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.

A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy

OBJECTIVE

Although gastrostomy feeding tends to have fewer interruptions than naso-gastric feeding and is cosmetically more acceptable; there is little information on health-related quality of life (HRQoL) in these patients. This study aimed to measure the health-related quality of life of patients after gastrostomy placement.

DESIGN

Cross-sectional and prospective cohorts.

SETTING

Institutional and community-dwelling patients receiving nutritional support via a gastrostomy.

PARTICIPANTS

For the cross-sectional cohort, all individuals who have received a percutaneous gastrostomy from our unit (January 1994-December 1996) were included; 55 of the 102 patients who were still living agreed to follow-up assessment. For the prospective cohort, all patients referred to our unit for percutaneous gastrostomy (March 1997-June 1998) were eligible to participate; 54 of 88 patients (62%) consented and were recruited.

METHODS AND OUTCOME MEASURES

A cross-sectional assessment of patient outcome and health-related quality of life using SF-36, the Hospital Anxiety and Depression Scale and a disease-specific questionnaire (PEG-Qu) was carried out in patients in primary health care after receiving a gastrostomy. These assessments, plus the Modified Rankin Scale, were performed on patients studied at the time of gastrostomy placement, and after 1, 6 and 12 months of follow-up.

RESULTS

HRQoL questionnaires could be answered in less than half the patients. An overall rating of the effect of the gastrostomy on the patients' and carers' HRQoL showed a positive effect in 55% and 80%, respectively. A positive impression of the gastrostomy by the patient did not necessarily reflect an improvement in their nutritional status. Assessment of HRQoL in a cohort of gastrostomy patients showed deficiencies in the physical domain but not mental function (anxiety or depression), energy or health perception. Neither physical function nor level of cognition at time of gastrostomy placement appear to be able to predict patient survival. Nutritional outcome was not related to HRQoL outcome.

CONCLUSION

The majority of patients and carers rate gastrostomy positively. Patients who were 75 years or older had a poorer survival compared to younger patients, but gender, physical or cognitive function had no predictive value on survival.

Sudden neonatal death in PACAP-deficient mice is associated with reduced respiratory chemoresponse and susceptibility to apnoea

Pituitary adenylate cyclase-activating polypeptide (PACAP)-deficient mice are more prone to sudden death during postnatal weeks 1-3 than wild-type littermates. Given that PACAP is localized in brainstem regions associated with respiratory chemosensitivity, we examined whether PACAP-null neonates have reduced respiratory responses to hypoxia and hypercapnia. Using unrestrained, whole-body, flow-through plethysmography we found that, by postnatal day 4, the PACAP-null neonates had significantly reduced ventilation during baseline breathing, and blunted responses to both hypoxia (10% O2-90% N2) and hypercapnia (8% CO2-92% air). To determine whether the respiratory phenotype of the PACAP-null mice may contribute to their greater neonatal mortality, we used ECG to examine respiration and cardiovascular function of littermates. We demonstrate that, under conditions that exacerbate mortality of knockout but not wild-type animals, PACAP-deficient mice experience prolonged apnoeas that precede atrio-ventricular block. Both apnoeas and atrio-ventricular block were absent in wild-type littermates. These data suggest that PACAP-deficiency results in higher neonatal mortality primarily as a result of respiratory control defects and raise the possibility that mutations in genes encoding components of the PACAP signalling pathways may contribute to neonatal breathing disorders in humans.

Long-term maintenance of weight loss in patients with severe mental illness through a behavioural treatment programme in the UK

OBJECTIVE

Obesity is common among people with severe mental illness (SMI). We report our experience from the first 4 years of The Cromwell House weight management clinic.

METHOD

Ninety-three patients with SMI aged 43.7 +/- 1.2 years referred themselves to this clinic. The patients were seen in weekly group sessions that involved weight measurement, discussion and education.

RESULTS

Mean baseline weight was 89.5 +/- 1.8 kg [body mass index (BMI) 32.3 +/- 0.5 kg/m(2)]. Twenty-three per cent dropped out within the first 8 weeks. There was progressive statistically significant reduction in mean weight and BMI throughout the duration of monitoring with no suggestion of a plateau. The mean final weight loss was 6.2 +/- 0.6 kg. Weight loss was correlated only with the number of sessions attended (r = 0.53, P < 0.0001).

CONCLUSION

Long-term weight management of obese and overweight patients with severe forms of mental illness was possible through the provision of simple lifestyle advice within the group setting.

Respiratory control in neonatal rats exposed to prenatal cigarette smoke

RATIONALE

Prenatal cigarette smoke (CS) exposure, increased environmental temperature, and hypoxic episodes have been postulated as major risk factors for sudden infant death syndrome.

OBJECTIVES

To test the hypothesis that maternal CS exposure disrupts eupneic breathing and depresses breathing responses of neonatal rats to thermal and hypoxic challenges.

METHODS

Experiments were performed on 1-week-old rat pups exposed prenatally to CS (n = 39) or room air (sham; n = 30). Breathing patterns were recorded by whole-body plethysmography during thermoneutral or hyperthermic states under normoxic and hypoxic conditions.

MEASUREMENTS AND MAIN RESULTS

Mean pup weight, breaths per minute, and gasping respiratory patterns were measured for both smoke- and sham-exposed groups during thermoneutral and hyperthermic states under normoxic and hypoxic conditions. Under thermoneutral conditions, hypoxia caused gasping in CS-exposed animals but not in sham-exposed animals. Furthermore, under hyperthermic conditions, whereas hypoxia induced gasping in both groups, only CS-exposed animals exhibited a pronounced and longer lasting respiratory depression after the termination of hypoxia.

CONCLUSIONS

We show that prenatal CS exposure increases the likelihood of gasplike respiration and provide the first experimental evidence that the combined effects of prenatal CS exposure and hyperthermia dramatically prolong the time required for neonates to return to eupneic breathing after hypoxia. These observations provide important evidence of how prenatal CS exposure, hypoxic episodes, and hyperthermia might place infants at higher risk for sudden infant death syndrome.

Successful pregnancy in a patient with chronic intestinal pseudo-obstruction while on ambulatory percutaneous endoscopic gastrostomy feeding

We report a case of ambulatory endoscopic gastrostomy feeding via a low profile button device using a portable feeding pump. This provided successful nutritional support to a patient with chronic intestinal pseudo-obstruction who became pregnant while on gastrostomy feeding. She successfully completed her pregnancy with nutritional support through the gastrostomy. The portable feeding pump gave her excellent quality of life both indoors and outdoors, and she could continue feeding without interrupting her daily housework, shopping and babycare.

Prenatal cigarette smoke exposure and postnatal respiratory responses to hypoxia and hypercapnia

Prenatal cigarette smoke (CS) exposure, in combination with hypoxia and/or hyperthermia can lead to gasping and attenuated recovery from hypoxia in 7 days old rat pups. We studied 95 unanesthetized spontaneously breathing 14 days old rat pups to investigate if the destabilizing effects of increased ambient temperature and prenatal CS exposure on respiratory control observed in 7 days old rats were still evident at day 14. This postnatal age was selected as it is beyond the analogous risk period for SIDS in human. Furthermore, we investigated if the breathing responses to hypercapnia are affected by prenatal CS exposure. Since high ambient (HA) temperature can lead to gasping and aberrant respiratory control, we recorded respiratory patterns at low (24-25°C) and high (29-30°C) ambient temperatures, and under hypoxic or hypercapnic states. No gasping was observed in 14 days old rat pups. During hypoxia, breathing frequency increased in the CS-exposed group under low and HA temperatures. Rectal temperature decreased only in the sham group in response to low ambient temperature hypoxia. At HA temperature, breathing frequency increased in both sham and CS-exposed groups during hypercapnia, however, it remained elevated during washout period only in the sham group. We demonstrate that prenatal CS exposure continues to have profound effects on respiratory and thermoregulatory responses to hypoxia and hypercapnia at day 14. The attenuated respiratory and thermoregulatory responses to acute hypoxia and hypercapnia on day 14 demonstrate a strong interaction between CS exposure, respiratory control, and thermoregulation during postnatal maturation.

Cross-sectional and prospective studies of nutritional indices after percutaneous gastrostomy

OBJECTIVE

Formal monitoring of nutritional status may be lacking in many patients after gastrostomy. We aimed to study nutritional assessment and its problems in patients after gastrostomy in a cross-sectional study, assess prospectively the changes in nutritional status of patients at 1 month and 6 months after gastrostomy placement, and determine the prognostic value of nutritional indices assessed at the time of gastrostomy placement.

DESIGN

We used cross-sectional and prospective cohorts. The subjects were institutional and community patients receiving percutaneous gastrostomy in a teaching hospital.

METHOD

We studied patients living in the community and in long-term care institutions after gastrostomy. In the cross-sectional study, we observed all individuals who received a percutaneous gastrostomy from the Gastrointestinal Unit, Western General Hospital, Edinburgh from January 1994 to December 1996. In the prospective study, we observed consecutive referrals of patients to the Gastrointestinal Unit for percutaneous gastrostomy from March 1997 to June 1998. Nutritional status was assessed using: weight (kg), height or stature estimated from knee-height (m), mid-upper arm circumference and triceps skinfold thickness. Body mass index, arm-muscle circumference and corrected arm-muscle area were calculated. A blood sample was taken to assess micronutrient status.

RESULTS

In the cross-sectional study, 215 patients were identified who had received a percutaneous gastrostomy during the 3-year period 1994-1996. The weight and height measurements obtained in patients after gastrostomy were not as successful as upper-arm anthropometry. Of the 55 who were alive, traceable and agreed to take part in the study, 8% were under-nourished by corrected arm-muscle area at a median of 16 months after gastrostomy placement, whilst 57% had biochemical evidence of macro- or micronutrient deficiency. In the prospective study, 54 out of 87 patients referred for percutaneous gastrostomy agreed to participate. Using corrected arm-muscle area, 14% of patients were under-nourished at the time of gastrostomy placement. Changes in nutritional status at 1 month and 6 months post gastrostomy were mixed across the patient groups. Patients with a depleted corrected arm-muscle area <or= 21.4 cm2 (<or= 21.6 cm2 for women) at the time of gastrostomy had significantly poorer survival than patients with corrected arm-muscle area of > 21.6 cm2 (log-rank test 9.05; P = 0.003, relative risk 4.7). All patients in whom corrected arm-muscle area had increased at the 1-month follow-up survived to 6 months post gastrostomy.

CONCLUSIONS

Assessment of nutritional status may be difficult in gastrostomy-fed patients. Upper-arm anthropometry is more often successful than other assessment methods and gives prognostic information.

Radiological insertion of gastrostomy in patients in whom endoscopy was unsuccessful

INTRODUCTION

Endoscopy is the standard technique of percutaneous gastrostomy placement, but failure of placement may occur due to difficulty with intubation or previous abdominal surgery. A review of personal experience is made.

PATIENTS AND METHODS

Between January 1997 and May 1998, 90 gastrostomy devices were successfully placed endoscopically in our unit. Endoscopic placement was unsuccessful in 3 patients and not attempted in a further 7 because of oro-pharyngeal obstruction. These 10 patients (6 male, 4 female, aged 51-84 years) had advanced neuro-degenerative disease or malignancy of the head and neck or oesophagus. All patients underwent radiological insertion of a gastrostomy tube by the 'push' method after insufflation of air into the stomach via a naso-gastric tube.

RESULTS

Radiological insertion of gastrostomy device was successful in 9 out of 10 patients. Failure occurred in 1 patient due to inability to pass a naso-gastric tube and surgical gastrostomy was required. Pain at the gastrostomy site was the most common problem post-procedure and 4 patients still required analgesia on discharge. One patient developed a wound infection. There were no procedure-related deaths. The 30-day mortality due to all causes was 20%. Only 1 patient remained alive at 6 months.

DISCUSSION

Availability of a radiologist trained in the placement of percutaneous gastrostomy allowed 99% of such devices to be placed percutaneously, even in those patients in whom endoscopy was not possible. However advanced underlying disease in this patient group results in a high mortality.