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Kuut TA, Müller F, Csorba I, Braamse A, Aldenkamp A, Appelman B, Assmann-Schuilwerve E, Geerlings SE, Gibney KB, Kanaan RAA, Mooij-Kalverda K, Hartman TCO, Pauëlsen D, Prins M, Slieker K, van Vugt M, Keijmel SP, Nieuwkerk P, Rovers CP, Knoop H. Efficacy of Cognitive-Behavioral Therapy Targeting Severe Fatigue Following Coronavirus Disease 2019: Results of a Randomized Controlled Trial. Clin Infect Dis 2023; 77:687-695. [PMID: 37155736 PMCID: PMC10495128 DOI: 10.1093/cid/ciad257] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/19/2023] [Accepted: 04/22/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Severe fatigue following coronavirus disease 2019 (COVID-19) is prevalent and debilitating. This study investigated the efficacy of cognitive-behavioral therapy (CBT) for severe fatigue following COVID-19. METHODS A multicenter, 2-arm randomized controlled trial was conducted in the Netherlands with patients being severely fatigued 3-12 months following COVID-19. Patients (N = 114) were randomly assigned (1:1) to CBT or care as usual (CAU). CBT, targeting perpetuating factors of fatigue, was provided for 17 weeks. The primary outcome was the overall mean difference between CBT and CAU on the fatigue severity subscale of the Checklist Individual Strength, directly post-CBT or CAU (T1), and after 6 months (T2). Secondary outcomes were differences in proportions of patients meeting criteria for severe and/or chronic fatigue, differences in physical and social functioning, somatic symptoms, and problems concentrating between CBT and CAU. RESULTS Patients were mainly nonhospitalized and self-referred. Patients who received CBT were significantly less severely fatigued across follow-up assessments than patients receiving CAU (-8.8 [95% confidence interval {CI}, -11.9 to -5.8]); P < .001), representing a medium Cohen's d effect size (0.69). The between-group difference in fatigue severity was present at T1 (-9.3 [95% CI, -13.3 to -5.3]) and T2 (-8.4 [95% CI, -13.1 to -3.7]). All secondary outcomes favored CBT. Eight adverse events were recorded during CBT, and 20 during CAU. No serious adverse events were recorded. CONCLUSIONS Among patients, who were mainly nonhospitalized and self-referred, CBT was effective in reducing fatigue. The positive effect was sustained at 6-month follow-up. CLINICAL TRIALS REGISTRATION Netherlands Trial Register NL8947.
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Affiliation(s)
- Tanja A Kuut
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Fabiola Müller
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Irene Csorba
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Annemarie Braamse
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arnoud Aldenkamp
- Department of Lung Medicine, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Suzanne E Geerlings
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Institute for Infection and immunity, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Katherine B Gibney
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, 3000 Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, 3000 Victoria, Australia
| | - Richard A A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, 3084 Victoria, Australia
| | - Kirsten Mooij-Kalverda
- Department of Pulmonology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud Institute for Health Sciences, 6500 HB Nijmegen, The Netherlands
| | - Dominique Pauëlsen
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Maria Prins
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Institute for Infection and immunity, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Infectious Diseases, Public Health Service of Amsterdam, 1018 WT Amsterdam, The Netherlands
| | - Kitty Slieker
- Department of Internal Medicine, Bernhoven Hospital, 5406 PT Uden, The Netherlands
| | - Michele van Vugt
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Institute for Infection and immunity, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Stephan P Keijmel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Pythia Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Institute for Infection and immunity, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Chantal P Rovers
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Hans Knoop
- Department of Medical Psychology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Guo L, Appelman B, Mooij-Kalverda K, Houtkooper RH, van Weeghel M, Vaz FM, Dijkhuis A, Dekker T, Smids BS, Duitman JW, Bugiani M, Brinkman P, Sikkens JJ, Lavell HAA, Wüst RCI, van Vugt M, Lutter R. Prolonged indoleamine 2,3-dioxygenase-2 activity and associated cellular stress in post-acute sequelae of SARS-CoV-2 infection. EBioMedicine 2023; 94:104729. [PMID: 37506544 PMCID: PMC10406961 DOI: 10.1016/j.ebiom.2023.104729] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Post-acute sequela of SARS-CoV-2 infection (PASC) encompass fatigue, post-exertional malaise and cognitive problems. The abundant expression of the tryptophan-catabolizing enzyme indoleamine 2,3-dioxygenase-2 (IDO2) in fatal/severe COVID-19, led us to determine, in an exploratory observational study, whether IDO2 is expressed and active in PASC, and may correlate with pathophysiology. METHODS Plasma or serum, and peripheral blood mononuclear cells (PBMC) were obtained from well-characterized PASC patients and SARS-CoV-2-infected individuals without PASC. We assessed tryptophan and its degradation products by UPLC-MS/MS. IDO2 activity, its potential consequences, and the involvement of the aryl hydrocarbon receptor (AHR) in IDO2 expression were determined in PBMC from another PASC cohort by immunohistochemistry (IHC) for IDO2, IDO1, AHR, kynurenine metabolites, autophagy, and apoptosis. These PBMC were also analyzed by metabolomics and for mitochondrial functioning by respirometry. IHC was also performed on autopsy brain material from two PASC patients. FINDINGS IDO2 is expressed and active in PBMC from PASC patients, as well as in brain tissue, long after SARS-CoV-2 infection. This is paralleled by autophagy, and in blood cells by reduced mitochondrial functioning, reduced intracellular levels of amino acids and Krebs cycle-related compounds. IDO2 expression and activity is triggered by SARS-CoV-2-infection, but the severity of SARS-CoV-2-induced pathology appears related to the generated specific kynurenine metabolites. Ex vivo, IDO2 expression and autophagy can be halted by an AHR antagonist. INTERPRETATION SARS-CoV-2 infection triggers long-lasting IDO2 expression, which can be halted by an AHR antagonist. The specific kynurenine catabolites may relate to SARS-CoV-2-induced symptoms and pathology. FUNDING None.
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Affiliation(s)
- Lihui Guo
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Amsterdam Institute for Infection and Immunity, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Kirsten Mooij-Kalverda
- Department Pulmonary Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Riekelt H Houtkooper
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Institute, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Institute, Amsterdam, the Netherlands
| | - Michel van Weeghel
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Institute, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Institute, Amsterdam, the Netherlands; Core Facility Metabolomics, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Frédéric M Vaz
- Core Facility Metabolomics, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Inborn Errors of Metabolism, Amsterdam, the Netherlands
| | - Annemiek Dijkhuis
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Tamara Dekker
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Barbara S Smids
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jan Willem Duitman
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department Pulmonary Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Marianna Bugiani
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Brinkman
- Department Pulmonary Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jonne J Sikkens
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - H A Ayesha Lavell
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Rob C I Wüst
- Laboratory for Myology, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Michèle van Vugt
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - René Lutter
- Department Experimental Immunology, Amsterdam Infection and Immunity Center, Amsterdam University Medical Centers (UMC), location Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department Pulmonary Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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Crombag LMM, Mooij-Kalverda K, Szlubowski A, Gnass M, Tournoy KG, Sun J, Oki M, Ninaber MK, Steinfort DP, Jennings BR, Liberman M, Bilaceroglu S, Bonta PI, Korevaar DA, Trisolini R, Annema JT. EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial. Respirology 2021; 27:152-160. [PMID: 34792268 PMCID: PMC9299594 DOI: 10.1111/resp.14182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/15/2021] [Accepted: 10/12/2021] [Indexed: 12/17/2022]
Abstract
Background and objective Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head‐to‐head comparison of both routes has never been performed. Methods Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)‐B‐guided nodal sampling, and to 22‐ or 25‐G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow‐up at 6 months. Results A total of 358 patients were randomized: 185 patients to EBUS‐transbronchial needle aspiration (EBUS‐TBNA) and 173 to EUS‐B‐fine‐needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63–76) for EBUS‐TBNA and 68% (118/173; 95% CI, 61–75) for EUS‐B‐FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71–84) for EBUS‐TBNA and 82% (115/141; 95% CI, 74–87) for EUS‐B‐FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity. Conclusion Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS‐B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients. This global RCT in patients with suspected sarcoidosis stage I/II with an indication for endosonographic nodal sampling showed a similarly high granuloma detection rate and sensitivity for diagnosing sarcoidosis with endobronchial ultrasound versus endoscopic ultrasound‐B. The findings imply that both diagnostic tests (endobronchial/oesophageal) can be used safely and universally in suspected sarcoidosis patients.
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Affiliation(s)
- Laurence M M Crombag
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kirsten Mooij-Kalverda
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Maciej Gnass
- Endoscopy Unit, John Paul II Hospital, Kraków, Poland
| | - Kurt G Tournoy
- Department of Respiratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jiayuan Sun
- Department of Respiratory Endoscopy and Interventional Pulmonology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Masahide Oki
- Department of Respiratory Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Maarten K Ninaber
- Department of Respiratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel P Steinfort
- Department of Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Barton R Jennings
- Department of Respiratory Medicine, Monash Health, Clayton, Victoria, Australia
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, CR-CHUM, Montreal, Québec, Canada
| | - Semra Bilaceroglu
- Department of Respiratory Medicine, Health Sciences University, Izmir, Turkey.,Dr. Suat Seren Training and Research Hospital for Thoracic Medicine and Surgery, Yenişehir Mahallesi, Izmir, Turkey
| | - Peter I Bonta
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rocco Trisolini
- Interventional Pulmonology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jouke T Annema
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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