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.

Patellar ligament desmopathy in the horse – a review and comparison to human patellar tendinopathy (‘Jumper’s knee’)

Patellar ligament desmopathy in horses is regarded as an uncommon condition with unclear aetiology. Of the three patellar ligaments in the horse, the intermediate is the one most often diagnosed with desmopathy in horses presenting with chronic lameness. This structure corresponds to the patellar tendon in humans. As diagnostic imaging modalities continuously improve, changes in echogenicity of the patellar ligaments are identified ultrasonographically with increasing frequency. However, disruption of the normal fibre pattern may be present also in patellar ligaments in horses that show no signs of lameness. Similarly, there is a poor correlation between pain and diagnostic imaging findings in human patellar tendinopathy. Consequently, there appears to be a knowledge gap pertaining to normal ultrasonographic variation and diagnostic criteria for disease of the patellar ligaments in horses. Furthermore, local anaesthetic techniques to verify the diagnosis are poorly described, and due to the low number of treated cases, no specific treatment modality can be recommended on a scientific basis. The aim of this paper is to review the current knowledge regarding the pathogenesis, diagnosis and management of patellar ligament desmopathy in horses, compare this condition with patellar tendinopathy in humans, and identify areas for further research to increase the diagnostic accuracy in horses. We conclude that there is a profound need for better descriptions of ultrasonographic variation and pathological changes of the equine patellar ligaments. Identification of areas of maximal ligament strain and descriptions of early histopathological changes could render more information on the possible aetiology, preventive measurements and treatment options of desmopathy. Description of regional innervation could aid in development of methods for diagnostic anaesthesia to verify pain originating from the ligaments.

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.

Tailoring interfacial effect in multilayers with Dzyaloshinskii-Moriya interaction by helium ion irradiation

We show a method to control magnetic interfacial effects in multilayers with Dzyaloshinskii-Moriya interaction (DMI) using helium (He[Formula: see text]) ion irradiation. We report results from SQUID magnetometry, ferromagnetic resonance as well as Brillouin light scattering results on multilayers with DMI as a function of irradiation fluence to study the effect of irradiation on the magnetic properties of the multilayers. Our results show clear evidence of the He[Formula: see text] irradiation effects on the magnetic properties which is consistent with interface modification due to the effects of the He[Formula: see text] irradiation. This external degree of freedom offers promising perspectives to further improve the control of magnetic skyrmions in multilayers, that could push them towards integration in future technologies.

Utility of fractional exhaled nitric oxide suppression as a prediction tool for progression to biologic therapy

Rationale

The utility of fractional exhaled nitric oxide (F _ENO) suppression (FeNOSuppT) to identify non-adherence to inhaled corticosteroid (ICS) treatment has previously been reported, but whether it can predict clinical outcome remains unclear.

Objectives

We examined the utility of FeNOSuppT in prediction of progression to biologic agents or discharge from specialist care.

Methods

FeNOSuppT was measured at home using remote monitoring technology of inhaler use alongside daily F _ENO measurement over 7 days. Long-term clinical outcomes in terms of progression to biologic agent or discharge from specialist care were compared for non-suppressors and suppressors.

Measurements and main results

Of the 162 subjects, 135 successfully completed the test with 81 (60%) positive F _ENO suppression tests. Subjects with a negative FeNOSuppT were more likely to proceed to biologic therapy (39 of 54 patients, 72%) compared to those with a positive FeNOSuppT (35 of 81 patients, 43%, p=0.001). In subjects with a positive FeNOSuppT, predictors of progression to biologic therapy included higher dose of maintenance steroid at initial assessment and prior intensive care unit admission. These subjects had a significant rise in F _ENO between post-suppression test and follow-up (median, 33 (IQR 25-55) versus 71 (IQR 24-114); p=0.009), which was not explained by altered corticosteroid dose.

Conclusions

A negative FeNOSuppT correlates with progression to biologic therapy. A positive FeNOSuppT, with subsequent maintenance of "optimised" F _ENO, predicts a subgroup of patients in whom asthma control is preserved with adherence to high-dose ICS/long-acting β2 agonist and who can be discharged from specialist care.

Feasibility, reproducibility, and clinical implications of the fully automated assessment for global longitudinal strain

Background

Despite of evidence on its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine because it requires proficiency and is time-consuming. Automated assessment of GLS may be a solution to these barriers. This study sought to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semi-automated and manual assessment for global longitudinal strain.

Methods

In this validation study, different methods for the assessment of GLS were applied to echocardiograms of 561 asymptomatic people (age 71±5 years) with heart failure (HF) risk factors, recruited from the community. All patients were followed up for new-onset of HF and cardiovascular death. Measurement of GLS was repeated using the same apical images on three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semi-automated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator). We defined abnormal GLS for discrimination of LV systolic dysfunction using the cut-off of GLS =18% (absolute value).

Results

AutoStrain measurements were feasible in 99.5% of patients. Calculation time for automated (0.5±0.1 min/patient) and semi-automated assessment (2.7±0.6 min/patient) were significantly shorter than that for manual assessment (4.5±1.6 min/patient) (both p&lt;0.001), and the automated assessment showed excellent reproducibility. There was considerable discordance between automated and semi-automated/manual GLS (Figure 1), but normal systolic function was reliable identified. The prediction of cardiovascular events was reliable with automated, semi-automated and manual GLS (Figure 2).

Conclusion

A novel fully automated assessment for GLS is a feasible, rapid, reproducible and clinically applicable means of assessing LV function, and measurements in the normal range predict a favorable outcome.

Figure 1

Funding Acknowledgement

Type of funding source: None

The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial

Background

Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI.

Methods

With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions.

Discussion

The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC.

Trial registration

NCT03984396. Registered on 13 June 2019

432 Traditional markers of myocardial dysfunction fail to detect marked reductions in physical capacity amoung chemotherapy patients

Methods

95 patients who were due to commence anti-cancer treatment (n = 58 anthracycline chemotherapy for breast cancer; n = 25 Bruton’s tyrosine kinase inhibitor and n = 12 allogeneic stem cell transplant for haematological cancers) completed a pre-treatment and follow-up assessment within 6 months of initiating treatment. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP) and cardiopulmonary exercise test (CPET, VO2peak) were measured.

Results

Of 95 participants who underwent baseline testing, follow-up CPET and echocardiography data was available in 89 participants. LV function was normal prior to treatment (LVEF 61.5 ± 5.9%; GLS -19.4 ± 2.3) but VO2peak (23.4 ± 6.5ml/kg/min) was only 83 ± 21% (range 47-146%) of age-predicted. After treatment, we observed marked reductions in fitness (Δ-2.1 ± 3.7 ml/kg/min or -9 ± 15%, P &lt; 0.001) which was associated with small non-clinically significant changes in LV function (LVEF Δ-2.4 ± 6.4% P = 0.001; GLS Δ-0.5 ± 1.9 P = 0.018). Troponin was increased significantly (4.0 ± 5.5 to 23.5 ± 22.5ng/ml, P &lt; 0.001), with no change in BNP (37.5 ± 31.4 to 32.7 ± 22.0pg/ml, P = 0.87). Current diagnostic criteria for cardiac toxicity were not met in any patient despite some patients developing disabling reductions in functional capacity (VO2peak &lt; 16ml/min/kg).

Conclusion

Despite normal resting LV function prior to commencing treatment VO2peak was below age predicted. Treatment further impaired exercise cardiovascular function with minimal impact on resting measures of LV function. The assessment of cardiovascular function using CPET prior to, and following chemotherapy may be a more sensitive means of identifying patients at increased risk of future heart failure.

'Desculturización,' urbanization, and nutrition transition among urban Kichwas Indigenous communities residing in the Andes highlands of Ecuador

BACKGROUND

The nutrition transition continues to affect populations throughout the world. The added impact of market integration and urbanization exacerbates the impact of the nutrition transition upon Indigenous populations worldwide.

OBJECTIVES

This study aims to explore the nutritional concerns of the urban Kichwas community residing in the Andes highlands of Ecuador.

STUDY DESIGN

This is a qualitative study.

METHODS

Eight focus groups were conducted with Kichwas men and women in November 2015 in the Imbabura province of the Andes in Ecuador.

DATA ANALYSIS

Applied thematic analysis was used to analyze findings regarding nutrition.

RESULTS

The participants shared concerns regarding increased intake of fast food, poor meal timing, and a shift in the child's food preferences that rejects traditional foods. They attributed these concerns to urbanization resulting from an increase in dual-income households and a loss of cultural identity.

CONCLUSIONS

Synergistic cultural factors are related to nutritional concerns voiced by the urban Kichwas community.

PUBLIC HEALTH IMPLICATIONS

Syndemic theory is a useful interpretive lens regarding nutritional trends within the Kichwas communities as they relate to the increased risk of chronic disease.

3224Incremental benefit of left ventricular global longitudinal strain over clinical and left atrial parameters for predicting new-onset atrial fibrillation

Background

Although LV hypertrophy and dysfunction are associated with atrial fibrillation (AF), AF often occurs in the absence of LV hypertrophy or reduced ejection fraction. The effect of subclinical LV dysfunction on AF has not been fully studied.

Purpose

We sought the association between subclinical LV dysfunction (measured with global longitudinal strain, GLS) and new-onset AF.

Methods

This observational study evaluated 531 consecutive patients (median age, 67 years [interquartile range, 56 to 78]; 56% male), without a history of AF who underwent strain echocardiography after cryptogenic stroke. The CHARGE-AF score was used to calculate the 5-year risk of developing AF. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir strain, pump strain, and conduit strain) and LV strain (GLS). A strain analysis was conducted using a dedicated software package, using R-R gating. The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared.

Results

Over 2.5 years of follow-up, 61 patients (11%) had new-onset AF. Patients who developed AF were older, had a higher CHARGE-AF score, larger LA volume, worse LA strain, and worse GLS than those who did not. Areas under the receiver-operating curve for GLS (0.84) was comparable to CHARGE-AF (0.79), LA pump strain (0.83), and LA reservoir strain (0.85). In the nested Cox models, GLS demonstrated an independent and incremental predictive value over the clinical and LA parameters (Figure). Moreover, adding GLS to the combined clinical and LA parameters model resulted in a significantly improved reclassification (net reclassification improvement, 0.32; p=0.016). Importantly, the predictive value of GLS was confirmed in patients with abnormal LA volumes (LA volume index≥34ml/m2) but not in patients with normal LA volumes.

Figure 1

Conclusion

GLS is associated with new-onset AF, especially in patients with abnormal LA volumes. This effect is independent of and incremental to the clinical and LA parameters.

P4377Use of LV Deformation Imaging to predict long term Heart Failure Risk in high risk patients

Background

The increasing prevalence of heart failure (HF), due to hypertension, ischaemic heart disease, diabetes, obesity, and ageing population demands identification of at-risk subgroup whom we could target on prevention strategies. In a same cohort of patients at risk of HF (70% with CAD), 13% developed new HF hospitalization or death over 4.3 years of follow-up, however, disease management program did not confer any benefit to outcome and LV ejection fraction (EF) was not predictive of progression to HF. Better risk stratification strategies are needed. In this study, we sought whether advanced echo measure on deformation, global longitudinal strain (GLS) would predict HF admission over a long term follow up and thereby define an at-risk group. Aim: To determine which of the LV morphology, function and deformation parameters, best predict new HF admission or HF death in pts at risk but without prior dx of HF.

Method

Echocardiograms (including measurement of LV, size, function, morphology and deformation) were obtained in 431 inpatients (mean age 65±11, 72% male) at risk of HF. LV global longitudinal strain (GLS) and strain rate (GLSR) were measured offline (EchoPac, GE). Long term (9 years) follow up data were obtained via data linkage.

Results

63 pts (15%) reached the end-point of HF admission or HF death. LV deformation showed a univariable association with outcome (Table). In multivariable analysis, including known significant predictors of outcome (age, sex, BMI, diabetes, hypertension), GLS less than 18 remained an independent predictor (Table), in addition to age and DM at baseline. EF and LV mass were not predictors of heart failure.

HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value Age 1.1 (1–1.1) <0.01 1.1 (1–1.1) 0.04 1 (1–1.1) 0.04 Sex 1.0 (0.6–1.7) 0.9 0.8 (0.4–1.8) 0.6 0.8 (0.4–1.8) 0.6 BMI 1.0 (1–1.1) 0.05 1 (0.9–1.1) 0.7 1 (0.9–1.1) 0.7 DM 2.6 (1.6–4.3) <0.01 2.7 (1.4–5.3) <0.01 2.7 (1.4–5.2) 0.04 LVMI 1.0 (1.0–1.0) <0.01 1 (0.9–1.0) 0.7 1 (0.99–1.0) 0.7 Impaired EF, % 1.0 (0.9–1.0) <0.01 1 (0.9–1.0) 0.16 0.97 (0.94–1.0) 0.04 Diastolic dysfunction 2.3 (1.4–3.7) <0.01 0.8 (0.3–1.7) 0.5 0.7 (0.3–1.7) 0.5 GLS 1.3 (1.4–1.2) <0.01 1.1 (1–1.2) 0.07 GLS <18 5.3 (2.8–10.2) <0.01 2.3 (1.1–5.1) 0.04

Conclusion

GLS <18 is independently associated with increasing new onset heart failure admission and HF mortality in patients at risk of HF.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Mentorship Programs for Transplant Patients

The concept of mentoring has been used successfully in numerous settings, but only in the past decade have mentoring programs been used with organ transplant recipients. This paper describes how the Toronto Multi Organ Transplant Mentor Programme works, is administered, augments patient care, is evaluated, and has been adapted to meet the needs of various transplant patient populations.