Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

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.

How does multi-set high-load resistance exercise impact neuromuscular function in normoxia and hypoxia?

This study examined whether hypoxia during multi-set, high-load resistance exercise alters neuromuscular responses. Using a single-blinded (participants), randomised crossover design, eight resistance-trained males completed five sets of five repetitions of bench press at 80% of one repetition maximum in moderate normobaric hypoxia (inspiratory oxygen fraction = 0.145) and normoxia. Maximal isometric bench press trials were performed following the warm-up, after 10 min of altitude priming and 5 min post-session (outside, inside and outside the chamber, respectively). Force during pre-/post-session maximal voluntary isometric contractions and bar velocity during exercise sets were measured along with surface electromyographic (EMG) activity of the pectoralis major, anterior deltoid and lateral and medial triceps muscles. Two-way repeated measures ANOVA (condition×time) were used. A significant time effect (p = 0.048) was found for mean bar velocity, independent of condition (p = 0.423). During sets of the bench press exercise, surface EMG amplitude of all studied muscles remained unchanged (p > 0.187). During maximal isometric trials, there were no main effects of condition (p > 0.666) or time (p > 0.119), nor were there any significant condition×time interactions for peak or mean forces and surface EMG amplitudes (p > 0.297). Lower end-exercise blood oxygen saturation (90.9 ± 1.8 vs. 98.6 ± 0.6%; p < 0.001) and higher blood lactate concentration (5.8 ± 1.4 vs. 4.4 ± 1.6 mmol/L; p = 0.007) values occurred in hypoxia. Acute delivery of systemic normobaric hypoxia during multi-set, high-load resistance exercise increased metabolic stress. However, only subtle neuromuscular function adjustments occurred with and without hypoxic exposure either during maximal isometric bench press trials before versus after the session or during actual exercise sets.

Effect of warm-up on intermittent sprint performance

We aimed to investigate the effects of different warm-up (WUP) intensities on 10 min of subsequent intermittent-sprint running performance. Eleven male, team-sport players performed four trials in a randomized, cross-over design, consisting of an intermittent-sprint protocol (15 × 20-m sprints) that followed either no-WUP or one of three 10-min WUP trials that varied in intensity. Warm-up intensities were performed at either (1) half the difference between anaerobic threshold (AT) and lactate threshold (LT) [(AT-LT)/2] below the LT = WUP 1; (2) midway between LT and AT level = WUP 2; (3) [(AT-LT)/2] above AT = WUP 3. Sprint times were fastest following WUP 3, compared with all other trials, for sprints 1-9 and 14, as well as for total accumulated sprints, with these results supported by moderate to large effect size (ES; range: d = -0.50 to -1.06) and "possible" to "almost certain" benefits. Warm-up 3 resulted in faster intermittent-sprint running performance compared with lower intensity WUPs and no WUP for the first 6 min of sprinting, with accumulated sprints for the entire 10 min protocol also being faster after WUP 3. This information may be pertinent to coaches of team-sport games with respect to player substitutions.

Effects of a recovery swim on subsequent running performance

The effects of a swimming-based recovery session implemented 10 h post high intensity interval running on subsequent run performance the next day was investigated. Nine well trained triathletes performed two high intensity interval running sessions (HIIS) (8x3 min at 85-90% VO(2peak) velocity), followed 10 h later by either a swim recovery session (SRS) (20x100 m at 90% of 1 km time trial speed), or a passive recovery session (PRS). Subsequently, a time to fatigue run (TTF) was completed 24 h post-HIIS. Venous blood samples were taken pre-HIIS and pre-TTF to determine the levels of circulating C-Reactive Protein (CRP). Subjects were also asked to rate their perceived recovery prior to commencing the TTF run. The SRS resulted in a significantly longer (830+/-198 s) TTF as compared to PRS (728+/-183 s) ( P=0.005). There was also a significant percentage change from baseline in the CRP levels 24 h post-HIIS (SRS=-23%, PRS=+/-5%, P=0.007). There were no significant differences in perceived recovery between two conditions ( P=0.40) . The findings of the present study showed that a swimming-based recovery session enhanced following day exercise performance, possibly due to the hydrostatic properties of water and its associated influence on inflammation.

Primary tumours of the liver in children: an African perspective

Primary tumours of the liver present diagnostic and management difficulties. In Africa, outcomes reflect limitations imposed by comorbidity and lack of resources, both human and material, for major liver resection. Whilst hepatoblastoma and hepatocellular carcinoma can be readily distinguished on clinical and biochemical grounds, there is a high incidence of sarcomatous tumours that mandate biopsy. In our experience, hepatocellular carcinoma in childhood is a lethal condition, usually bilateral and associated with hepatitis B infection. Sarcomatous tumours are often resectable but have a high rate of local recurrence. Hepatoblastoma is a surgically curable tumour in many patients. Resection for benign liver tumours can be safely accomplished and augments institutional experience with major liver surgery.

Malignant solid tumours in neonates: an African perspective

Malignant tumours in the neonate are distinct pathologically, clinically, and therapeutically from those in older children or adults. Behaviour cannot be directly implied from the histological appearance, and risk stratification is therefore difficult and complex. We review 42 patients seen over a 20-year period. Neuroblastoma (NB) was the commonest tumour seen (11), but the soft-tissue sarcomas were the dominant group (14). The initial management was surgical when possible. Chemotherapy, despite appropriate dose reduction, had significant morbidity and mortality. Whilst the outcome for congenital fibrosarcoma was good (6/7, 86%), there were no survivors amongst 5 patients with rhabdomyosarcoma. In the absence of cytogenetic and biochemical markers, risk stratification amongst babies with NB was based upon INSS staging. Stage I disease was associated with a good prognosis, whilst stage IV disease was uniformly fatal. Stage IVs disease had only 50% early survival. Patients with renal tumours, whether nephroblastoma or mesoblastic nephroma, did well. Only patients with morphologically immature teratomas were included, amongst whom there are 2 of 7 (29%) known survivors, but 43% have been lost to follow-up and their status is unknown. These figures are consistent with other reports from Africa.

Metastatic carcinoma in the neck from an occult primary lesion

Over an 11-year period, from January 1980 to December 1990, 23 patients with metastatic carcinoma of the neck were admitted to Addington Hospital with an unknown primary lesion. More than 50% of patients presented with disease in the N3 nodal stage. Sixteen patients had squamous cell carcinoma, 6 undifferentiated carcinoma and 1 adenocarcinoma. The diagnoses were made by means of fine-needle aspiration cytology and histological assessment of the neck nodes. Twenty-one patients were treated with radiotherapy and 2 with surgery. The primary tumour became apparent in only 4 (17%) patients, 7, 8, 9, and 12 months respectively after initial presentation. The sites were the base of tongue in 2, the pyriform fossa in 1 and the scalp in the remaining patient. The overall 3-year and 5-year survival rates were 26% and 17% respectively.

Hydrocarbon ingestion in children: a six-year retrospective study

The results of a six-year retrospective study of 116 children admitted with the diagnosis of hydrocarbon ingestion showed that the major toxicity of hydrocarbons was to the respiratory tract, with 79 patients (68%) developing pneumonia. There was a significantly higher initial white blood cell count in children who developed pneumonia (15,900/cu mm vs 12,000/cu mm, p less than .001). All hydrocarbon products studied had a similar incidence of complicatons, except turpentine products, which had a significantly lower incidence of pneumonia (p less than .005). There was no correlation between amount ingested and development of complicatons. Initial treatment, which consisted of induced vomiting, gastric lavage, administration of oil or saline cathartics, was not associated with fewer complications. Oil administration correlated with higher incidence of pneumonia (p less than .025). The present study recomends only supportive treatment following hydrocarbon ingestion in children.