Genomic characteristics and clinical effect of the emergent SARS-CoV-2 B.1.1.7 lineage in London, UK: a whole-genome sequencing and hospital-based cohort study

Background

Emergence of variants with specific mutations in key epitopes in the spike protein of SARS-CoV-2 raises concerns pertinent to mass vaccination campaigns and use of monoclonal antibodies. We aimed to describe the emergence of the B.1.1.7 variant of concern (VOC), including virological characteristics and clinical severity in contemporaneous patients with and without the variant.

Methods

In this cohort study, samples positive for SARS-CoV-2 on PCR that were collected from Nov 9, 2020, for patients acutely admitted to one of two hospitals on or before Dec 20, 2020, in London, UK, were sequenced and analysed for the presence of VOC-defining mutations. We fitted Poisson regression models to investigate the association between B.1.1.7 infection and severe disease (defined as point 6 or higher on the WHO ordinal scale within 14 days of symptoms or positive test) and death within 28 days of a positive test and did supplementary genomic analyses in a cohort of chronically shedding patients and in a cohort of remdesivir-treated patients. Viral load was compared by proxy, using PCR cycle threshold values and sequencing read depths.

Findings

Of 496 patients with samples positive for SARS-CoV-2 on PCR and who met inclusion criteria, 341 had samples that could be sequenced. 198 (58%) of 341 had B.1.1.7 infection and 143 (42%) had non-B.1.1.7 infection. We found no evidence of an association between severe disease and death and lineage (B.1.1.7 vs non-B.1.1.7) in unadjusted analyses (prevalence ratio [PR] 0·97 [95% CI 0·72–1·31]), or in analyses adjusted for hospital, sex, age, comorbidities, and ethnicity (adjusted PR 1·02 [0·76–1·38]). We detected no B.1.1.7 VOC-defining mutations in 123 chronically shedding immunocompromised patients or in 32 remdesivir-treated patients. Viral load by proxy was higher in B.1.1.7 samples than in non-B.1.1.7 samples, as measured by cycle threshold value (mean 28·8 [SD 4·7] vs 32·0 [4·8]; p=0·0085) and genomic read depth (1280 [1004] vs 831 [682]; p=0·0011).

Interpretation

Emerging evidence exists of increased transmissibility of B.1.1.7, and we found increased virus load by proxy for B.1.1.7 in our data. We did not identify an association of the variant with severe disease in this hospitalised cohort.

Funding

University College London Hospitals NHS Trust, University College London/University College London Hospitals NIHR Biomedical Research Centre, Engineering and Physical Sciences Research Council.

Practical approach to management of respiratory complications in neurological disorders

Patients with certain neurological diseases are at increased risk of developing chest infections as well as respiratory failure due to muscular weakness. In particular, patients with certain neuromuscular disorders are at higher risk. These conditions are often associated with sleep disordered breathing. It is important to identify patients at risk of respiratory complications early in the course of their disease, although patients with neuromuscular disorders often present in the acute setting with respiratory involvement. This review of the respiratory complications of neurological disorders, with a particular focus on neuromuscular disorders, explores why this happens and looks at how to recognize, investigate, and manage these patients effectively.

Successes and Challenges of Implementing Tobacco Dependency Treatment in Health Care Institutions in England

There is a significant body of evidence that delivering tobacco dependency treatment within acute care hospitals can deliver high rates of tobacco abstinence and substantial benefits for both patients and the healthcare system. This evidence has driven a renewed investment in the UK healthcare service to ensure all patients admitted to hospital are provided with evidence-based interventions during admission and after discharge. An early-implementer of this new wave of hospital-based tobacco dependency treatment services is "the CURE project" in Greater Manchester, a region in the North West of England. The CURE project strives to change the culture of a hospital system, to medicalise tobacco dependency and empower front-line hospital staff to deliver an admission bundle of care, including identification of patients that smoke, provision of very brief advice (VBA), protocolised prescription of pharmacotherapy, and opt-out referral to the specialist CURE practitioners. This specialist team provides expert treatment and behaviour change support during the hospital admission and can agree a support package after discharge, with either hospital-led or community-led follow-up. The programme has shown exceptional clinical effectiveness, with 22% of all smokers admitted to hospital abstinent from tobacco at 12 weeks, and exceptional cost-effectiveness with a public value return on investment ratio of GBP 30.49 per GBP 1 invested and a cost per QALY of GBP 487. There have been many challenges in implementing this service, underpinned by the system-wide culture change and ensuring the good communication and engagement of all stakeholders across the complex networks of the tobacco control and healthcare system. The delivery of hospital-based tobacco dependency services across all NHS acute care hospitals represents a substantial step forward in the fight against the tobacco epidemic.

Treatment of tobacco dependence in UK hospitals: an observational study

Over a million smokers are admitted to hospitals in the UK each year. The extent to which tobacco dependence is identified and addressed in this population is unclear. Data on 14,750 patients from 146 hospitals collected for the British Thoracic Society smoking cessation audit were analysed to determine smoking prevalence, attempts to ask smokers about quitting, and referrals to smoking cessation services. Associations with hospital organisational factors were assessed by logistic regression. Overall hospital smoking prevalence was 25%. Only 28% of smokers were asked whether they would like to quit, and only one in 13 smokers was referred for treatment of tobacco dependence. There was a higher chance of smokers being asked about quitting in organisations with smoke-free sites, dedicated smoking cessation practitioners, regular staff training, and availability of advanced pharmacotherapy. Treatment of tobacco dependence in smokers attending UK hospitals is poor and could be associated with organisational factors.

Thrombotic thrombocytopenic purpura in a patient with HIV from Zimbabwe

A woman in her 40s originally from Zimbabwe presented to our accident department in the UK with a 4 day history of menorrhagia and exertional chest pain. Her clinical examination was unremarkable. Routine blood tests revealed a haemoglobin value of 6.8 g/dl and a platelet count of 15×10(9)/l, with normal renal function and coagulation profile. Blood film showed microangiopathic haemolytic anaemia and thrombocytopenia. On direct questioning, she admitted to being HIV positive, and receiving antiviral therapy at another hospital. A diagnosis of HIV associated thrombotic thrombocytopenic purpura (TTP) was made. The patient was transferred to a tertiary centre for urgent plasma exchange. She required 8 days of 1.5 litre exchanges with solvent detergent fresh frozen plasma (FFP) and high dose steroids. She responded within 24 h with increasing haemoglobin and platelet counts, and at discharge her haemoglobin was 10.7 g/dl and platelet count 253×10(9)/l.

'The dark before the dawn': the 2021 British Thoracic Society Audit of the treatment of tobacco dependency in acute trusts

Smoking remains the single largest cause of preventable death, disability and health inequality. Smoking tobacco directly contributes to over 500 000 hospital admissions each year, making hospitals an important location to optimise treatment for tobacco dependency. The third British Thoracic Society Tobacco Dependency Audit was undertaken to determine how effectively national standards for treating tobacco-dependent smokers have been implemented and assess if any progress has been made from previous audits. Data on 14579 patients from 119 hospitals revealed 21% of patients were current smokers, 45% were offered very brief advice and 5% prescribed combination nicotine replacement therapy or varenicline. Only 9% completed a consultation with a specialist tobacco dependency practitioner during their inpatient stay and fewer than 1% of smokers were abstinent at 4 weeks following discharge. Clinical leadership of tobacco dependency services was deficient, and staff were ill equipped in supporting current smokers in their efforts to quit with only 50% of trusts offering regular smoking cessation training. There has been little meaningful improvement from previous audits and there remains woefully inadequate provision of tobacco dependency treatment for patients who smoke. The National Health Service (NHS) Long Term Plan has committed substantial, new funding to the NHS to ensure every patient that smokes admitted to hospital will be offered evidence-based support and treatment for tobacco dependency. The findings of this audit highlight the urgency with which this programme must be implemented to tackle the greatest cause of premature death in the UK and to achieve the wider well-recognised benefits for the healthcare system.

Successful outcome of accidental ethylene glycol poisoning despite delayed presentation

A 69-year-old man presented to the emergency department after being found unconscious by his son. He had experienced headache the previous day but had been otherwise well. Investigations revealed a severe metabolic acidosis, raised lactate and acute kidney injury. The calculated anion and osmolar gap were both elevated at 37.7 and 39.3, respectively. Due to his reduced Glasgow coma score (GCS) he was intubated and a CT scan performed: only a small, mature pontine infarct was found of uncertain significance. Further questioning of the family revealed accidental ingestion of 150 ml of a 'blue liquid' 24 h earlier (later identified as car screenwash). With ethylene glycol (EG) poisoning suspected, he was given intravenous ethanol, fomepizole (a competitive inhibitor of alcohol dehydrogenase) and haemofiltration. Despite the delayed presentation, prompt recognition and treatment of EG poisoning led to a successful discharge in this case.

Low-dose CT for lung cancer screening in a high-risk population (SUMMIT): a prospective, longitudinal cohort study

BACKGROUND

Low-dose CT screening reduces lung cancer mortality. In advance of planned national lung cancer screening programmes, research is needed to inform policies regarding implementation. We aimed to assess the implementation of low-dose CT for lung cancer screening in a high-risk population and to validate a multicancer early detection blood test.

METHODS

In this prospective, longitudinal cohort study, individuals aged 55-77 years recorded as current smokers in their primary care records at any point within the past 20 years were identified from 329 primary care practices in London (UK) and invited for a lung health check via postal letter. Individuals meeting the 2013 United States Preventive Services Taskforce criteria (current or former smokers within the past 15 years with at least 30 pack-year smoking histories) or having a Prostate, Lung, Colorectal and Ovarian 2012 model 6-year risk of 1·3% or greater, and not currently receiving treatment for an active cancer (except adjuvant hormonal therapy), were eligible for the study. These individuals underwent lung cancer screening via non-contrast, thin collimation low-dose CT. In this analysis, we report the results of the baseline round of low-dose CT screening. Key primary endpoints were those associated with examining the performance of a lung cancer screening service. Outcome measures were analysed on a per-participant level using descriptive frequencies. The study was registered with ClinicalTrials.gov, NCT03934866.

FINDINGS

Between April 8, 2019, and May 14, 2021, 12 773 participants were recruited and analysed. 7353 (57·6%) of 12 773 participants were male and 5420 (42·4%) were female, and 10 665 (83·5%) participants were White. 261 (2·0%) of 12 773 participants were diagnosed with lung cancer (including 163 [1·3%] participants with screen-detected lung cancer and 98 [0·8%] with delayed screen-detected lung cancer [ie, after a 3-month or 6-month nodule follow-up CT]) and 276 (2·2%) participants were diagnosed with any intrathoracic malignancy after a positive baseline screen. 207 (79·3%) of 261 individuals with prevalent screen-detected lung cancer were diagnosed at stage I or II and surgical resection was the primary treatment modality in 201 (77·0%) of 261 individuals. Including cases where multiple resections were done in the same participant (eg, for synchronous primaries), 28 (11·6%) of 241 surgical resections were benign, and there was one (0·4%) death within 90 days of surgery. At 12 months, the episode sensitivity of our low-dose CT screening protocol for detecting lung cancer was 97·0% (95% CI 95·0-99·1; 261 of 269 participants). The specificity was 95·2% (94·8-95·6; 11 905 of 12 504 participants), with a false-positive rate of 4·8% (4·4-5·2).

INTERPRETATION

Large-scale lung cancer screening is effective and can be delivered efficiently to an ethnically and socioeconomically diverse population.

FUNDING

GRAIL.