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

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Structural and Functional Recovery of Sensory Cilia in <i>C</i>. <i>elegans</i> IFT Mutants upon Aging

<div><p>The majority of cilia are formed and maintained by the highly conserved process of intraflagellar transport (IFT). Mutations in IFT genes lead to ciliary structural defects and systemic disorders termed ciliopathies. Here we show that the severely truncated sensory cilia of hypomorphic IFT mutants in <i>C</i>. <i>elegans</i> transiently elongate during a discrete period of adult aging leading to markedly improved sensory behaviors. Age-dependent restoration of cilia morphology occurs in structurally diverse cilia types and requires IFT. We demonstrate that while DAF-16/FOXO is dispensable, the age-dependent suppression of cilia phenotypes in IFT mutants requires cell-autonomous functions of the HSF1 heat shock factor and the Hsp90 chaperone. Our results describe an unexpected role of early aging and protein quality control mechanisms in suppressing ciliary phenotypes of IFT mutants, and suggest possible strategies for targeting subsets of ciliopathies.</p></div

Cilia of the ASI sensory neurons elongate in aged IFT mutants.

<p><b>(A)</b> (Left) Cartoon of a worm showing a representative sensory neuron in the worm head. Cilia are present at the dendritic ends at the nose (box). (Right) Diagrammatic representation of the structure of a typical cilium and IFT in <i>C</i>. <i>elegans</i>. Arrows indicated direction of IFT. TZ—transition zone (showing Y-link microtubule-to-membrane connectors). <b>(B)</b> Representative images of ASI cilia in 1d and 7d old adult wild-type (WT) and <i>osm-6(p811)</i> mutants. Arrowheads indicate the cilia base. Anterior is at top. ASI cilia were visualized via expression of a GFP-tagged SRG-36 GPCR protein expressed under the ASI-specific <i>str-3</i> promoter. Scale bar: 5 μm. <b>(C)</b> Quantification of ASI cilia length in animals of the indicated genetic backgrounds at different larval stages (L2, L4) or days of adulthood. Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. * and *** indicate different from 1d within a genotype at <i>P</i><0.05 and 0.001, respectively; ^# and ^### indicate different from L2 within a genotype at <i>P</i><0.05 and 0.001, respectively (Kruskal-Wallis test with post hoc paired comparisons). n>30 for each; ≥3 independent experiments. Animals were grown at either 20°C or 25°C for each set of experiments (indicated at top right). <b>(D)</b> Quantification of ASI cilia length in 1d and 7d old animals of the indicated genotypes grown at 20°C. ASI cilia were visualized via expression of <i>str-3</i>p::<i>srg-36</i>::<i>gfp</i>. Alleles used in the double mutant strains were <i>osm-6(p811)</i>, <i>osm-5(p813)</i>, and <i>daf-10(e1387)</i>. Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. * and *** indicate different from 1d within a genotype at <i>P</i><0.05 and 0.001, respectively (Wilcoxon Mann-Whitney U test). n>30 for each; ≥3 independent experiments.</p

Cilia-dependent sensory behaviors are improved in aged IFT-B mutants.

<p><b>(A)</b> Chemotaxis responses of 1d and 7d old animals of the indicated genotypes to a point source of bacteria (see <a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006325#sec012" target="_blank">Materials and Methods</a>). Positive chemotaxis indices indicate attraction. ** and *** indicate different from 1d within a genotype at <i>P</i><0.01 and 0.001, respectively (Kruskal-Wallis non parametric test). Error bars are SEM. n>200 animals each from 8 independent assays. <b>(B)</b> Fraction of animals of the indicated genotypes and ages that remain within a ring of 8M glycerol after 2 minutes. Error bars are SEM. *** indicate different from 1d at <i>P</i>< 0.001 within a genotype (Kruskal-Wallis non-parametric test). n>100 animals each from 10 independent assays. <b>(C)</b> Length of ASH cilia in 7d old wild-type, <i>osm-5(p813)</i> and <i>osm-6(p811)</i> animals that remained within (inside), or escaped (outside), a ring of 8M glycerol after 2 minutes. Horizontal lines indicate 25^th, 50^th and 75^th percentiles. *** indicates different from 1d within a genotype at <i>P</i>< 0.001 (Wilcoxon Mann-Whitney U test). n≥15 animals for each condition.</p

Improved protein quality control mechanisms may underlie age-dependent cilia recovery in IFT mutants.

<p><b>(A-D)</b> Quantification of ASI cilia length in animals of the indicated genotypes and adult ages. Alleles used were <i>osm-6(p811)</i>, <i>daf-16(mu86)</i>, and <i>hsf-1(sy441ts)</i>. ASI cilia were visualized via expression of <i>str-3</i>p::<i>srg-36</i>::<i>gfp</i> (A,C,D) or <i>srg-47</i>p::<i>TagRFP</i> (B). An <i>hsf-1</i> cDNA tagged with <i>gfp</i>, and <i>hsf-1</i> and <i>daf-21</i> sense and antisense sequences were expressed in ASI under the <i>srg-47</i> promoter. Lines 1 and 2 represent independent transgenic lines. Animals were grown at 20°C (A,C,D) or 25°C (B). Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. * and *** indicate different from 1d within a genotype at <i>P</i><0.05 and 0.001, respectively (Wilcoxon Mann-Whitney U test). n>30 for each; ≥3 independent experiments. <b>(E)</b> Quantification of ASI cilia length in 1d and 4d old animals of the indicated genotypes, expressing <i>srg-47</i>p::<i>osm-5(p813)</i>::<i>gfp</i>. ASI cilia were visualized via expression of <i>srg-47</i>p::<i>TagRFP</i>. Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. *** indicates different from 1d of the same genotype at <i>P</i><0.001 (Wilcoxon Mann-Whitney U test). n>50 each; 3 independent experiments. <b>(F)</b> Quantification of ASI cilia length in 1d and 4d old animals of the indicated genotypes. ASI cilia were visualized via expression of <i>str-3</i>p::<i>srg-36</i>::<i>gfp</i>. Animals were grown on 10 μM Bortezomib (BTZ). Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. *** indicates different from 1d within a genotype at <i>P</i><0.001; ^### indicates different between the indicated conditions at <i>P</i><0.001 (Wilcoxon Mann-Whitney U test). n>50 each; 3 independent experiments.</p

Cilia of multiple sensory neurons exhibit structural recovery in aged IFT mutants.

<p><b>(A)</b> Representative images of the fan-shaped AWC, and rod-like ASE, cilia in 1d and 7d old wild-type and <i>osm-6(p811)</i> mutants. Cilia were visualized via expression of <i>ceh-36</i>p::<i>gfp</i> which drives expression in AWC and ASE [<a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006325#pgen.1006325.ref044" target="_blank">44</a>]. White and yellow arrowheads mark the bases of the AWC and ASE cilia, respectively. Arrows mark the AWC cilia membraneous expansions (‘fans’). Numbers indicate the percentage of animals exhibiting phenotypes similar to those shown; n≥12 for each. Anterior is at top. Scale bar: 5 μm. <b>(B)</b> Quantification of AWC cilia fan area (left) and ASE cilia length (right) in 1d and 7d old wild-type and <i>osm-6(p811)</i> mutants. *** indicates different from 1d within a genotype at <i>P</i><0.001 (Wilcoxon Mann-Whitney U test). n>30 each; 3 independent experiments. <b>(C)</b> Representative images of ASH cilia in 1d and 7d old adult wild-type (WT) and <i>osm-6(p811)</i> mutants. Arrowheads indicate the cilia base. ASH neuronal processes including cilia are marked via expression of GFP under the <i>sra-6</i> promoter. The cilium base is marked via localization of MKSR-2::TagRFP. Anterior is at top. Scale bar: 5 μm. <b>(D)</b> Quantification of ASH cilia length in wild-type and <i>osm-6(p811)</i> mutants at the indicated days of adulthood. *** indicates different from 1d within a genotype at <i>P</i><0.001 (Wilcoxon Mann-Whitney U test). n>30 for each; ≥3 independent experiments. <b>(E)</b> Transmission electron microscopy of amphid channel sensory pores in adult 1d and 7d animals. Images acquired from serial cross sections of wild-type and <i>osm-6(m533)</i> mutant worms; each image pair consists of a low magnification image of the entire nose tip (left) and a high magnification image of an amphid pore (right; boxed regions in images at left). Numbers (microns) denote proximal positioning of section relative to the distal-most first section in the series; section positions also indicated in schematic. The schematic is a longitudinal representation of a wild-type amphid neuronal pore, enveloped by supporting sheath and socket glial cells. Pores consist of 10 ciliary axonemes (only 3 are shown), each with distal segment (DS; singlet microtubules), middle segment (MS; doublet microtubules), transition zone (TZ) and periciliary membrane (PCMC) subcompartments. Bars; 2 μm (low magnification images), 200 nm (high magnification images).</p

IFT motor proteins are necessary for age-dependent cilia recovery in IFT mutants.

<p><b>(A)</b> Quantification of ASI cilia length in 1d and 7d old animals of the indicated genotypes. ASI cilia were visualized via expression of <i>str-3</i>p::<i>srg-36</i>::<i>gfp</i>. Alleles used in the double mutant strains were <i>osm-6(p811)</i>, <i>kap-1(ok676)</i> and <i>osm-3(p802)</i>. Horizontal lines indicate 25^th, 50^th and 75^th percentiles; bars indicate 5^th and 95^th percentiles. *, ** and *** indicate different from 1d within a genotype at <i>P</i><0.05, 0.01 and 0.001, respectively (Wilcoxon Mann-Whitney U test). n>30 for each; ≥3 independent experiments. <b>(B)</b> Histograms of KAP-1::GFP and <b>(C)</b> OSM-3::GFP anterograde velocities in the ASH/ASI cilia of 1d and 7d old wild-type or <i>osm-6(p811)</i> mutants. <i>kap-1</i>:<i>gfp</i> and <i>osm-3</i>::<i>gfp</i> were expressed under the <i>sra-6</i> promoter. IFT could not be reliably quantified in short cilia in 1d old <i>osm-6</i> mutants. Anterograde velocities in the middle and distal segments are indicated by black and gray bars, respectively; average velocities are indicated at top right in each panel in corresponding colors. See <a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1006325#pgen.1006325.s008" target="_blank">S2 Table</a> for statistical analyses.</p