Long COVID and post-acute sequelae of SARS-CoV-2 pathogenesis and treatment: A Keystone Symposia report

In 2023, the Keystone Symposia held the first international scientific conference convening research leaders investigating the pathology of post-acute sequelae of COVID-19 (PASC) or Long COVID, a growing and urgent public health priority. In this report, we present insights from the talks and workshops presented during this meeting and highlight key themes regarding what researchers have discovered regarding the underlying biology of PASC and directions toward future treatment. Several themes have emerged in the biology, with inflammation and other immune alterations being the most common focus, potentially related to viral persistence, latent virus reactivation, and/or tissue damage and dysfunction, especially of the endothelium, nervous system, and mitochondria. In order to develop safe and effective treatments for people with PASC, critical next steps should focus on the replication of major findings regarding potential mechanisms, disentangling pathogenic mechanisms from downstream effects, development of cellular and animal models, mechanism-focused randomized, placebo-controlled trials, and closer collaboration between people with lived experience, scientists, and other stakeholders. Ultimately, by learning from other post-infectious syndromes, the knowledge gained may help not only those with PASC/Long COVID, but also those with other post-infectious syndromes.

Renal artery embolisation: indications and utilisation at Tygerberg Hospital

BACKGROUND

To evaluate the indications, efficacy and outcomes of endovascular renal artery embolisation (RAE) in the management of renal haemorrhage, specifically in cases of non-iatrogenic origin.

METHOD

This is a retrospective case note review of 92 patients who underwent RAE in the period from August 1999 to August 2014 at Tygerberg Hospital.

RESULTS

Renal artery embolisation was performed in a total of 92 patients. The indication was traumatic renal injury in 60 patients (65.2%), with mean age 28.2 years. The mechanism of injury was stabbing (55.4%), blunt trauma (7.6%) and gunshot (2.2%). Digital subtraction angiography (DSA) showed pseudo-aneurysm in 32.6%, arteriovenous fistula in 19.6% and segmental artery injury in 13%. Embolisation success: 85% after one, 88.9% after a second attempt, with an overall success rate of 98.3% after two attempts. In 20 of the 92 patients (mean age 50.2 years) the indication was malignancy (21.7%). Other cases included iatrogenic haematuria (4.3%) and angiomyolipoma (3.3%). Embolisation was repeated in 16.3%, with eventual success rate of 93.8%. Post-embolisation syndrome was the most common complication, seen in 9.8% of all cases. Of the 9 patients who returned for follow-up with renogram imaging, 4 had a differential function of > 20% of the embolised kidney.

CONCLUSION

Renal artery embolisation remains a very successful method of managing renal haemorrhage at this hospital, whether this results from trauma, malignancy, iatrogenic or other causes.

P5-23-03: Breast Cancer in Elderly Treatment Algorithm – A New Approach To Optimize the Management of Breast Cancer in Older Patients

Background: Elderly patients have been receiving a sub-standard treatment for early breast cancer when compared to younger age group patients. A higher percentage of them are being treated with primary endocrine therapy (PET) based on the premise that they may not survive surgery or live long enough to benefit from it. In clinical practice, however, there is no validated assessment in place to assess their surgical risk or estimate their life expectancy. This study aimed to optimize the treatment of early breast cancer in older patients using comprehensive geriatric assessment (CGA). It tested the hypothesis that CGA could be used to predict 2-year survival in older breast cancer patients. Based on that a treatment algorithm was devised which could be used to recommend whether PET or surgery plus endocrine treatment would be best indicated in individual patients. Methods: The study included women >70 years of age with early breast cancer, seen in a dedicated Leicester clinic between 04/2005 and 04/2007. All patients had comprehensive assessment including documentation of co-morbidities, Mini-mental state examination (MMSe), Geriatric depression score (GDS), Activities of daily living (ADL), Instrumental activities of daily living (IADL) and American society of anesthesiologist score (ASA). Analysis was performed to find components of the CGA that were helpful in predicting 2-year survival in these patients.

Results: 123 patients were included; age range was 70–94 (median-82). Twenty-two patients died within 2-years. Logistic regression analysis found MMSe, ADL, and ASA score to have an independent association with 2-year survival. A statistically significant correlation (p-value 0.000) was found between the dichotomized combined-score of these components and 2-year survival. Breast Cancer in Elderly Treatment Algorithm (BCETA) was devised using the scores of these three components. Patients who scored one or higher (high-risk group), were found to have <48% two-year survival; those, who scored zero (low-risk group), have >86% chance of two-year survival. The overall accuracy for the algorithm was 81%.

Conclusion: Breast Cancer in Elderly Treatment Algorithm is a new and systematic approach to optimize the management of breast cancer in elderly patients. It is helpful in identifying high-risk patients with expected short-survival who may benefit from PET, if their cancer is hormone receptor positive. Patients with predicted longer life expectancy (low-risk) may be recommended standard treatment. A prospective study is ongoing at Leicester research clinic to validate the results.

BREAST CANCER IN ELDERLY TREATMENT ALGORITHM

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COMPREHENSIVE GERIATRIC ASSESSMENT

Prediction of First Phase Formation at Au-METAL Interfaces Using the Effective Heat of Formation Model

The effective heat of formation model enables heats of formation to be calculated as a function of concentration. By choosing the effective concentration at the growth interface to be that of the liquidus minimum, the model correctly predicL. first phase formation for 14 binary systems for which experimental data was found, except for the Au-Cu system which does not have a well-defined minimum on the liquidus curve.

Prediction of Silicide First Phase and Phase Sequence from Heats of Formation

An effective heat of formation (δH') is formulated, enabling δH' to be calculated as a function of the concentration of metal and silicon available for interaction to form a silicide. A rule for first phase formation is proposed according to which, “The first silicide compound to form during metal-silicon interaction is the congruent phase with the most negative effective heat of formation at the concentration of the lowest eutectic temperature of the binary system.” The effective heat of formation concept is also extended to predict subsequent phase sequence.

Educational games for health professionals

BACKGROUND

The use of games as an educational strategy has the potential to improve health professionals' performance (e.g. adherence to standards of care) through improving their knowledge, skills and attitudes.

OBJECTIVES

The objective was to assess the effect of educational games on health professionals' performance, knowledge, skills, attitude and satisfaction, and on patient outcomes.

SEARCH STRATEGY

We used a comprehensive search strategy including an electronic search of the following databases: DARE, EPOC register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, ERIC, and Dissertation Abstracts Online (search date: January 2007). We also screened the reference list of included studies and relevant reviews, contact authors of relevant papers and reviews, and searched ISI Web of Science for papers citing studies included in the review

SELECTION CRITERIA

We included randomized controlled trials (RCT), controlled clinical trials (CCT), controlled before and after (CBA) and interrupted time-series analysis (ITS). Study participants were qualified health professionals or in postgraduate training. The intervention was an educational game with "a form of competitive activity or sport played according to rules".

DATA COLLECTION AND ANALYSIS

Using a standardized data form we extracted data on methodological quality, participants, interventions and outcomes of interest that included patient outcomes, professional behaviour (process of care outcomes), and professional's knowledge, skills, attitude and satisfaction.

MAIN RESULTS

The search strategy identified 1156 citations. Out of 55 potentially eligible citations, we included one RCT. The methodological quality was fair. The game, used as a reinforcement technique, was based on the television game show "Family Feud" and focused on infection control. The study did not assess any patient or process of care outcomes. The group that was randomized to the game had statistically higher scores on the knowledge test (P = 0.02).

AUTHORS' CONCLUSIONS

The findings of this systematic review do not confirm nor refute the utility of games as a teaching strategy for health professionals. There is a need for additional high-quality research to explore the impact of educational games on patient and performance outcomes.

Shanxi Province Cervical Cancer Screening Study: a cross-sectional comparative trial of multiple techniques to detect cervical neoplasia

OBJECTIVE

The aim of this study was to design a cervical cancer screening algorithm for the developing world that is highly sensitive for cervical intraepithelial neoplasia (CIN) II, III, and cancer and highly specific for CIN II and III, making it possible to ablate the transformation zone without histologic confirmation.

METHODS

In rural Shanxi Province, China, we examined 1997 women ages 35-45. Each subject underwent a self-test for intermediate and high-risk HPV (by HC-II assay), fluorescence spectroscopy, a liquid-based Pap (read manually and by computer and used as a direct test for HPV), a visual inspection (VIA) diagnosis, and colposcopy with multiple cervical biopsies.

RESULTS

Mean age was 39.1 +/- 3.16 years, mean number of births was 2.6 +/- 0.93. Based on tests administered, 4.3% subjects had > or =CIN II. All subjects with > or =CIN II had either a ThinPrep Pap (> or =ASCUS) or a positive HPV direct test. The sensitivity and specificity for the detection of > or =CIN II were, respectively, 83 and 86% for the HPV self-test, 95 and 85% for the HPV direct test, 94 and 78% for the ThinPrep Pap (> or =ASCUS), 77 and 98% for the ThinPrep Pap (> or =HGSIL), 94 and 9% for fluorescence spectroscopy, 71 and 74% for VIA, and 81 and 77% for colposcopy.

CONCLUSION

Based on these data and the existing healthcare infrastructure in China, we believe that further refinement of primary HPV screening using centralized labs is indicated. Self-testing in the local villages may be effective with improvements in the devices and techniques.

Prevalence of cervical cancer and feasibility of screening in rural China: a pilot study for the Shanxi Province Cervical Cancer Screening Study

For cervical cancer screening to be feasible in developing countries, it must be accurate, inexpensive, and easy to administer. We conducted a pilot study in rural Shanxi Province, People's Republic of China, to determine disease prevalence and study feasibility in preparation for a large-scale comparative trial of 6 screening tests. One-hundred and thirty-six nonpregnant women with no history of hysterectomy, pelvic radiation, or Papanicolaou tests were screened in a rural clinic. Ten percent of the women enrolled reported abnormal vaginal bleeding and 45% reported abnormal vaginal discharge. The tests were the Papanicolaou test (both conventional and ThinPrep), a self-administered swab test by Hybrid Capture II for high-risk human papillomavirus (HPV), a test for high-risk HPV from residual PreservCyt medium, fluorescence spectroscopy, and visual inspection of the cervix by a clinician. All women also underwent colposcopy and biopsies as the reference standard. Biopsies showed 12 of 136 women had >/= high-grade squamous intraepithelial lesions (HGSIL). Screening was completed in 5 half-day sessions, the procedures went smoothly, and local cooperation was enthusiastic. Disease prevalence in Xiangyuan and Yangcheng Counties, Shanxi Province, can be estimated at 8.8% (95% CI, 4.5% to 15.0%). Screening 1000-2000 patients would be sufficient to detect a 10% difference in accuracy between diagnostic tests. The proposed large-scale trial is feasible.

Cervical and vaginal cytologic smears suggestive of adenocarcinoma

OBJECTIVE

To determine the appropriate evaluation of women with cervical cytologic smears suggestive of adenocareinoma.

STUDY DESIGN

Of 1,192,972 smears obtained between July 1989 and March 1992, 57 (0.005%) were interpreted as adenocarcinoma, adenocarcinoma in situ or "rule out" adenocarcinoma. Review of medical records allowed the determination of pathologic diagnoses in 46 of 57 women. Thirty of the 46 cytologic smears were reviewed.

RESULTS

Fifteen of the 46 women were premenopausal and < 50 years of age. Twenty-three were asymptomatic, 22 had abnormal vaginal bleeding, and 1 had increasing abdominal girth. Twenty-nine (63%) of the 46 women had cancer, 12 (26%) had cervical intraepithelial neoplasia 2 (CIN 2) or 3, and 5 (11%) had CIN 1, condyloma or no pathology. Of the 29 women with cancer, 11 had cervical cancer, 1 had vaginal cancer, 13 had uterine cancer, and 4 had extrauterine cancer. Nineteen of 22 women (86%) with abnormal vaginal bleeding had cancer; 9 of 23 asymptomatic women had cancer (39%) (chi 2 = 9.84, P < .01).

DISCUSSION

Women with smears suggestive of adenocarcinoma require biopsy of cervical or vaginal masses, colposcopy with directed biopsy, endocervical curettage and endometrial biopsy. If cancer is not diagnosed, cervical conization with dilatation and curettage (D&C) is indicated. If conization with D&C is negative, laparoscopy is indicated to exclude extrauterine cancer.

Presentation of cervical cancer

To determine how patients with invasive cervical cancer present and whether presentation affects disease-free survival (DFS), a review of 81 patients treated for cervical cancer by the Division of Gynecologic Oncology and Pelvic Surgery at the Southern California Permanente Medical Group between January 1, 1986, and December 31, 1986, was performed. Fifty-six percent of patients presented with abnormal vaginal bleeding, twenty-eight percent presented with abnormal Papanicolaou (Pap) smears, nine percent presented with pain, four percent presented with vaginal discharge, and four percent presented with other symptoms. Follow-up was 24 to 41 months. Patients presenting with abnormal Pap smears had DFS of 96%. Those presenting with abnormal vaginal bleeding had DFS of 51% and those presenting with pain had DFS of 29%. Presentation strongly influences DFS (chi 2 = 16.8, P less than 0.001). Of women presenting with abnormal Pap smears, 87% were Stage I and 13% were Stage II. Of women presenting with other than abnormal Pap smears, 40% were Stage I, 34% were Stage II, and 26% were Stage III or IV. Presentation with abnormal Pap smear and stage are significantly related (chi 2 = 14.8, P less than 0.001). Of women presenting with abnormal Pap smears, 89% had cancers 0 to 2 cm, 5% had cancers 2.1 to 4 cm, and 5% had cancers greater than 4 cm in diameter. Of women presenting with other than abnormal Pap smears, 21% had cancers 0 to 2 cm, 26% had cancers 2.1 to 4 cm, and 53% had cancers greater than 4 cm in diameter. Presentation with abnormal Pap smear is significantly associated with tumor size (chi 2 = 25.4, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)