STIMULATE-ICP-Delphi (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways Delphi): Study protocol

Introduction As mortality rates from COVID-19 disease fall, the high prevalence of long-term sequelae (Long COVID) is becoming increasingly widespread, challenging healthcare systems globally. Traditional pathways of care for Long Term Conditions (LTCs) have tended to be managed by disease-specific specialties, an approach that has been ineffective in delivering care for patients with multi-morbidity. The multi-system nature of Long COVID and its impact on physical and psychological health demands a more effective model of holistic, integrated care. The evolution of integrated care systems (ICSs) in the UK presents an important opportunity to explore areas of mutual benefit to LTC, multi-morbidity and Long COVID care. There may be benefits in comparing and contrasting ICPs for Long COVID with ICPs for other LTCs. Methods and analysis This study aims to evaluate health services requirements for ICPs for Long COVID and their applicability to other LTCs including multi-morbidity and the overlap with medically not yet explained symptoms (MNYES). The study will follow a Delphi design and involve an expert panel of stakeholders including people with lived experience, as well as clinicians with expertise in Long COVID and other LTCs. Study processes will include expert panel and moderator panel meetings, surveys, and interviews. The Delphi process is part of the overall STIMULATE-ICP programme, aimed at improving integrated care for people with Long COVID. Ethics and dissemination Ethical approval for this Delphi study has been obtained (Research Governance Board of the University of York) as have approvals for the other STIMULATE-ICP studies. Study outcomes are likely to inform policy for ICPs across LTCs. Results will be disseminated through scientific publication, conference presentation and communications with patients and stakeholders involved in care of other LTCs and Long COVID

Long Covid active case finding study protocol: A co-produced community-based pilot within the STIMULATE-ICP study (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways)

Background and aim Long Covid is a significant public health concern with potentially negative implications for health inequalities. We know that those who are already socially disadvantaged in society are more exposed to COVID-19, experience the worst health outcomes and are more likely to suffer economically. We also know that these groups are more likely to experience stigma and have negative healthcare experiences even before the pandemic. However, little is known about disadvantaged groups' experiences of Long Covid, and preliminary evidence suggests they may be under-represented in those who access formal care. We will conduct a pilot study in a defined geographical area in London, United Kingdom to test the feasibility of a community-based approach of identifying Long Covid cases that have not been clinically diagnosed and have not been referred to Long Covid specialist services. We will explore the barriers to accessing recognition, care, and support, as well as experiences of stigma and perceived discrimination. Methods This protocol and study materials were co-produced with a Community Advisory Board (CAB) made up primarily of people living with Long Covid. Working with voluntary organisations, a study leaflet will be distributed in the local community to highlight Long Covid symptoms and invite those experiencing them to participate in the study if they are not formally diagnosed. Potential participants will be assessed according to the study's inclusion criteria and offered the opportunity to participate if they fit them. Awareness of Long Covid and associated symptoms, experiences of trying to access care, as well as stigma and discrimination will be explored through qualitative interviews with participants. Upon completion of the interviews, participants will be offered a referral to the local social prescribing team to receive support that is personalised to them potentially including, but not restricted to, liaising with their primary care provider and the regional Long Covid clinic

The Recovery of Repeated-Sprint Exercise Is Associated with PCr Resynthesis, while Muscle pH and EMG Amplitude Remain Depressed

The physiological equivalents of power output maintenance and recovery during repeated-sprint exercise (RSE) remain to be fully elucidated. In an attempt to improve our understanding of the determinants of RSE performance we therefore aimed to determine its recovery following exhaustive exercise (which affected intramuscular and neural factors) concomitantly with those of intramuscular concentrations of adenosine triphosphate [ATP], phosphocreatine [PCr] and pH values and electromyography (EMG) activity (a proxy for net motor unit activity) changes. Eight young men performed 10, 6-s all-out sprints on a cycle ergometer, interspersed with 30 s of recovery, followed, after 6 min of passive recovery, by five 6-s sprints, again interspersed by 30 s of passive recovery. Biopsies of the vastus lateralis were obtained at rest, immediately after the first 10 sprints and after 6 min of recovery. EMG activity of the vastus lateralis was obtained from surface electrodes throughout exercise. Total work (TW), [ATP], [PCr], pH and EMG amplitude decreased significantly throughout the first ten sprints (P<0.05). After 6 min of recovery, TW during sprint 11 recovered to 86.3±7.7% of sprint 1. ATP and PCr were resynthesized to 92.6±6.0% and 85.3±10.3% of the resting value, respectively, but muscle pH and EMG amplitude remained depressed. PCr resynthesis was correlated with TW done in sprint 11 (r = 0.79, P<0.05) and TW done during sprints 11 to 15 (r = 0.67, P<0.05). There was a ~2-fold greater decrease in the TW/EMG ratio in the last five sprints (sprint 11 to 15) than in the first five sprints (sprint 1 to 5) resulting in a disproportionate decrease in mechanical power (i.e., TW) in relation to EMG. Thus, we conclude that the inability to produce power output during repeated sprints is mostly mediated by intramuscular fatigue signals probably related with the control of PCr metabolism

Average peak power output (A), total work done (B) and EMG amplitude (root mean square) (C) of the vastus lateralis muscle for the entire group over the 15 sprints.

<p>Data are presented as means ± SEM, expressed as a percent of sprint 1 (n = 8).</p

Total work done during five consecutive sprints (full bar height, TW_5SPT) and the initial sprint (height of the dark lower portion, TW_1SPT).

<p>The difference between these respective mechanical works is illustrated by the white upper portion of the bar. Numeric values (mean ± SEM) for the ratio of TW_5SPT/TW_1SPT appear within the bars. Data for the bars are mean values and are presented as Joules per kilogram body mass (n = 8). * Significant differences between the ratios, P<0.05.</p

Muscle phosphocreatine (PCr) recovery following the 6 min of passive recovery was positively related to: A) the total work done during sprint 11 (r = 0.79, P<0.05) and, B) the total work done across the five consecutive sprints (r = 0.67, P<0.05).

<p>Muscle phosphocreatine (PCr) recovery following the 6 min of passive recovery was positively related to: A) the total work done during sprint 11 (r = 0.79, P<0.05) and, B) the total work done across the five consecutive sprints (r = 0.67, P<0.05).</p

Schematic representation of the experimental design (10×6-s/30-s ten sprints of 6 s in duration each interspersed with 30 s of recovery; 5×6-s/30-s five sprints of 6 s in duration each interspersed with 30 s of recovery).

<p>A total of three muscle biopsies was obtained from each subject during the muscle biopsy condition.</p

Evolution of the total work done (TW, black column), EMG root mean square of the vastus lateralis muscle (RMS, white column), and TW/RMS ratio (cross-hatch column) for the entire group over selected sprints.

<p>Data are presented as means ± SEM, expressed as a % of sprint 1 (n = 8). * Significantly different from Sprint 1, P<0.05; † Significantly different from Sprint 10, P<0.05; § Significantly different from Sprint 10, P<0.05.</p

Muscle ATP, PCr, Lac, H⁺ and pH in the vastus lateralis muscle at rest (Pre), following the completion of ten, 6-s cycling sprints interspersed with 30 s of recovery (Post 0), and after 6 min of recovery (Post 6).

<p>Values are means ± SD, <i>N</i> = 7 men. ATP = adenosine triphosphate; PCr = phosphocreatine; Lac = lactate; H⁺ = hydrogen ions; dm, dry muscle. * Significantly differences from Pre values, † Significant differences from Post 0 values, P<0.05.</p