COVID-19 trajectories among 57 million adults in England: a cohort study using electronic health records

BACKGROUND: Updatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, we aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework. METHODS: In this cohort study, we used eight linked National Health Service (NHS) datasets for people in England alive on Jan 23, 2020. Data on COVID-19 testing, vaccination, primary and secondary care records, and death registrations were collected until Nov 30, 2021. We defined ten COVID-19 phenotypes reflecting clinically relevant stages of disease severity and encompassing five categories: positive SARS-CoV-2 test, primary care diagnosis, hospital admission, ventilation modality (four phenotypes), and death (three phenotypes). We constructed patient trajectories illustrating transition frequency and duration between phenotypes. Analyses were stratified by pandemic waves and vaccination status. FINDINGS: Among 57 032 174 individuals included in the cohort, 13 990 423 COVID-19 events were identified in 7 244 925 individuals, equating to an infection rate of 12·7% during the study period. Of 7 244 925 individuals, 460 737 (6·4%) were admitted to hospital and 158 020 (2·2%) died. Of 460 737 individuals who were admitted to hospital, 48 847 (10·6%) were admitted to the intensive care unit (ICU), 69 090 (15·0%) received non-invasive ventilation, and 25 928 (5·6%) received invasive ventilation. Among 384 135 patients who were admitted to hospital but did not require ventilation, mortality was higher in wave 1 (23 485 [30·4%] of 77 202 patients) than wave 2 (44 220 [23·1%] of 191 528 patients), but remained unchanged for patients admitted to the ICU. Mortality was highest among patients who received ventilatory support outside of the ICU in wave 1 (2569 [50·7%] of 5063 patients). 15 486 (9·8%) of 158 020 COVID-19-related deaths occurred within 28 days of the first COVID-19 event without a COVID-19 diagnoses on the death certificate. 10 884 (6·9%) of 158 020 deaths were identified exclusively from mortality data with no previous COVID-19 phenotype recorded. We observed longer patient trajectories in wave 2 than wave 1. INTERPRETATION: Our analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. We have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources. FUNDING: British Heart Foundation Data Science Centre, led by Health Data Research UK

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Back to Basics: Searching For a Comprehensive Framework for Exploring Individual Differences In Zebrafish (\u3ci\u3eDanio rerio\u3c/i\u3e) Behavior

Individual differences (IDs) in behavior among nonhuman animals have been documented in a wide range of taxa. Although traditionally considered noise around an average, other potentially adaptive sources of phenotypic variation exist. IDs in behavior that are consistent across time and context are more recently recognized as expressions of underlying personality traits, which may even be heritable. Unfortunately, despite the rapid advances that have been made in animal personality research utilizing fish the last decade, a few have detailed the groundwork necessary to document consistency in behavior across time and context. This foundation is required, by definition, before one can draw conclusions about personality traits. Here, we examine whether IDs in behavior are consistent over time and across contexts and explore the construct validity of six commonly used behavioral assays for examining four personality traits: aggression, boldness, fear, and exploration. Thirty zebrafish (Danio rerio) were exposed twice each to a small open field, large open field, mirror, emergence, novel object, and predator response test. Results revealed consistency in most behavioral measures across both time and context. There was mixed evidence for the construct validity of these assays in capturing the targeted personality traits

Common Bottlenose Dolphin, Tursiops truncatus, Behavioral Response to a Record-Breaking Flood Event in Pensacola Bay, Florida

Common bottlenose dolphins, Tursiops truncatus, can suffer health complications from prolonged freshwater exposure; however, little is known about how dolphins behaviorally respond to flood events. We investigated whether dolphins mitigated their freshwater exposure by moving south towards the estuary mouth and/or towards deeper areas with higher salinities in response to a record-breaking flood in Pensacola Bay, Florida. In total, 144 dolphin groups observed during 45 population dynamic surveys were analyzed across two flood-impacted sampling sessions and their respective seasonal control sessions. Kernel density estimates demonstrated southern movement towards the estuary mouth during flood-impacted sessions, but this distribution change was limited. Species distribution models showed that dolphins did not move to deeper areas after the flood and dolphin distribution was not substantially altered by flood-induced salinity changes. The estuary system exhibits strongly stratified waters with broad salinity ranges even during the flood. Dolphins may have mitigated the severity of freshwater exposure by capitalizing on these stratified areas as they continued to use habitat affected by the flood. A lack of avoidance of low salinity could result in this dolphin population being at greater risk for health problems, which should be considered in future population management and conservation

Back To Basics: Searching For A Comprehensive Framework For Exploring Individual Differences In Zebrafish (Danio Rerio) Behavior

Individual differences (IDs) in behavior among nonhuman animals have been documented in a wide range of taxa. Although traditionally considered noise around an average, other potentially adaptive sources of phenotypic variation exist. IDs in behavior that are consistent across time and context are more recently recognized as expressions of underlying personality traits, which may even be heritable. Unfortunately, despite the rapid advances that have been made in animal personality research utilizing fish the last decade, a few have detailed the groundwork necessary to document consistency in behavior across time and context. This foundation is required, by definition, before one can draw conclusions about personality traits. Here, we examine whether IDs in behavior are consistent over time and across contexts and explore the construct validity of six commonly used behavioral assays for examining four personality traits: aggression, boldness, fear, and exploration. Thirty zebrafish (Danio rerio) were exposed twice each to a small open field, large open field, mirror, emergence, novel object, and predator response test. Results revealed consistency in most behavioral measures across both time and context. There was mixed evidence for the construct validity of these assays in capturing the targeted personality traits. © 2014, Mary Ann Liebert, Inc

A Methodological Review of Personality-Related Studies in Fish: Focus on the Shy-Bold Axis of Behavior

Personality research has begun to take hold in the animal kingdom as psychologists turn to animal models to investigate various aspects of personality. Similarly, behavioral ecologists and related fields have begun to explore the idea that individual variation in behavior is more than just noise around an average for a given population or group of interest. As a result, many have begun to turn to personality-related questions to explain individual differences in animal behavior. Collectively, psychologists, ecologists and related fields have created a boom in animal personality-related research. This interest has expanded to a variety of fish species, with many studies focused on an important axis of behavior in humans: the shy-bold axis. Unfortunately, there has been very little consideration for the methodology employed. We review both the experimental and statistical methodology found in a body of research on fish species, for which personality-related research has been conducted. Our aim is to shed light on many important considerations that are often overlooked in order to facilitate research concerned with the reliability and validity of the many methods used

Alcohol-Induced Behavior Change in Zebrafish Models

Zebrafish are at the forefront of neurobiological research and have been gaining popularity as a viable and valid behavioral model in a variety of research applications (e.g., assessing drug induced behavioral changes). This model becomes even more attractive when considering the behavioral changes that follow exposure to compounds that are water-soluble. As such, several studies have implicated both acute and chronic ethanol exposure in the modulation of zebrafish behavior. Within this arena there appears to be a common trend across multiple studies. As with many drugs ethanol appears to influence behavior in a dose-dependent manner. In this review, we compare and contrast several studies that measure behavior as a result of alcohol exposure. Appended to this review are pilot data that report zebrafish blood alcohol concentrations as a function of acute exposure

Assessing Attention in the Zebrafish: Are We There Yet?

Traditionally, rodent sustained attention models are used for studying the neurobiological underpinnings of attention, for assessing the disruptive and interactive effects of drugs and environmental toxins and for predicting the efficacy of pharmacotherapies for attention disorders. Virtually all-major psychiatric disorders are characterized by disturbances in attention or concentration. Additionally, many psychoactive drugs produce simultaneous effects on a variety of psychological processes. Behavioral measures in tasks designed to assess cognitive processes in rodents characterize and dissociate these multiple influences. While the zebrafish (Danio rerio) has been at the vanguard of neurobiological research and is increasing in popularity as a model organism for behavioral applications, their attentional capacity has not been fully assessed. Here we review some of the more popular animal models and discuss the utility of a choice discrimination zebrafish model. (C) 2011 Elsevier Inc. All rights reserved