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.

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21

Background

Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection.

Methods

A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID.

Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea.

Discussion

Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals.

Trial registration

ClinicialTrials.gov NCT04900961. Prospectively registered on 25 May 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06632-y.

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.

Depression in Kraepelinian Schizophrenia

<p><strong>Objective.</strong> Depressive symptoms are prevalent, under- recognised and clinically important in patients suffering from schizophrenia. Depressive symptoms in schizophrenia patients are associated with distinct morbidity and mortality. The objective of this study was to investigate the prevalence of depressive symptoms in a subgroup of chronic schizophrenia, Kraepelinian schizophrenia, and the association with severity of illness. Kraepelinian schizophrenia is characterised by a chronic, unremitting, severe course of illness and severe deterioration of functioning in social, work and self-care domains. <strong></strong></p><p><strong>Method.</strong> The Calgary Depression Scale for Schizophrenia (CDSS) and the Clinical Global Impression Severity (CGI-S) scale were administered to 113 patients who fulfilled the criteria of Kraepelinian schizophrenia.<strong> </strong></p><p><strong>Results.</strong> Sixty-eight males and 45 females participated in the study. Of this group, 17.7% scored 5 or more on the CDSS. The CGI-S scores indicated that almost half of the patients were moderately ill (i.e. a score of 4 on the CGI-S scale). Of the patients, 94 were receiving first-generation antipsychotic medication and 19 second- generation antipsychotic medication. Thirteen patients were also receiving antidepressant medication.<strong> </strong></p><p><strong>Conclusion.</strong> The findings of this study are consistent with current reports in the literature that depressive symptoms are not common in Kraepelinian schizophrenia, even though patients are moderately to severely ill in both symptom and functional domains.</p>

Applicability of NINDS-sponsored studies to community-based physician involvement

Background: The National Institute of Neurological Disorders and Stroke (NINDS) Clinical Trials Group established the Clinical Research Collaboration (CRC) Project in 2005 to increase community-based physician involvement in NINDS-sponsored research.

Methods: We assessed a random sample of 112 of the more than 1,000 current NINDS-sponsored clinical research studies to determine which could involve community physicians in enrollment or follow-up. Scoring factors were based on the premise that participation is feasible for noninvasive studies with simple screening, and follow-up criteria and visit frequency consistent with usual care. Scored studies included 26 Phase III, 31 Phase I/II, and 55 nonclinical trials.

Results: Overall, 41% of the sampled research studies were considered conducive to community physician participation that exceeds referral only; 21% with participation in all study activities and 20% with ability to provide some follow-up. Specialized neuropsychological or neurologic scale testing was judged to exclude community physician participation in 16% of studies.

Conclusion: Many National Institute of Neurological Disorders and Stroke studies are available in which community-based physicians could participate. Involving community physicians may increase efficiency of completing clinical research and encourage application of research findings in community practices.

Overview of suspected adverse reactions to veterinary medicinal products reported in South Africa (March 2004 - February 2006) : report

The Veterinary Pharmacovigilance and Medicines Information Centre is responsible for the monitoring of veterinary adverse drug reactions in South Africa. An overview of reports of suspected adverse drug reactions received by the centre during the period March 2004 to February 2006 is presented. A total of 21 reports was received in the 2-year period, continuing the decline in the number of reports to a lower figure than in any previous year. This is surprising considering the legal obligation of the veterinary professionals to report all adverse drug reactions. Once again the majority of reports involved suspected adverse reactions that occurred in dogs and cats. Most of the products implicated were stock remedies. Veterinarians predominantly administered these products.

Overview of suspected adverse reactions to veterinary medicinal products reported in South Africa (March 2003 - February 2004)

The Veterinary Pharmacovigilance and Medicines Information Centre is responsible for the monitoring of veterinary adverse drug reactions in South Africa. An overview of reports of suspected adverse drug reactions received by the centre during the period March 2003 to February 2004 is given. A total of 20 reports was received. This had declined from the previous year. The general apathy with regards to the reporting of adverse drug reaction has prompted the Medicines Control Council to make reporting a legal obligation on all members of the veterinary and medical profession as from August 2004. The majority of reports involved suspected adverse reactions that occurred in dogs and cats. Most of the products implicated were Stock Remedies. Veterinarians predominantly administered these products. Only two reports were received from a veterinary pharmaceutical company.

Refining the primary open-angle glaucoma GLC1C region on chromosome 3 by haplotype analysis

The GLC1C locus for primary open-angle glaucoma (POAG) is inherited as an autosomal dominant trait. This region on chromosome 3 is 11 cM long. DNA samples from members of a Greek and an American GLC1C family were obtained to determine whether additional typing of microsatellite markers in family members might narrow the region. GLC1C family members were evaluated clinically for POAG on the basis of open angles, intraocular pressures, cupping of discs, and visual fields. DNA samples from the Greek and Oregon GLC1C families were used to further refine the GLC1C region using microsatellite markers. A total of 22 affected members were identified in the two families. Common alleles for D3S3637 and D3S3612 were present in the disease haplotype from both families, suggesting that they may have a common founder. A newly diagnosed patient in the American family had a recombination in the distal portion of the GLC1C haplotype. This recombination narrows the GLC1C region from 11 to 4 cM.

Death due to air embolism during sexual intercourse in the puerperium

We describe the cases of two young women who died due to air embolism during sexual intercourse early in the puerperium.

Sampling for vaginal candidosis: how good is it?

In defined patient populations attending a genitourinary medicine department, screening for vaginal candidosis resulted in 26.3% positive rate. Microscopy using Gram-stained slide was useful in early diagnosis and resulted in the detection of 64.8% of symptomatic cases. Samples from the anterior fornix proved most sensitive for culture diagnosis while the left lateral vaginal wall proved least sensitive (positive predictive value 0.88 cf 0.81).

Fatal diltiazem overdose: report of four cases and review of the literature

Four fatal cases of diltiazem overdose are described and compared with previously published cases. Clinical sequelae include all grades of heart block, hypotension and ultimately death. Management includes gastric lavage and oral administration of activated charcoal at presentation. Further symptomatic treatment with inotropic agents and temporary cardiac pacing may be required. If these measures are successful, recovery occurs within 36 hours in uncomplicated cases. Toxicological data have been reviewed but currently drug levels can only offer a retrospective analysis of the severity of overdoses. As the use and risk of abuse of diltiazem increases, these reports serve to highlight the possible hazards and to alert physicians to what must be regarded as a dangerous and potentially lethal drug in overdosage.

Plasmid DNA analysis, biotyping, and antimicrobic susceptibility as subtyping tests for Klebsiella pneumoniae and Klebsiella oxytoca

We compared plasmid DNA analysis, biotyping by Vitek, and disk diffusion antimicrobic susceptibility as subtyping tests of Klebsiella pneumoniae and Klebsiella oxytoca. The 92 tested isolates were from alternate, culture-positive patients over 6 months. No outbreak or cluster of infections was recognized during this interval. Plasmid DNA was detected in 85% of the isolates. Each isolate except one had a reproducible absence of plasmid DNA or a reproducible plasmid DNA profile on repetitive testing. Restriction endonuclease enzyme analysis of plasmid DNA was necessary to distinguish differences among some isolates that had only large plasmids. Isolates with only large plasmids represented 18% of the collection. Of the 78 isolates with plasmid DNA, all but two were considered different from one another by plasmid DNA analysis. Biotyping and antimicrobic susceptibility testing were not highly reproducible. In addition, biotyping did not demonstrate a sufficient variety of patterns among the isolates for subtyping purposes. We conclude that plasmid DNA analysis is very useful as a subtyping test for isolates of K. pneumoniae and K. oxytoca. Neither biotyping nor antimicrobial susceptibility as performed in our laboratory had sufficient discriminatory power and reproducibility for subtyping these organisms.

Bioconversion of the sodium salt of Simvastatin (MK-733) to 6-desmethyl-6-α-hydroxymethyl Simvastatin

An actinomycete (MA 6474, ATCC 53828) isolated from a soil sample (Mutare, Zimbabwe) was found to biotransform the sodium salt of Simvastatin (MK-733) to 6-alpha-hydroxymethyl MK-733, 6-beta-hydroxymethyl MK-733, and 6-ring-hydroxy MK-733. The bioconversion efficiency to the desired compound, 6-alpha-hydroxymethyl MK-733, was enhanced by optimizing the physico-chemical parameters of the process. In shake flask cultures, addition of magnesium (0.125 mg/l Mg SO4.7H2O) to the medium resulted in a five-fold increase in the rate of bioconversion to the alpha diastereomer. The ratio of bioconversion products (6-alpha-hydroxymethyl,6-beta-hydroxymethyl, and 6-ring-hydroxy MK-733) was regulated by pH. Process improvements and scale up in 23-1 fermentors, which consisted of a controlled addition of substrate (MK-733), resulted in a 2-fold increase in alpha diastereomer production (42 vs. 79 U/ml) and a 23-fold rate increase in the formation of alpha-diastereomer. A high diastereomeric ratio (alpha: beta = 9:1) facilitated downstream processing.

Plasmid DNA fingerprinting of Acinetobacter calcoaceticus subspecies anitratus from intubated and mechanically ventilated patients

Forty-three intubated and mechanically ventilated patients in five intensive care units (ICUs) of one hospital developed respiratory colonization or infection with Acinetobacter calcoaceticus subspecies anitratus over a 16-month interval. Neither the frequency nor rate of A anitratus isolation exceeded the hospital endemic norms. Single isolates from 34 of the patients were subtyped by plasmid DNA analysis, two biotyping systems and antimicrobial susceptibility to 24 drugs. Plasmid DNA fingerprints were distinct in 18 isolates (they differed from each other and all others), similar in two and identical or similar in ten. The latter group of isolates were recovered from patients in four ICUs. Reproducibility of biotyping was poor. Neither biotyping nor antimicrobial susceptibility were successful in identifying sameness among the group isolates nor differences among other isolates. We conclude that plasmid DNA fingerprinting should be used to assess the possibility of multiple patient transmissions of the same A anitratus strain in the absence of an obvious outbreak.

Properties of a class C beta-lactamase from Serratia marcescens

A beta-lactamase produced by a penicillin-resistant strain of Serratia marcescens was isolated and purified. The kcat. value for benzylpenicillin was about 5% of that observed for the best cephalosporin substrates. However, the low Km of the penam resulted in a high catalytic efficiency (kcat./Km) and the classification of the enzyme as a cephalosporinase might not be completely justified. It also exhibited a low but measurable activity against cefotaxime, cefuroxime, cefoxitin and moxalactam. Substrate-induced inactivation was observed both with a very good (cephalothin) or a very bad (moxalactam) substrate. The active site was labelled by beta-iodopenicillanate. Trypsin digestion produced a 19-residue active-site peptide whose sequence clearly allowed the classification of the enzyme as a class C beta-lactamase.

Discovery, purification and characterization of the angiotensin converting enzyme inhibitor, L-681,176, produced by Streptomyces sp. MA 5143a

L-681,176, an inhibitor of angiotensin converting enzyme was found in the culture filtrate of Streptomyces sp. MA 5143. The I50 of the crystalline inhibitor is about 1.3 micrograms/ml and the inhibition is reversed by zinc sulfate. In rats, L-681,176 exhibits a dose-related inhibition of the pressor response to angiotensin I with an ID50 of 142 mg/kg when administered intravenously. The structure of L-681,176 is similar to that of marasmine but lacking one carboxyl group. The maximum yield of L-681,176 occurs after three to four days growth at 28 degrees C.

Spirometric standards for healthy black adults

Forced expiratory spirometric studies were performed on 512 nonsmoking black adult men and women with negative cardiorespiratory histories. Regression equations were calculated for forced vital capacity (FVC), percent vital capacity in 1 second (% FEV(1)), and forced midexpiratory flow rate FEF(25-75)%), using height and age. These equations resulted in predicted values 3.5 to 23 percent lower than commonly used standards. The wide range of variation means that a single correction factor is inadequate when considering ethnic differences. In contrast, FEV(1)/FVC was within the accepted range of normal for all ethnic groups. In the 30 percent of subjects in whom sitting height was measured, it was not significantly different from one half the standing height; thus, sitting height is also an inadequate correction factor. Tables of predicted values were constructed for easy reference, with the hope that use of racespecific standards for pulmonary function testing will become widespread.