Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design

IMPORTANCE

SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis.

METHODS

RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms.

DISCUSSION

RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.

REGISTRATION

NCT05172024.

An examination of housing interventions among youth experiencing homelessness: an investigation into racial/ethnic and sexual minority status

OBJECTIVES

The purpose of this study is to explore main and interaction effects of minority and multiple minority statuses on exits from homelessness and the stability of homelessness exits overtime.

METHODS

This study utilized the Homeless Management Information System administrative data of 10 922 youth experiencing homelessness collected from a convenience sample of 16 geographically diverse communities across the USA between 2015-17. Using multinomial logistic regression analyses and logistic regression, main effects and interaction effects of racial/ethnic minority identity and sexual/gender minority identity were examined on various homelessness exits (n = 9957) and housing sustainability (n = 5836).

RESULTS

Black youth, relative to White youth, were disproportionately exiting homelessness through incarceration (P < 0.001). Black and Latinx youth were less likely to successfully self-resolve their homelessness (both P < 0.05). Black heterosexual and Black and Latinx non-heterosexual youth were most frequently lost to the homeless system (all P < 0.01). Black youth, relative to White youth, were approximately half as likely to remain stably housed after returning to family (P < 0.01).

CONCLUSIONS

With respect to housing exits and exit stability, Black and Latinx heterosexual youth are consistently at a disadvantage. Homelessness/housing systems and programs need to conduct a deeper investigation into how they implement and develop equitable outreach and engagement practices.

Acupoint stimulation improves pain and quality of life in head and neck cancer patients with chemoradiotherapy: a randomized controlled trial

Objective

This study aimed to evaluate the effect of acupoint stimulation on pain, negative moods, and quality of life for head and neck cancer (HNC) patients who underwent concurrent chemoradiotherapy (CCRT).

Methods

This randomized controlled trial recruited participants from a medical center and randomly assigned using a permuted block randomization list with computer-generated random serial numbers into the AcuCare group (n ​= ​46) receiving acupoint stimulation with transcutaneous acupoint electrical stimulation (TAES) and auricular acupressure (AA) or the control group (n ​= ​46) without any acupoint stimulation. Outcomes were repeatedly assessed pain intensity using the visual analogue scale, negative moods using the hospital anxiety and depression scale, and quality of life (QoL) using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire—Head and Neck 35.

Results

After adjusting varying mucositis grades and time-dependent growth effects, the generalized estimating equations showed a significantly increase in pain intensity at weeks 1, 2, 3, and 6 (P ​< ​0.05), but not in negative moods (P ​> ​0.05), compared to baseline and control group. Analysis of covariance showed a significant group-difference in the senses problems of QoL (F ​= ​7.33, P ​= ​0.01) at Week 6.

Conclusions

This study supports that acupoint stimulation could effectively reduce pain and improve senses problem of QoL for patients with HNC.

Trial registration

This study was registered at https://clinicaltrials.gov/NCT03640195.

Pharmacology of AMG 181, a human anti-α4 β7 antibody that specifically alters trafficking of gut-homing T cells

BACKGROUND AND PURPOSE

AMG 181 is a human anti-α4 β7 antibody currently in phase 1 and 2 trials in subjects with inflammatory bowel diseases. AMG 181 specifically targets the α4 β7 integrin heterodimer, blocking its interaction with mucosal addressin cell adhesion molecule-1 (MAdCAM-1), the principal ligand that mediates α4 β7 T cell gut-homing.

EXPERIMENTAL APPROACH

We studied the in vitro pharmacology of AMG 181, and the pharmacokinetics and pharmacodynamics of AMG 181 after single or weekly i.v. or s.c. administration in cynomolgus monkeys for up to 13 weeks.

KEY RESULTS

AMG 181 bound to α4 β7 , but not α4 β1 or αE β7 , and potently inhibited α4 β7 binding to MAdCAM-1 (but not vascular cell adhesion molecule-1) and thus inhibited T cell adhesion. Following single i.v. administration, AMG 181 Cmax was dose proportional from 0.01 to 80 mg·kg(-1) , while AUC increased more than dose proportionally. Following s.c. administration, dose-proportional exposure was observed with single dose ranging from 5 to 80 mg·kg(-1) and after 13 weekly doses at levels between 20 and 80 mg·kg(-1) . AMG 181 accumulated two- to threefold after 13 weekly 80 mg·kg(-1) i.v. or s.c. doses. AMG 181 had an s.c. bioavailability of 80%. The linear elimination half-life was 12 days, with a volume of distribution close to the intravascular plasma space. The mean trend for the magnitude and duration of AMG 181 exposure, immunogenicity, α4 β7 receptor occupancy and elevation in gut-homing CD4+ central memory T cell count displayed apparent correlations.

CONCLUSIONS AND IMPLICATIONS

AMG 181 has in vitro pharmacology, and pharmacokinetic/pharmacodynamic and safety characteristics in cynomolgus monkeys that are suitable for further investigation in humans.

Mutations of p53 gene in hepatocellular-carcinoma (hcc) correlate with tumor progression and patient prognosis - a study of 138 patients with unifocal hcc

The mutation spectrum of p53 gene and its biological significance were studied in 138 patients with unifocal primary hepatocellular carcinoma (HCC) in Taiwan. The p53 mutations were detected in 51 cases (37%); 36 (71%) were missense mutations. The others (29%) included mutations at the intron-exon junctions (5 cases), deletion or insertion (4 cases), nonsense mutations (4 cases), and silent mutations (2 cases). The mutation sites were scattered from exons 4 to 10, predominantly (75%) in exons 5, 7, and 8. Of these mutations, 72% were transversions, mostly G:C --> T:A change (46%); while only 28% were transitions. Mutation occurred at codon 249 only in 14 cases (10%), but accounted for 27% of the mutations. The p53 mutations correlated with allele loss of p53 locus (52% vs 17% p<0.02), alpha-fetoprotein elevation (45% vs 28%, p<0.04), and poorly differentiated HCC (46% vs 10%, p<0.0001). The p53 mutation rate was two times higher in large than in small HCC (48% vs 26%, p<0.008), and in more advanced tumor (stage 3 vs stages 1 and 2: 49% vs 21%, p<0.0007). HCC patients with mutated p53 gene had a worse outcome (5-year survival; 18% vs 38%, p<0.008). We conclude that p53 gene mutation is common in advanced HCC, occurs as a late event in HCC growth, correlates with tumor progression and aggression, and is a useful molecular prognostic parameter of HCC. The p53 mutation patterns did not correlate with HBV or HCV infection. The frequency of p53 mutations did not differ between Taiwanese patients and mainland Chinese in Taiwan. However, mutation at codon 249 was more common in Taiwanese patients (p<0.05), while mutations of other types more frequent in the mainlanders (p<0.03). Hence endogenous and exogenous factors other than aflatoxin may also play a role in p53 mutation in HCC.

The tale of TL1A in inflammation

TL1A (also known as TNFSF15) is a tumor necrosis factor (TNF) family member expressed by monocytes, macrophages, dendritic cells (DCs), synovial fibroblasts, and endothelial cells in response to stimulation by cytokines, immune complexes, and microorganisms. Its cell surface receptor, DR3 (also known as TNFSF25, WSL-1, TRAMP, and LARD), is mainly expressed by T cells.

Monoclonal antibodies to B and T lymphocyte attenuator (BTLA) have no effect on in vitro B cell proliferation and act to inhibit in vitro T cell proliferation when presented in a cis, but not trans, format relative to the activating stimulus

B and T lymphocyte attenuator (BTLA) is an immunoglobulin superfamily member surface protein expressed on B and T cells. Its ligand, herpesvirus entry mediator (HVEM), is believed to act as a monomeric agonist that signals via the CRD1 of HVEM to inhibit lymphocyte activation: HVEM is also the receptor for lymphotoxin-α and LIGHT, which both bind in the CRD2 and CRD3 domains of the HVEM molecule, and for CD160 which competes with BTLA. We have shown that recombinant HVEM and a panel of different monoclonal antibodies specifically bind murine BTLA on both B and T cells and that some antibodies inhibit anti-CD3ε-induced T cell proliferation in vitro, but only when constrained appropriately with a putatively cross-linking reagent. The antibodies had no significant effect on in vitro T cell proliferation in a mixed lymphocyte reaction (MLR) assay nor on in vitro DO11.10 antigen-induced T cell proliferation. None of these antibodies, nor HVEM-Fc, had any significant effect on in vitro B cell proliferation induced by anti-immunoglobulin M antibodies (±anti-CD40) or lipopolysaccharide. We further elucidated the requirements for inhibition of in vitro T cell proliferation using a beads-based system to demonstrate that the antibodies that inhibited T cell proliferation in vitro were required to be presented to the T cell in a cis, and not trans, format relative to the anti-CD3ε stimulus. We also found that antibodies that inhibited T cell proliferation in vitro had no significant effect on the antibody captured interleukin-2 associated with the in vivo activation of DO11.10 T cells transferred to syngeneic recipient BALB/c mice. These data suggest that there may be specific structural requirements for the BTLA molecule to exert its effect on lymphocyte activation and proliferation.

A prediction model for type 2 diabetes risk among Chinese people

AIMS/HYPOTHESIS

A range of prediction rules for the onset of type 2 diabetes have been proposed. However, most studies have been conducted in white groups and it is not clear whether these models apply to Asian populations. The purpose of this study was to construct a simple points model for predicting incident diabetes among Chinese people.

METHODS

We estimated the 10 year risk of diabetes in a cohort study of middle-aged and elderly participants who were free from diabetes at baseline. Cox regression coefficients were used to construct the simple points model and the discriminatory ability of the resulting prediction rule was determined using AUC and net reclassification improvement and integrated discrimination improvement statistics. Fivefold random splitting was used to test the internal validity and obtain bootstrap estimates of the AUC.

RESULTS

Of the 2,960 participants without diabetes at the baseline examination, 548 developed type 2 diabetes during a median 10 year follow-up period. Age (four points), elevated fasting glucose (11 points), body mass index (eight points), triacylglycerol (five points), white blood cell count (four points) and a higher HDL-cholesterol (negative four points) were found to strongly predict diabetes incidence in a multivariate model. The estimated AUC for the model was 0.702 (95% CI 0.676-0.727). This model performed better than existing prediction models developed in other populations, including the Prospective Cardiovascular Münster, Cambridge, San Antonia and Framingham models for diabetes risk.

CONCLUSIONS/INTERPRETATION

We have constructed a model for predicting the 10 year incidence of diabetes in Chinese people that could be useful for identifying individuals at high risk of diabetes in the Chinese population.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0-5mm (mean 2.3mm). The intraoperative mouth opening was 12-20mm (mean 16 mm) after submucous release, and 32-42 mm (mean 35.5mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8-9 cm in length and 2-2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18-38 mm (mean 28.2mm) after a mean of 21 months' follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.

Promoter methylation and protein expression of the Slit2 and Robo1 genes in resected esophageal squamous cell carcinoma

10032

Background: Recent epigenetic studies suggest that the slit-robo pathway is involved in tumorigenesis of a number of human cancers and a role of SLIT2 as a tumor suppressor gene. In view of lack of epigenetic studies of SLIT2 and ROBO1 genes in squamous cell esophageal carcinoma (ESCC), we investigate whether promoter methylation is responsible for aberrant protien expression of SLIT2 and ROBO1 and whether promoter methylation and aberrant protein expression of these two genes are related to prognosis after resection for ESCC. Methods: We analyzed promoter methylation of SLIT2 and ROBO1 using methylation-specific polymerase chain reaction (MSP) and their protein expression using immunohistochemistry in 60 resected tumor specimens. The Pearson χ2 test was used to compare promoter methylation and protein expression of SLIT2 and ROBO1 among patients with different clinicopathological parameters. Concordance analysis was performed between promoter methylation and protein expression of these two genes. Results: Promoter methylation of SLIT2 and ROBO1 was observed in 43 (71.6%) and 16 (26.6%) of the 60 resected specimens, respectively (P = 0.002). Aberrant protein expression of SLIT2 and ROBO1 was observed in 51 (85%) and 23 (38.3%), respectively (P < 0.001). Promoter methylation of SLIT2 correlated well with smoking (P = 0.046), betel nut chewing (P = 0.032), staging (P = 0.018) and tumor (T) factor (P < 0.001) of the TNM system and its aberrant protein expression correlated well with betel nut chewing (P = 0.038), staging (P = 0.025) and nodal (N) involvement (P = 0.004). Promoter methylation and protein expression of ROBO1 did not correlate with any of these clinicopathologic parameters. A concordance rate of 88.2% and 74.2% was present between expression of SLIT2 and ROBO1 protein and their promoter methylation (P < 0.001) and (P = 0.004), respectively. Conclusions: Aberrant expression of SLIT2 and ROBO1 protein is frequently associated with the presence of ESCC, with SLIT2 a more predominant one. Promoter methylation is one of the major mechanisms responsible for aberrant protein expression of these two genes in resected ESCC. Promoter methylation and aberrant protein expression of SLIT2 may predict prognosis after resection for ESCC.

No significant financial relationships to disclose.

Patient attitude and survival in advanced non-small cell lung cancer (NSCLC): Results of a prospective observational study

7148

Background: A physician’s ability to accurately identify a patient’s attitude toward treatment is critical. The primary objective of this study (B9E-AA-JHSH) was to evaluate patient attitudes as predictors of survival independently of currently known predictive variables, and secondarily, whether physician-assessed patient attitudes differed from patient-assessed attitudes. Methods: This was a non-interventional, prospective, observational study of patients from 19 countries of Asia, Central Eastern Europe, and Latin America. Eligible patients had stage IIIB/IV NSCLC not amenable to curative surgery/radiotherapy, gemcitabine and cis/carboplatin as part of treatment, and were chemonaive. Physicians and patients used a 7-item questionnaire to assign patient attitudes to 1 of 4 categories using a pre-defined algorithm: A = Cure; B = Maximum extension of survival with acceptance of high toxicity; C = Maximum extension of survival only if coupled with normal lifestyle; and D = Symptom relief. Enrolled patients were followed until 18 months from enrolment, death, or loss to follow up. Results: From Sept 2002 to Dec 2003, 1,985 patients were enrolled; the majority were male (73.4%), <70 yrs (83.9%), and had stage IV disease (79.2%), PS 0–1 (79.2%), and tumor-related symptoms (89.2%). Distribution of patient-assessed attitudes were A = 0%, B = 55%, C = 25%, and D = 20%. From category B-D, median survival (B = 14.6 months, C = 13.5, D = 12.5) and 1-year survival (B = 57.6%, C = 56.2%, D = 51.2%) both decreased but the differences were not statistically significant. Adjustment for known predictive variables eliminated this decreasing trend. Physician-assessed patient attitudes were lower than patient-assessed attitudes (p < .0001); however, the difference was less for patients with disease-related symptoms (p = .03). Conclusions: This is the largest analysis to date of patient attitudes when treated with gemcitabine and cis/carboplatin. Patient attitudes were not significant predictors of survival; however, physicians do underestimate patients’ desire for extended survival compared to symptom relief. Also, it was interesting to see a comparatively longer median and 1-year survival in routine practice compared to reports in clinical trial settings.

[Table: see text]