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.

Evaluation of the toxicity of concentrated barley beta-glucan in a 28-day feeding study in Wistar rats

Beta-glucans are water-soluble cell-wall polysaccharides consisting of (1-->3,1-->4)-linked beta-D-glucopyranosyl monomers that comprise a considerable proportion of soluble fiber from certain grains including oats and barley. Consumption of foods containing beta-glucan or beta-glucan-enriched fractions prepared from these grains lower serum cholesterol concentrations in humans and in animal models of hypercholesterolemia. The present study was conducted to evaluate the toxicity of beta-glucan-enriched soluble fiber from barley in Wistar rats on dietary administration at concentrations of 0.7, 3.5 and 7% beta-glucan for 28 days. There were no adverse effects on general condition and behavior, growth, feed and water consumption, feed conversion efficiency, red blood cell and clotting potential parameters, clinical chemistry values, and organ weights. Necropsy and histopathology findings revealed no treatment-related changes in any organ evaluated. A dose-dependent increase in full and empty cecum weight was observed. This is a common physiological response of rodents to high amounts of poorly digestible, fermentable carbohydrates, and was of no toxicological concern. The only finding of possible biological relevance was an increase in the number of circulating lymphocytes observed in males. However, the increase was not dose-dependent and was not observed in females. Results of this study demonstrated that consumption of concentrated barley beta-glucan was not associated with any obvious signs of toxicity in Wistar rats even following consumption of large quantities.

Neuropsychological prediction of conversion to dementia from questionable dementia: statistically significant but not yet clinically useful

BACKGROUND

Verbal memory impairment, one of the earliest signs of Alzheimer's disease (AD), may help identify people with cognitive impairment, insufficient for a diagnosis of dementia (questionable dementia: QD), at risk of developing AD. Other cognitive parameters have been found that may indicate which people with QD will go on to develop dementia. Nevertheless, some researchers have reported only partial success in differentiating between mild AD and age related cognitive impairment.

OBJECTIVES

To discover if there are early, pre-clinical cognitive markers that could help identify patients attending our memory clinic who were at risk of developing dementia.

METHODS

Multidisciplinary assessment of a consecutive sample of 195 patients with QD seen in a National Health Service hospital outpatient clinic; 135 seen for a mean follow up of 24.5 months.

RESULTS

Conversion rate to dementia was 27.4% (37 of 135). A diagnosis of probable or possible AD was made in 15.6% (21 of 135) of cases. Despite statistically significant differences in some cognitive tasks between those who did and those who did not go on to dement, Cox regression analyses failed to improve prediction rates markedly above base rates and were unstable.

CONCLUSION

A large number of studies claim good prediction of conversion to dementia using cognitive test scores. Although this study produced similarly good sensitivity and specificity values, proper consideration of the statistical analyses and their clinical significance suggested that these prediction methods are currently too imprecise for clinical use. Use of cognitive indicators combined with neuroradiological, neuropathological, and genetic factors for predicting conversion to dementia might prove more reliable but may be beyond the scope of many geriatric services.

Multiple sites on Streptococcus gordonii surface protein PadA bind to platelet GPIIbIIIa

Infective endocarditis is a life threatening disease caused by a bacterial infection of the endocardial surfaces of the heart. The oral pathogen, Streptococcus gordonii is amongst the most common pathogens isolated from infective endocarditis patients. Previously we identified a novel cell wall protein expressed on S. gordonii called platelet adherence protein A (PadA) that specifically interacts with platelet GPIIb/IIIa. The interaction between PadA and GPIIb/IIIa resulted in firm platelet adhesion, dense granule secretion and platelet spreading on immobilised S. gordonii. This study set out to identify specific motifs on the PadA protein that interacts with platelet GPIIb/IIIa. Proteomic analysis of the PadA protein identified two short amino acid motifs which have been previously shown to be important for fibrinogen binding to GPIIb/IIIa and contributing to the generation of outside-in signalling. Site directed mutagenesis on the PadA protein in which ₄₅₄AGD was substituted to AAA, and the ₃₈₃RGT was substituted to AAA suggests the RGT motif has no role in supporting platelet adhesion however plays a role in dense granule secretion and platelet spreading. In contrast to this the AGD motif has no role to play in supporting firm platelet adhesion or dense granule secretion however plays a role in platelet spreading. These results suggest that multiple sites on S. gordonii PadA interact with GPIIb/IIIa to mediate a number of platelet responses that likely contribute to the thrombotic complications of infective endocarditis.

Concerted functions of Streptococcus gordonii surface proteins PadA and Hsa mediate activation of human platelets and interactions with extracellular matrix

A range of Streptococcus bacteria are able to interact with blood platelets to form a thrombus (clot). Streptococcus gordonii is ubiquitous within the human oral cavity and amongst the common pathogens isolated from subjects with infective endocarditis. Two cell surface proteins, Hsa and Platelet adherence protein A (PadA), in S. gordonii mediate adherence and activation of platelets. In this study, we demonstrate that PadA binds activated platelets and that an NGR (Asparagine-Glycine-Arginine) motif within a 657 amino acid residue N-terminal fragment of PadA is responsible for this, together with two other integrin-like recognition motifs RGT and AGD. PadA also acts in concert with Hsa to mediate binding of S. gordonii to cellular fibronectin and vitronectin, and to promote formation of biofilms. Evidence is presented that PadA and Hsa are each reliant on the other's active presentation on the bacterial cell surface, suggesting cooperativity in functions impacting both colonization and pathogenesis.

A clinical observational analysis of aerosol emissions from dental procedures

Aerosol generating procedures (AGPs) are defined as any procedure releasing airborne particles <5 μm in size from the respiratory tract. There remains uncertainty about which dental procedures constitute AGPs. We quantified the aerosol number concentration generated during a range of periodontal, oral surgery and orthodontic procedures using an aerodynamic particle sizer, which measures aerosol number concentrations and size distribution across the 0.5-20 μm diameter size range. Measurements were conducted in an environment with a sufficiently low background to detect a patient's cough, enabling confident identification of aerosol. Phantom head control experiments for each procedure were performed under the same conditions as a comparison. Where aerosol was detected during a patient procedure, we assessed whether the size distribution could be explained by the non-salivary contaminated instrument source in the respective phantom head control procedure using a two-sided unpaired t-test (comparing the mode widths (log(σ)) and peak positions (DP,C)). The aerosol size distribution provided a robust fingerprint of aerosol emission from a source. 41 patients underwent fifteen different dental procedures. For nine procedures, no aerosol was detected above background. Where aerosol was detected, the percentage of procedure time that aerosol was observed above background ranged from 12.7% for ultrasonic scaling, to 42.9% for 3-in-1 air + water syringe. For ultrasonic scaling, 3-in-1 syringe use and surgical drilling, the aerosol size distribution matched the non-salivary contaminated instrument source, with no unexplained aerosol. High and slow speed drilling produced aerosol from patient procedures with different size distributions to those measured from the phantom head controls (mode widths log(σ)) and peaks (DP,C, p< 0.002) and, therefore, may pose a greater risk of salivary contamination. This study provides evidence for sources of aerosol generation during common dental procedures, enabling more informed evaluation of risk and appropriate mitigation strategies.

A purchaser experience of managing new expensive drugs: interferon beta

Interferon beta is a new and expensive drug for treating multiple sclerosis. One published trial has shown that it reduces the exacerbation rate in patients who have relapsing-remitting disease without important disability. This paper describes the development of a strategy for purchasing the drug in one region of England before its licensing. Purchasers felt unable to decline funding for this marginally effective drug and thereby undertake explicit rationing. To ensure prescribing was within the guidelines, a vast communication network had to be sustained with managers, general practitioners, neurologists, the Multiple Sclerosis Society, and professional advisers in all the purchasing authorities. The workload involved was considerable. The dilemma of rationing in a public service with a high political profile is demonstrated.

Asthma control and morbidity: a comparison of inhaler devices

This study assessed the difference in efficacy and patient morbidity when asthma drug therapy was administered by either a dry powder device (DPD) or metered dose inhaler (MDI). It assessed 27 patients who had used an MDI for at least six months before transferring to a DPD because of inadequate inhaler technique. Documentary evidence was collected retrospectively from the medical records six months before and six months after the change and outcomes were measured by daily bronchodilator therapy, daily inhaled steroid therapy, frequency of night-time wakening due to asthma symptoms, and peak expiratory flow rates. Patient symptoms and asthma control were found to be improved by the correct delivery of medication via DPD compared with an MDI.

Vertical segmental anterior mandibular distraction to aid closure of a severe anterior open bite associated with an accentuated reverse curve of Spee

Background:

The correction of severe anterior open bite is technically challenging, often requiring the use of complex orthodontic mechanics and/or orthognathic surgery and has a relatively high risk of relapse. A marked reverse curve of Spee in the lower arch presents additional challenges when correcting a severe anterior open bite.

Methods and Materials:

A 22.2-year-old Caucasian man presented with concerns relating to poor anterior occlusion associated with a 1.3-cm anterior open bite. There was an accentuated reverse curve of Spee to the lower arch, an increased maxillary-mandibular plane angle and increased lower face height. Multidisciplinary treatment involving the use of segmental anterior mandibular distraction to level the curve of Spee before undertaking a Le Fort I posterior maxillary impaction is described in this case report.

Results:

Long-term post-treatment records showed stable anterior open bite correction.

Conclusions:

This case report illustrates the successful use of segmental anterior mandibular vertical distraction followed by conventional Le Fort I posterior impaction surgery to correct a severe anterior open bite associated with an accentuated reverse curve of Spee and high maxillary-mandibular plane angle.

The perceptions of undertaking a higher degree alongside orthodontic speciality training: a cross-sectional survey of British Orthodontic Society members

Introduction In the UK, orthodontic speciality training takes place over three years full-time. In addition to the clinical training, there is an expectation that trainees undertake a higher degree. Currently, there is little evidence regarding the impact of undertaking a higher degree on specialist orthodontists.Aims Investigate UK orthodontists' perceptions of undertaking a higher degree alongside speciality training.Materials and methods A cross-sectional research study involving the distribution of an anonymous, descriptive, online, questionnaire-based survey between May and June 2021 via the British Orthodontic Society. Data were obtained in relation to the impact of undertaking a higher degree on the completion of speciality training, research skills, delivery of patient care and career opportunities.Results In total, 166 questionnaires were completed (approximately 13.3% response rate). Most respondents 'agreed' or 'strongly agreed' that undertaking a higher degree had improved their scientific (77.1%) and critical appraisal skills (80.7%), job prospects (60.2%) and career opportunities (63.9%). Most respondents felt the benefits of the higher degree outweighed the associated costs (65.1%) and was a worthwhile component of training (69.3%).Conclusions Specialist orthodontists place a high value on undertaking a higher degree. The results of this questionnaire should be of importance to stakeholders involved in the development of the orthodontic curriculum.

Microbial colonisation associated with conventional and self-ligating brackets: a systematic review

BACKGROUND

Decalcification and gingivitis caused by plaque accumulation around brackets are common iatrogenic effects of fixed appliances. The influence of conventional versus self-ligating bracket design on microbial colonisation is unknown.

OBJECTIVE

To assess the levels of microbial colonisation associated with conventional and self-ligating brackets.

SEARCH SOURCES

Three databases were searched for publications from 2009 to 2021.

DATA SELECTION

Randomised controlled trials comparing levels of microbial colonisation before and during treatment with conventional and self-ligating brackets were assessed independently and in duplicate.

DATA EXTRACTION

Data were extracted independently by two authors from the studies that fulfilled the inclusion criteria. Risk of bias assessments were made using the revised Cochrane risk of bias tool for randomized trials. The quality of the included studies was assessed using the Critical Appraisal Skills Programme Checklist.

RESULTS

A total of 11 randomised controlled trials were included in this systematic review. Six of the studies were found to be at low risk of bias and five presented with some concerns. The studies were considered moderate to high quality. Five trials reported no statistically significant difference in microbial colonisation between bracket types. The remaining studies showed mixed results, with some reporting increased colonisation of conventional brackets and others increased colonisation of self-ligating brackets. The heterogeneity of study methods and outcomes precluded meta-analysis.

CONCLUSION

Of the 11 studies included in this systematic review, five found no differences in colonisation between conventional and self-ligating brackets. The remaining studies showed mixed results. The evidence is inconclusive regarding the association between bracket design and levels of microbial colonisation.

Perceptions of undertaking a higher degree alongside dental specialty training: A cross-sectional survey of UK dental specialty trainees

INTRODUCTION

The curricula for UK dental specialty training have recently been under review and until 2024, completion of a research component during training in Dental Public Health, Oral Microbiology and Orthodontics has been mandatory (with an alternative route for Orthodontics involving the submission of two scientific papers for those trainees not wishing to undertake a higher degree). Anecdotally, some trainees in other dental specialties choose to undertake higher degrees alongside specialty training.

AIMS

The aims were to investigate how many dental specialty registrars study for higher degrees alongside specialty training, and whether undertaking a higher degree alongside specialty training has an impact on completion of training, research skills, research experience, patient care and career opportunities.

MATERIALS AND METHODS

This was a cross-sectional study design, involving the distribution of an online, anonymous questionnaire-based survey to UK dental specialty registrars in November and December 2022.

RESULTS

In total, 38 questionnaires were completed, representing a 7.7% response rate of the entire dental specialty registrar cohort in the UK and 42% of those who received it. Most respondents (76.3%) were either studying or had completed a clinically relevant higher degree prior to specialty training. Most respondents (76.3%) reported that the higher degree increased career opportunities and gave them additional skills.

CONCLUSIONS

Dental specialty trainees who responded to this survey perceived the higher degree to be beneficial in terms of preparing for exams, gaining skills in critical appraisal and for increasing future career opportunities.

Cultivation techniques for the erythrocytic stages of malaria parasites

The study of the biochemistry, physiology, and immunology of plasmodia has been restricted by the difficulty of maintaining the parasites in isolation from the host. Some success has been achieved in cultivating them in vitro, using tissue cultures and chick embryo techniques to study exoerythrocytic states and the sporogonic cycle, but no completely successful method has been found for studying the asexual and sexual stages of plasmodia in circulating red blood cells. The relative slowness with which techniques for continuous in vitro cultivation have been developed is the result of inadequate knowledge of the biochemistry of the parasites and of the blood and its constituents. However, radioactive labelling techniques applied to P. knowlesi cultures are beginning to yield data of fundamental importance. Existing methods for the short-term in vitro cultivation of plasmodia are potentially very useful for analysing malarial antigens, for developing vaccines, and for screening and studying antimalarial drugs. Investigations of the physicochemical requirements for the in vitro preservation of red blood cells are required, and more emphasis should be given to the study of plasmodia with longer cycles. Differences between the metabolism of plasmodia in vivo and in vitro should be studied and the growth factors in normal plasma identified. Studies of the membrane of the parasites and of the red blood cells, of the immune response, and of extracellular methods for the cultivation of plasmodia should be extended.

The Postgraduate Educational Environment at a United Kingdom Dental School: A Quantitative Study Using a Modified Dundee Ready Educational Environment Measure Questionnaire

INTRODUCTION

Quantitative research on postgraduate (PG) dental students' perceptions of their educational environment is lacking. The aim of this research was to increase our understanding of taught PG dental students' educational environment.

METHODS

A modified Dundee Ready Educational Environment Measure (DREEM) questionnaire was distributed to PG students at the University of Bristol Dental School. DREEM scores in relation to five domains (learning, teaching, academic, atmosphere and social), as well as total DREEM scores, were derived. In addition, demographic and global questions relating to blended learning and teaching support were captured. DREEM domain and total scores were summarised using medians, interquartile ranges and full ranges. Demographic data and answers to additional global questions were categorised as frequencies and percentages.

RESULTS

Thirty-four participants (50% response rate) from four different taught PG programmes responded. Total DREEM scores suggest most PG students' perceived educational environment to be 'excellent' (55.9%) or 'more positive than negative' (41.2%). The highest scoring domain was teaching, while the lowest scoring was social. Global questions indicated good teaching support and acceptance of blending learning, although the reduced face to face peer/teacher contact did not meet the needs of some (20.5%) participants.

CONCLUSIONS

Although the DREEM measure has been used widely in dental training, its use has been limited in PG dental settings. The teaching and learning environment at the University of Bristol was rated highly. The lower social scoring highlights potential deficiencies within the educational environment of these PG students.

The pupillary light reflex in aging and Alzheimer's disease

The pupillary light reflex is reported to be reduced in amplitude in Alzheimer's disease (AD). The purpose of this study was to determine whether this effect is measurable under conditions typical of clinical rather than laboratory settings. A head-mounted infra-red videopupillometer was used to measure the amplitude of pupillary constriction in 12 patients with probable AD, 12 healthy age-matched older adults and 12 young adults. The constriction to the onset of bright light relative to the resting amplitude was significantly reduced in AD compared with both control groups. This result is consistent with an acetylcholine-related deficit in AD and supports the findings of Prettyman et al. and Fotiou et al. The impairment is likely to be caused by degeneration in relays in the midbrain but cholinergic deficits in the peripheral parasympathetic pathway cannot be excluded. The variation in pupillary response between individuals may preclude its use for diagnostic purposes. However, if the changes in pupillary response in AD are related to change in neurotransmitter status, then the value of such a technique may be in its use in providing an objective, non-invasive monitor of physiological abnormality with which to follow disease progression and treatment efficacy.

Long-term treatment outcomes from the perspective of a patient with unilateral cleft lip and palate

The management of patients with orofacial cleft (OFC) often extends from diagnosis or birth well into adulthood and requires many different specialists within multidisciplinary teams (MDT). The aims of treatment are to restore form and function relating to hearing, speech, occlusion and facial aesthetics. People with OFCs that include the lip, alveolus and palate (cleft lip and palate (CLP)) require several different staged and coordinated surgical and non-surgical interventions, and the treatment pathway is associated with a heavy burden of care. Due to the extensive nature of the interaction with these patients, MDT members have opportunities to provide enhanced patient-centred care and support. This case report provides an overview of the current knowledge of the aetiology of OFC and the management of these patients. It provides a unique perspective from one of the coauthors who has a unilateral CLP (UCLP) and reports on his treatment experiences and long-term treatment outcomes. By having a better understanding of the impact of UCLP and treatment provided, MDT members can not only provide improved clinical treatment but also offer improved patient experiences for those with craniofacial anomalies, in particular, an increased awareness of the psychosocial challenges, they endure throughout their treatment pathway and beyond.