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

National Environmental Policy During the Clinton Years

We review major developments in national environmental policy during the Clinton Administration, defining environmental policy to include not only the statutes, regulations, and policies associated with reducing pollution, but also major issues of public lands management and species preservation. We adopt economic criteria for policy assessment - principally efficiency, cost-effectiveness, and distributional equity. While the paper is primarily descriptive, we highlight a set of five themes that emerge in the economics of national environmental policy over the past decade. First, over the course of the decade, national environmental targets were made more stringent, and environmental quality improved. Most important among the new targets were the National Ambient Air Quality Standards (NAAQS) for ambient ozone and particulate matter, issued by EPA in July 1997, which could turn out to be one of the Clinton Administration's most enduring environmental legacies. Also, natural resource policy during the Clinton years was heavily weighted toward environmental protection. Environmental quality improved overall during the decade, continuing a trend that began in the 1970s, although improvements were much less than during the previous two decades. Second, the use of benefit-cost analysis for assessing environmental regulation was controversial in the Clinton Administration, while economic efficiency emerged as a central goal of the regulatory reform movement in the Congress during the 1990s. When attention was given to increased efficiency, the locus of that attention during the Clinton years was the Congress in the case of environmental policies and the Administration in the case of natural resource policies. Ironically, the increased attention given to benefit-cost analysis may not have had a marked effect on the economic efficiency of environmental regulations. Third, cost-effectiveness achieved a much more prominent position in public discourse regarding environmental policy during the 1990s. From the Bush Administration through the Clinton Administration, interest and activity regarding market-based instruments for environmental protection - particularly tradeable permit systems - continued to increase. Fourth, the Clinton Administration put much greater emphasis than previous administrations on expanding the role of environmental information disclosure and voluntary programs. While such programs can provide cost-effective ways of reaching environmental policy goals, little is known about their actual costs or effectiveness. Fifth and finally, the Environmental Protection Agency placed much less emphasis on economic analysis during the 1990s. EPA leadership was more hostile to economic analysis than it had been under the prior Bush Administration, and it made organizational changes to reflect this change in priorities