemolysis was not observed from Day 4 of haemolytic anaemia onset. In conclusion, human intravenous immunoglobulin-induced haemolytic anaemia should be considered in dogs that develop haemolysis following the administration of human intravenous immunoglobulin.