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.

BSHI/BTS guidance on crossmatching before deceased donor kidney transplantation

All UK H&I laboratories and transplant units operate under a single national kidney offering policy, but there have been variations in approach regarding when to undertake the pre‐transplant crossmatch test. In order to minimize cold ischaemia times for deceased donor kidney transplantation we sought to find ways to be able to report a crossmatch result as early as possible in the donation process. A panel of experts in transplant surgery, nephrology, specialist nursing in organ donation and H&I (all relevant UK laboratories represented) assessed evidence and opinion concerning five factors that relate to the effectiveness of the crossmatch process, as follows: when the result should be ready for reporting; what level of donor HLA typing is needed; crossmatch sample type and availability; fairness and equity; risks and patient safety. Guidelines aimed at improving practice based on these issues are presented, and we expect that following these will allow H&I laboratories to contribute to reducing CIT in deceased donor kidney transplantation.

Leaders promote attendance in sport and exercise sessions by fostering social identity

Sport and exercise participation exert a positive effect on numerous aspects of individuals' health. Although sport and exercise leaders have generally been observed to play a key role in shaping group members' behavior, our understanding of their impact on group members' attendance in sport and exercise sessions is limited. To address this, and building on promising findings in other domains, we examined the associations between perceptions of sport and exercise leaders' engagement in social identity leadership, group identification, and attendance. A sample of 583 participants from sports teams (n = 307) and exercise groups (n = 276) completed questionnaires measuring identity leadership, group identification, and attendance. Analyses demonstrated that perceptions of leader engagement in social identity leadership were positively associated with members' group identification, and that this in turn was positively associated with their attendance in either a sports group or an exercise group. Moreover, there was a significant indirect effect for perceptions of leader engagement in identity leadership on group members' attendance through their greater identification with these groups. Findings highlight the importance of considering the impact sport and exercise leaders have on group members' attendance and suggest that leaders who represent, advance, create, and embed a shared sense of identity (ie, a shared sense of "us") among attendees can promote participation in sport and exercise.

Is extended pelvic lymph node dissection for prostate cancer the only recommended option? A systematic over-view of the literature

OBJECTIVE

Pelvic lymph node dissection (PLND) is performed alongside radical prostatectomy as the most accurate method of staging prostate cancer. Yet the potential therapeutic benefits of lymphadenectomy are yet to be confirmed.

MATERIAL AND METHODS

A PubMed database search was performed to identify all papers comparing techniques for PLND or none. The primary outcome measure was long term oncological outcomes. Studies looking at men with clinically localized prostate cancer at the time of radical prostatectomy who received no adjuvant treatment were included. Previous reviews and single case reports were excluded. The subsequent available papers were then systematically reviewed.

RESULTS

Limited PLND provides no benefit in low risk prostate cancer and is unlikely to provide a therapeutic benefit in higher risk groups either when compared with no PLND. Extended PLND may provide some therapeutic benefit, particularly in patients with occult metastases; however, the evidence base for this is not particularly strong and may be down to statistical phenomena.

CONCLUSION

When performed in prostate cancer patients, PLND should be extended, as it is a more accurate staging tool and may provide therapeutic benefit to some patients. However, to properly assess this, randomised controlled studies need to be performed in this area.

Chronic periodontitis can affect the levels of potential oral cancer salivary mRNA biomarkers

BACKGROUND AND OBJECTIVE

More than 100 salivary constituents have been found to show levels significantly different in patients with oral squamous cell carcinoma (OSCC) from those found in healthy controls, and therefore have been suggested to be potential salivary biomarkers for OSCC detection. However, many of these potential OSCC salivary biomarkers are also involved in chronic inflammation, and whether the levels of these biomarkers could be affected by the presence of chronic periodontitis was not known. The objective of this pilot study was therefore to measure the levels of seven previously reported potential OSCC salivary mRNA biomarkers in patients with chronic periodontitis and compare them to levels found in patients with OSCC and healthy controls. The seven salivary mRNAs were interleukin (IL)-8, IL-1β, dual specificity phosphatase 1, H3 histone family 3A, ornithine decarboxylase antizyme 1, S100 calcium-binding protein P (S100P) and spermidine/spermine N1-acetyltransferase 1.

MATERIAL AND METHODS

Unstimulated whole saliva samples were collected from a total of 105 human subjects from the following four study groups: OSCC; CPNS (chronic periodontitis, moderate to severe degree, non-smokers); CPS (chronic periodontitis, moderate to severe degree, smokers); and healthy controls. Levels of each mRNA in patient groups (OSCC or chronic periodontitis) relative to the healthy controls were determined by a pre-amplification reverse transcription-quantitative polymerase chain reaction approach with nested gene-specific primers. Results were recorded and analyzed by the Bio-Rad CFX96 Real-Time System. Mean fold changes between each pair of patient vs. control groups were analyzed by the Mann-Whitney U-test with Bonferroni corrections.

RESULTS

Only S100P showed significantly higher levels in patients with OSCC compared to both patients with CPNS (p = 0.003) and CPS (p = 0.007). The difference in S100P levels between patients with OSCC and healthy controls was also marginally significant (p = 0.009). There was no significant difference in the levels of salivary IL-8, IL-1β and dual specificity phosphatase 1 mRNAs between patients with OSCC and patients with CPNS (p = 0.510, 0.058 and 0.078, respectively); no significant difference in levels of salivary ornithine decarboxylase antizyme 1 and spermine N1-acetyltransferase mRNAs between patients with OSCC and patients with CPS (p = 0.318 and 0.764, respectively); and no significant difference in levels of the H3 histone family 3A mRNA between patients with OSCC and either CPS (p = 0.449) or healthy controls (p = 0.107).

CONCLUSIONS

Salivary S100P mRNA could be a reliable biomarker for OSCC detection, regardless of the presence of chronic periodontitis. The presence of chronic periodontitis could significantly affect the levels of the other six mRNAs, and negatively influence reliability for using them as biomarkers for oral cancer detection.

Appraising the mitogenicity of insulin analogues relative to human insulin-response to: Weinstein D, Simon M, Yehezkel E, Laron Z, Werner H. Insulin analogues display IGF-I-like mitogenic and anti-apoptotic activity in cultured cancer cells. Diabetes Metab Res Rev 2009; 25(1): 41-9

Interest in mitogenic and potentially carcinogenic effects of insulin and insulin analogues has been renewed by several recent publications that have examined the relationship between cancer and insulin analogues. Actions mediated through the insulin-like growth factor-I receptor in a hyperinsulinaemic state have been implicated mechanistically. Both type 2 diabetes and endogenously elevated insulin-like growth factor-I have been epidemiologically linked to malignancies. Therefore, in vitro mitogenic effects and binding affinities of the various analogues have been analysed. A recent publication by Weinstein et al. studied the in vitro mitogenic and anti-apoptotic activities of insulin analogues, and their conclusion asserts that insulins glargine, detemir, and lispro displayed proliferative and anti-apoptotic effects in a number of malignant cell lines. However, their conclusions are not supported by the data which are not complete and lack clear statistical significance. This data should be interpreted cautiously in light of all other presently available scientific evidence. Prospective, randomized clinical trials will best address any direct relationship between insulin analogues and cancer. Until those studies are designed and completed, clinicians should consider the demonstrated strong benefit of glycaemic control in balance with any alleged risk.

Managing chronic headaches in the clinic

Chronic daily headache (CDH), which is often linked to a history of migraine, tension-type headache and the abuse of headache medications, and cluster headache are the best known of the chronic headaches. These headaches may not be well recognised or well treated in primary care. This article outlines the development of management algorithms for these headache subtypes, designed for use by the primary care physician with an interest in headache. Principles of care for chronic headaches include implementation of screening procedures, differential diagnosis, tailoring of management to the individual's needs, proactive follow-up and a team approach to care. These principles can be customised to the headache subtype by the selection of appropriate therapies. The optimal treatments for CDH include physical therapy to the neck if there is any stiffness there, withdrawal of abused medications and treatment of any subsequent withdrawal symptoms and headache prophylaxis, together with the provision of acute medications as rescue therapy. Optimal treatments for cluster headache include short- and long-term prophylaxis to prevent the headaches developing and acute medications for use as rescue. If treatment is ineffective, alternative medications can be provided at follow-up, with the possibility of referral for refractory patients.

Acetylcholinesterase promotes beta-amyloid plaques in cerebral cortex

Studies in vitro have suggested that acetylcholinesterase (AChE) may interact with beta-amyloid to promote deposition of amyloid plaques in the brain of patients with Alzheimer's disease. To test that hypothesis in vivo, we crossed Tg2576 mice, which express human amyloid precursor protein and develop plaques at 9 months, with transgenic mice expressing human AChE. The resulting F1 hybrids (FVB/N x [C57B6 x SJL/J]) expressed both transgenes in brain. By 6 months of age, their cerebral cortex showed authentic plaques that stained both by thioflavin S and by beta-amyloid 1-40 and 1-42 immunohistochemistry. The plaques also stained positively for other components including Cd11b, GFAP, and AChE. Plaque onset in the hybrids occurred 30-50% sooner than in the parental lines. Plaque numbers increased with age and plaques remained more numerous in the doubly transgenic animals at 9 and 12 months. Quantitative immunoassay via ELISA also showed an increase of total amyloid content in brain at 9-12 months. These histological and biochemical results support the conclusion that AChE may play a role in pathogenesis of Alzheimer's disease

New guidelines for the management of migraine in primary care

Despite repeated initiatives over the past decade, migraine remains under-recognised, under-diagnosed and under-treated in everyday clinical practice. The Migraine in Primary Care Advisors (MIPCA) group has produced new guidelines for migraine management to attempt to rectify this situation. MIPCA is a group of physicians, nurses, pharmacists and other healthcare professionals dedicated to the improvement of headache management in primary care, who have also worked closely with the Migraine Action Association (the UK patients' group) in the development of these guidelines. The principles of the new MIPCA guidelines are: To arrange specific consultations for headache. To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation. To utilise a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary. To institute a process of management that is individualised for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management. To prescribe only treatments that have objective evidence of favourable efficacy and tolerability. To utilise prospective follow-up procedures to monitor the success of treatment. To organise a team approach to headache management in primary care.

Usage of triptans among migraine patients: an audit in nine GP practices

A retrospective audit was carried out to investigate triptan usage over a period of one year among 360 adult patients with migraine in nine GP practices in the UK and the Republic of Ireland. Data from patient records were analysed, in conjunction with replies to a questionnaire about patients' perceptions of their migraine and its treatment. The majority of patients included in the audit were women (83%), and most patients (81%) were aged between 35 and 64 years. Most patients in the audit population (60%) were in the lowest band of triptan usage (1-36 tablets prescribed over 12 months); 7% had moderate usage (37-53 tablets). A minority of patients appeared to be taking triptans in higher quantities: about 15% of patients had been prescribed 54-94 triptan tablets over a year, 9% had received prescriptions for 95-149 tablets and 7% had received prescriptions for 150 or more tablets. These results indicated that some migraine patients were using triptans at higher than expected rates, and suggested that some patients might have been using their prescribed triptans inappropriately to treat a headache that they incorrectly perceived as migraine (e.g. chronic daily headache). Analyses were carried out to identify predictors of high usage. Predictors identified included the use of several other (non-triptan) medications to treat conditions other than migraine, one triptan dose being reported as sufficient to treat an attack, patient's perception of all headaches as migraine and lack of concern about taking too much medication. Patients identified as using triptans at a higher than expected rate can be called in for review of migraine diagnosis, identification of possible causes of any increased frequency of attacks, and investigation of suspected non-migrainous headaches, such as chronic daily headache and medication-induced headaches. For GPs, such actions would help achieve and maintain a high standard of care for their migraine patients, thus helping to contribute towards meeting the demands of the clinical governance agenda. Audit of triptan usage may also offer financial benefits for the practice, since helping patients to avoid the inappropriate use of triptans could lead to reductions in the overall costs of triptan prescribing within the practice. The high usage predictors could be developed into a checklist of potential indicators for GPs to identify patients who may become high users if prescribed triptans and who might require closer monitoring. We recommend that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Although triptans are generally safe and well tolerated, unnecessary use of any medication should be avoided.

Three annual reports outstanding

Attractive appearance, creativity and quality are the earmarks of this year's winning annual reports. Top awards go to The University of Texas M.D. Anderson Cancer Center, Houston; the New York City Health and Hospitals Corp.; and Swedish American Health System, Rockford, Ill.

American hospitals react to terrorist attacks with determination

In this timely special section, editor Tom Rees recounts some of the swift, supportive actions health care providers took in response to the Sept. 11 terrorist attacks on the World Trade Center and the Pentagon.

Reports packed full of information

All of our community hospital winners succeed with relatively low-cost presentations. New York Methodist Hospital, Brooklyn, N.Y. takes first place; Cape Fear Valley Health System, Fayetteville, N.C. second; and Saint Francis Medical Center, Girardeau, Mo., third.

Hospitals report on cancer centers

Woman's Hospital, Baton Rouge, La., is first-place winner among cancer centers. Holy Cross Hospital's Michael and Dianne Bienes Comprehensive Cancer Center, Ft. Lauderdale, Fla., is named second; and, Cardinal Health System's Ball Cancer Center, Muncie, Ind., third.

Hospital's redesigned Web site patient-friendly, comprehensive. Site one-of-a-kind in Twin Cities market area

North Memorial Medical Center, Robbinsdale, Minn., has opened a brightly redesigned Web site. It is patient-friendly and features a different approach to provide healthcare information called "care areas," which are organized by condition, such as heart care, cancer care and childbirth. This approach led to the the site being named North Memorial Online Care Center.

Cleveland Clinic Health System introduces unique new logo. Symbol signals best community hospitals' link to world-class care

The Cleveland Clinic has long been recognized worldwide in the healthcare industry. Now it's extending that brand to a network of northeast Ohio community hospitals linked under the name of Cleveland Clinic Health System. The system has its own unique logo, a symbol that signals the best community hospitals' link to world-class care.

Cleveland Clinic television series enhances branding in active market

"Medical Miracles" premiered April 26. It is an information-packed series of programs showcasing The Cleveland Clinic's advanced medical practices. The Cleveland Clinic teamed with local NBC-affiliate, WKYC to develop half-hour shows on topics including neuro-sciences, orthopedics, eye, heart, pediatrics and cancer. As of this writing, three of the half-hour shows already have aired. They will resume in September, October and November, following a summer break. The collaboration is a healthy prospect all the way around. For Cleveland Clinic, it provides highly credible visibility in a competitive marketplace. And, according to WKYC president and general manager, Brooke Spectorsky, " Medical news and information is a high priority among our viewers."

Louisiana hospital's wellness center popular for health maintenance. East Jefferson General focuses on those 50 and over

East Jefferson General Hospital in Metairie, La., conducted comprehensive research prior to developing its new Wellness Center. Newspaper, direct mail and internal publications advertising boosted interest, as did employees wearing "Ask Me About The Wellness Center" buttons. Through satellite sales offices in the hospital and at a local shopping mall, more than 900 people purchased memberships before the center opened, and now an average of 600 to 700 people visit the center daily.

Reality TV positions heart center as cardiac care leader

Saint Thomas Heart Institute, Nashville, Tenn., has a long history of successful cardiac care. More than 200,000 patients have been treated at Saint Thomas. Earlier this year the hospital launched a new branding campaign that features former patients who have bonded with the institution. These former patients were provided MiniDV video cameras to record their stories. The campaign has attracted considerable attention, including newspaper and TV news coverage.

Seattle hospital opens renovated children's dental clinic. Joins effort to promote children's oral health

The pediatric dental clinic at Seattle's Children's Hospital and Regional Medical Center is filled to capacity, so marketers can invest efforts in community outreach and educational projects.

"Ten best" new market icon for children's hospitals. Institutions promote designation internally, externally

Institutions took different approaches to the honor of being named among the 10 best pediatric hospitals in the country. The most universal response was to celebrate the honor with employees through parties, banners and internal newsletters. Local news coverage was most welcome, too.

A good communications plan can defuse crisis situations

Community Health Partners, Lorain, Ohio, met the challenge of two nurses' strikes with comprehensive internal communications and conscientious media monitoring.

Television documentaries lifting hospital, medical center profiles

The nation's hospitals and medical centers are enjoying the legacy of TV audiences' addiction to medical dramas. Cable television has met the challenge with documentary coverage of real live hospitals. The medium offers many benefits and few disadvantages for those marketing managers with the courage to welcome camera crews. Lynn Hopkins Cantwell is director of public relations and marketing for Children's National Medical Center, Washington, D.C., which was covered in a seven-instrument "Lifeline" documentary for the Discovery Channel. James G. Gosky is director of communications for The MetroHealth System, Cleveland, which was the subject of two installments of "Trauma: Life in th ER," produced for the Learning Channel. These marketing pros describe the myriad details they faced when their respective hospitals went "on camera." Among the key factors were good communications with all constituents, attention to detail, and follow-up.

M.D. Anderson Network newsletter builds bonds with patients, survivors

Network, the quarterly newsletter of The University of Texas M.D. Anderson Cancer Center, Houston, builds relationships. Created in 1985 to "empower cancer survivors in the effort to take back control of their lives," it proves its worth in a recent readership survey.

Examination of the validity of the Social Support Survey using confirmatory factor analysis

The Social Support Survey (SSS), validated by Richman, Rosenfeld, and Hardy (1993), is a multidimensional self-report measure of social support tested with student athletes. The SSS contains eight dimensions of support. For each dimension of support the same four questions are posed. The SSS could, therefore, be scored in two ways: (a) to derive a score for the support dimensions; (b) to derive a score for the questions posed across all eight support dimensions. Confirmatory factor analyses of the SSS on 416 university athletes revealed poor fits to models for both the eight support dimensions and the four questions across all eight dimensions. This problem was clarified by using a multitrait-multimethod model, which led to improved model fit but revealed that most of the SSS items were two-dimensional. Caution should, therefore, be exercised in using the SSS as a measure of multidimensional social support.

Regional health systems address many audiences. Baptist uses language of the bard

Regional health systems address many audiences. The winners in this category are: Baptist Health Systems of South Florida, Coral Gables, Fla., first place; Memorial Hospital & Health System of South Bend, South Bend, Ind., second place; and Orlando Regional Healthcare, Orlando, Fla., third place.

Top selections reflect multiple strength. M.D. Anderson celebrates achievements

Three Overall Award-winning annual reports were selected this year: University of Texas M.D. Anderson Cancer Center, Houston, first place; Legacy Health System, Portland, Ore., second place; and Shands HealthCare, Tampa, Fla., third place. These reports reflected the multiple strengths of all the entrants.

Carolinas HealthCare attends to patients, amenities; builds business

Carolinas HealthCare System has grown into a nearly two billion dollar entity by focusing on patient needs and amenities in its health care facilities. Growth of the system, the largest in North and South Carolina, is due in large part to Harry A. Nurkin, president and CEO, who started out with a run-down hospital for indigents. With the approval of the hospital board, Nurkin launched a marketing effort that included taking a lesson from the founders of the Holiday Inn hotel chain. He remodeled and developed facilities that are pleasing to patients and visitors, moved patient parking closer to the hospitals' front doors, taught key hospital personnel the basics about marketing, aligned the system with ABA and NFL teams and conducted an aggressive advertising program.

Long Island health system's marketing about to shift gears. North Shore-LIJ Health identity established, expertise to be featured

More than two years ago, North Shore-Long Island Jewish Health System emerged from the combination of two well-respected health care institutions. In a new awareness campaign, the system has chosen to embrace its size and emphasize its benefits, including serving four million people and being the largest employer on Long Island.

Hospitals use contest, gifts to announce Web site advances. Good Samaritan, Carson-Tahoe also build patient databases

New explorations in Web site marketing from Good Samaritan Hospital in San Jose, Calif. and Carson-Tahoe Hospital in Carson City, Nev.