BACKGROUND:Preexisting multiple (two or more) long-term conditions (MLTCs) may negatively affect recovery after COVID-19. We investigated how preexisting MLTCs, including different categorization and patterns of MLTCs, affect 1-year health outcomes after severe COVID-19. METHODS:Adults post-hospitalization after COVID-19 were recruited during 2020-2021. We compared recovery at 1 year after discharge using adjusted multivariable logistic regression in 1:1 propensity-matched adults (for age, sex, ethnicity, social deprivation, obesity, and smoking history) with and without preexisting MLTCs. In adults with MLTCs, different categorization such as number of conditions, number and types of body systems involved (e.g. respiratory, cardiovascular), and latent class analysis-derived patterns of condition co-occurrence were assessed for their association with recovery at 1 year. RESULTS:A total of 647 adults with MLTCs were matched with 647 adults without MLTCs (n = 1294; 61.9% male, 79.6% of White ethnicity, median age 59 [interquartile range 52-67] years). The presence of MLTCs was associated with lower odds of feeling fully recovered (odds ratio 0.66 [95% confidence interval 0.51-0.85], P = 0.001). In those with MLTCs, recovery was negatively affected by number and type of body systems involved (e.g. respiratory [odds ratio 0.49 (95% confidence interval 0.34-0.69), P <0.001]) but not by the number of conditions (P >0.1). Four latent classes of MLTC co-occurrence were estimated with different risks of recovery (P <0.01). CONCLUSION:Adults with preexisting MLTCs were 34% less likely to feel fully recovered at 1 year after COVID-19 hospitalization than adults without MLTCs. We describe prognostic classifications of MLTCs, with future work needed to understand whether they have prognostication in broader post-acute infection sequalae.

Patients with end-stage kidney disease (ESKD) are at high risk of severe COVID-19. We performed longitudinal single-cell immune profiling of ESKD patients with COVID-19. Transcriptome, surface proteome, and immunoreceptor sequencing data were generated on 580,040 high-quality cells, derived from 187 samples from 61 patients. For a subset of individuals, we obtained samples before and during infection, allowing intra-individual comparison. Longitudinal profiling demonstrated distinct temporal gene expression trajectories in severe/critical versus mild/moderate COVID-19. We identified a population of transcriptionally distinct monocytes that emerged in peripheral blood following glucocorticoid treatment. Evaluation of clonal T cell dynamics showed that the fastest expanding clones were enriched in known SARS-CoV-2-specific sequences and shared across multiple patients. Comparison with external datasets revealed upregulation of immune cell TGF-β pathway expression in ESKD, irrespective of COVID-19 status. Our data delineate the temporal dynamics of the immune response in COVID-19 in a high-risk population.

How inflammation or disease regulates coronavirus lipid membranes is currently unknown, while patient-derived viral envelopes have never been structurally characterized. Here, we show that four cultured SARS-CoV-2 strains (England2, Alpha, Beta, and Delta) possess conserved, phospholipid- and cholesterol-rich envelopes, with pro-thrombotic and infection-promoting aminophospholipids (aPL) displayed predominantly on the outer leaflet (approximately 70-80%). Exposure to interleukin-4 (IL-4) markedly altered envelope fatty acyl composition, whereas interleukin-6 (with or without its soluble receptor IL-6Ra) and dexamethasone had no detectable effect. Viral envelopes were susceptible to hydrolysis by secretory phospholipase A2 (sPLA2), an enzyme associated with adverse clinical outcomes. SARS-CoV-2 isolated directly from patient saliva exhibited cholesterol-enriched envelopes that were highly conserved across clinical isolates. In addition, clinical samples contained pro-coagulant oxidized phospholipids and bioactive lipoxygenase (LOX)-derived oxylipins. The dominance of external facing pro-coagulant aPL and eoxPL may support known thrombotic complications of severe COVID19 viremia. Last, gene-silencing experiments demonstrated that 15-LOX2 is required for replication of related coronaviruses. Together, these findings reposition the coronavirus envelope as an active, dynamic structure rather than a passive scaffold, and challenge the protein-centric view of viral function. The lipid envelope is proposed as a potential therapeutic target through modulation of host innate immunity, and dampening thrombotic potential.

Background In patients with COVID-19 requiring supplemental oxygen, dexamethasone reduces acute severity and improves survival, but longer-term effects are unknown. We hypothesised that systemic corticosteroid administration during acute COVID-19 would be associated with improved health-related quality of life (HRQoL) one year after discharge. Methods Adults admitted to hospital between February 2020 and March 2021 for COVID-19 and meeting current guideline recommendations for dexamethasone treatment were included using two prospective UK cohort studies. HRQoL, assessed by EQ-5D-5L utility index, pre-hospital and one year after discharge were compared between those receiving corticosteroids or not after propensity weighting for treatment. Secondary outcomes included patient reported recovery, physical and mental health status, and measures of organ impairment. Sensitivity analyses were undertaken to account for survival and selection bias. Findings In 1,888 participants included in the primary analysis, 1,149 received corticosteroids. There was no between-group difference in EQ-5D-5L utility index at one year (mean difference 0.004, 95% CI: -0.026 to 0.034, p = 0.77). A similar reduction in EQ-5D-5L was seen at one year between corticosteroid exposed and non-exposed groups (mean (SD) change -0.12 (0.22) vs -0.11 (0.22), p = 0.32). Overall, there were no differences in secondary outcome measures. After sensitivity analyses modelled using a larger cohort of 109,318 patients admitted to hospital with COVID-19, EQ-5D-5L utility index at one year remained similar between the two groups. Interpretation Systemic corticosteroids for acute COVID-19 have no impact on the large reduction in HRQoL one year after hospital discharge. Treatments to address this are urgently needed. ### Competing Interest Statement AART declares that their institute was awarded a fellowship from British Heart Foundation and grant funding from Heart Research UK and National Institute for Health and Care Research; payment for lectures and presentations received from Janssen-Cilag Ltd; support for attending meetings from Janssen-Cilag Ltd. AH​ declares that their institute was awarded funding from UK Research and Innovation (MR/V027859/1), National Institute of Health Research (COV0319) and NIHR Manchester BRC; leadership or fiduciary role as Chair for NIHR Translational Research Collaboration. AS declares that their institute was awarded joint funding from UKRI & NIHR (MR/V027859/1 and COV0319) to complete this work. AB declares consulting fees from Roche, Merck, Sanofi and GSK. ABD​ declares that they were awarded funding from Wellcome Clinical Research Career Development Fellowship (216606/Z/19/Z) to complete this work. ADS​ declares that their institute was awarded grant funding from AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer outside the submitted manuscript; consulting fees from AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer, Insmed, Gilead; payment for lectures and presentations received by AstraZeneca, Bayer, GSK, Chiesi, Novartis, Pfizer, Insmed, Gilead, 30T; participation on a Data Safety Monitoring Board or Advisory Board for Bayer; receipt of drugs from GSK outside the submitted manuscript. AShe declares that their institute was awarded grant funding from NIHR and UKRI to complete this work; participation on a Data Safety Monitoring Board or Advisory Board for Astra-Zenecas Thrombotic Thrombocytopenic Taskforce; leadership or fiduciary role for UK and Scottish Government COVID-19 advisory groups. CE declares a grant from GSK. CEB declares that their institute received grant funding from NIHR/UKRI and NIHR to complete this work; their institute received grant funding from Nottingham Hospitals Charity and University of Nottingham. CEBr declares that their institute received grant funding from MRC/NIHR and NIHR to complete this work; their institute received grant funding from GSK, AZ, Sanofi, Regeneron, Roche, Genentech, BI, Novartis, Chiesi, 4Dpharma, Mologic; consulting fees from GSK, AZ, Sanofi, Regeneron, Roche, Genentech, BI, Novartis, Chiesi, 4Dpharma, Mologic, Areteia. DP declares funding from NIHR and MRC; leadership or fiduciary role for Faculty of Intensive Care Medicine Board. GPM declares funding from NIHR (RP-2017-ST2-007) to complete this work; funding from British Heart Foundation, Wellcome Trust and NIHR; research support from Resonance Health, Circle CVi and Perspectum. RGJ declares that their institute received funding from Astra Zeneca, Biogen, Galecto, GlaxoSmithKline, Nordic Biosciences, RedX and Pliant; consulting fees from AstraZeneca, Brainomix, Bristol Myers Squibb, Chiesi, Cohbar, Daewoong, GlaxoSmithKline, Veracyte, Resolution Therapeutics and Pliant; payment for lectures and presentations received from Boehringer Ingelheim, Chiesi, Roche, PatientMPower, AstraZeneca; payment for expert testimony from Pinsent Masons LLP; participation on a Data Safety Monitoring Board or Advisory Board for Boehringer Ingelheim, Galapagos, Vicore; leadership or fiduciary role for NuMedii and president for Action for Pulmonary Fibrosis. GC declares funding from GlaxoSmithKline and AstraZeneca; received honoraria for delivering talks from GSK, AZ, Chiesi, BI; participation on a Data Safety Monitoring Board or Advisory Board as Chair on the Act on COPD Programme for AZ in Scotland; leadership or fiduciary role as Chair for the Lothian Respiratory Managed Clinical Network. JDC declares funding from AstraZeneca, Boehringer Ingelheim, Grifols, Gilead sciences, Insmed, Genentech, Glaxosmithkline; consulting fees from AstraZeneca, Boehringer Ingelheim, Grifols, Gilead sciences, Insmed, Genentech, Glaxosmithkline, Antabio, Zambon, Trudell; leadership or fiduciary roles as Chief Editor of European Respiratory Journal, Chair of British Thoracic Society Science and Research Committee and Trustee of the British Thoracic Society. JTS declares funding from UKRI. JKQ declares that their institute received funding from Industrial Strategy Challenge Fund, the Medical Research Council, Health Data Research, GSK, BI, asthma+lung UK, AZ; consulting fees from GlaxoSmithKline, Evidera, Chiesi, AstraZeneca, Insmed. JP declares funding from Breathing Matters and UCL/H BRC (NIHR); consulting fees from The Limbic. JJ declares funding from Gilead, Microsoft Research, GlaxoSmithKline; consulting fees from Boehringer Ingelheim, Roche, GlaxoSmithKline, NHSX; payment for lectures and presentations received from Boehringer Ingelheim, Roche, GlaxoSmithKline, Takeda; support for attending meetings and/or travel from Boehringer Ingelheim; patents planned, issued or pending (UK patent application number 2113765.8 and UK patent application number GB2211487.0); participation on a Data Safety Monitoring Board or Advisory Board for Boehringer Ingelheim and Roche. JRH declares funding from AstraZeneca; consulting fees from AstraZeneca and GSK; payment for lectures and presentations received from AstraZeneca, Boehringer Ingelheim, Chiesi, Sanofi, Takeda; support for attending meetings and/or travel from AstraZeneca; participation on a Data Safety Monitoring Board or Advisory Board for AstraZeneca; Receipt of equipment from Nonin. LGH declares that their institute received funding from GSK, Astra Zeneca, Roche/Genentech; payment for lectures received from Astra Zeneca, Novartis, Roche / Genentech, Sanofi, Circassia, GlaxoSmithKline, Chiesi, Teva; support to travel to meetings from AstraZeneca and GSK; participation on a Data Safety Monitoring Board or Advisory Board for Novartis, Roche/Genentech, GSK, Teva and Celltrion. LH-W declares funding from NIHR (RfPB grant PB-PG-0317-20032). LVW declares funding from UK Research and Innovation (MR/V027859/1), GSK/Asthma + Lung UK (Professorship (C17-1)) and National Institute of Health Research (COV0319) to complete this work; funding from Orion Pharma, GSK, Genentech, AstraZeneca, Nordic Bioscience, Sysmex (OGT); Consulting fees Galapagos, Boehringer Ingelheim, GSK; support for attending meetings and/or travel Genentech; participation on Advisory Board for Galapagos; leadership or fiduciary roles as Associate Editor for European Respiratory Journal and Medical Research Council Board member and Deputy Chair. MGS declares grant funding from National Institute of Health Research UK, Medical Research Council UK and Health Protection Research Unit in Emerging & Zoonotic Infections, University of Liverpool to complete this work; participation on a Data Safety Monitoring Board or Advisory Board for Pfizer; leadership or fiduciary roles as Chair of Infectious Disease Scientific Advisory Board Integrum Scientific LLC and Director of MedEx Solutions Ltd; Stock or stock options as minority owner of Integrum Scientific LLC and majority owner of MedEx Solutions Ltd; receipt of equipment, materials, drugs, medical writing, gifts or other services from Chiesi Farmaceutici S.p.A.; non-remunerated independent member of HMG UK Scientific Advisory Group for Emergencies (SAGE), COVID-19 Response (March 2020 to March 2022) and non-remunerated independent member of HMG UK New Emerging Respiratory Virus Threats Advisory Group (NERVTAG) (2014 to July 2023). MJ declares funding from MRC to complete this work; funding from MRC, British Lung Foundation and Boehringher Ingelheim; consulting fees from Skyhawk therapeutics; leadership or fiduciary role in AAIR Charity Scientific Committee. MT declares grant funding from NIHR Cambridge BRC and NIHR HTA to complete this work; consulting fees from Jansen; support for attending meetings and/or travel from GSK, Jansen; participation on a Data Safety Monitoring Board or Advisory Board for ComCov and FluCov. MJR declares support for attending meetings and/or travel from Novartis Pharmaceuticals; stock or stock options from Novartis Pharmaceuticals and Roche Pharmaceuticals; employed full time as a Senior Clinical Development Medical Director at Novartis Pharmaceuticals. MJD declares grant funding from Novo Nordisk, Sanofi-Aventis, Lilly, Boehringer Ingelheim, AstraZeneca and Janssen; consulting fees from Eli Lilly, Boehringer Ingelheim, Novo Nordisk and Sanofi; payment for speaking for Boehringer Ingelheim, Lilly, Novo Nordisk, Sanofi, AstraZeneca, Amgen, Napp Pharmaceuticals and Novartis; advisory Board Member for Boehringer Ingelheim, Lilly, Novo Nordisk, Sanofi, Lexicon, Pfizer, Medtronic and ShouTi Pharma Inc., Zealand Pharma. MM declares that their institute received joint funding from UKRI & NIHR to complete this work. NDB declares they have received non-restrictive educational grants from Chiesi, AZ, and Teva for attending conferences; honoraria from TEVA, AZ, and GSK; support for attending meetings and/or travel from Chiesi and AZ; participation on a Data Safety Monitoring Board or Advisory Board for TEVA. NE declares receipt of equipment from Global Access Diagnostics (previously Mologic Inc). OCL declares that their institute received joint funding from UKRI & NIHR- grant (MR/V027859/1 and COV0319) to complete this work. PEP declares funding from NIHR. PJMO declares funding from UKRI-MRC/DHSC NIHR and UKRI-BEIS. RAE declares funding from UKRI/MRC/NIHR to complete this work; funding from Wolfson Foundation and Genentech/Roche; consulting fees from AstraZeneca/Evidera; payment for speaking fees from Boeringher and Moderna; support for attending meetings from Chiesi; leadership or fiduciary role as ERS Group 01.02 Pulmonary Rehabilitation and Chronic Care Secretary and ATS Pulmonary Rehabilitation Assembly Chair. RA declares lecture fees from Boehringer Ingelheim; support for attending meeting from Boehringer Ingelheim. SJS declares grants or contracts from NIHR (programme Grant (NIHR 202020)_, Wellcome Doctoral Training Programme, HTA Project Grant (NIHR: 131015), NIHR DHSC/UKRI COVID-19 Rapid Response Initiative, NIHR Global Research Group (NIHR 17/63/20), Actegy Limited and NIHR Senior Investigator; payment for presentations for GSK, Ministry of Justice, CIPLA, Sherbourne Gibbs; participation on NICE Expert Adviser Panel (long COVID), Wales Long COVID Advisory Board and NHS-E Long Covid Your Covid Recovery working group; leadership or fiduciary role as ATS Pulmonary Rehabilitation Assembly Chair, Clinical Lead RCP Pulmonary Rehabilitation Accreditation Scheme and Clinical Lead NACAP Audit for Pulmonary Rehabilitation. SR-J declares that their institute received funding from UKRI to complete this work; their institute received funding from NIHR Sheffield Biomedical Research centre, Bill & Melinda Gates Foundation, UKRI (MRC) and EDCTP. SH declares consulting fees from NovoNordisk; participation on a Data Safety Monitoring Board or Advisory Board for Eli Lilly with payments made Institution. SN declares grant funding from Oxford NIHR Biomedical Research centre. WD-CM declares that their institute received funding from National Institute for Health Research and NHS Accelerated Access Collaborative; leadership or fiduciary role as Honorary President of the Association for Respiratory Technology and Physiology. ### Clinical Protocols ### Funding Statement PHOSP-COVID is supported by a grant from the MRC-UK Research and Innovation and the Department of Health and Social Care through the National Institute for Health Research (NIHR) rapid response panel to tackle COVID-19. The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: PHOSP-COVID was approved by the Leeds West Research Ethics Committee (20/YH/0225) and is registered on the ISRCTN Registry ([ISRCTN10980107][1]). ISARIC was approved by the South Central - Oxford C Research Ethics Committee in England and the Scotland A Research Ethics Committee. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The PHOSP-COVID study website (https://www.phosp.org) contains an overview of the study, resources, information about people involved, and publications. Research activity using the study is organised across a series of Working Groups. These were established at the outset of the study to coordinate research, minimise duplication of efforts, and facilitate communication across research and clinical specialties. Researchers interested in undertaking research using PHOSP-COVID are encouraged to contact the relevant Working Group leads (https://www.phosp.org/working-group/) in the first instance. The data are currently held in the Outbreak Data Analysis Platform (ODAP, https://odap.ac.uk/). Researchers seeking to access these data are directed to https://www.phosp.org/resource/ for information and forms. Correspondence to be directed to Dr Rachael A Evans, the Co-Principal Investigator of PHOSP-COVID study phosp@leicester.ac.uk. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN10980107

Alveolar macrophages (AM) are key effectors of the immune response and are essential for host responses to S. pneumoniae. Mitochondria are highly dynamic organelles whose function aids in regulating the cell cycle, innate immunity, autophagy, redox signaling, calcium homeostasis, and mitochondrial quality control in AM. In response to cellular stress, mitochondria can engage in stress-induced mitochondrial hyperfusion (SIMH). The current study aimed to investigate the role of Mfn1 on mitochondrial control of reactive oxygen species (ROS) in AMs and the role of Mfn1 deficiency on immune responses to S. pneumoniae. Compared to Mfn1FloxCre- controls, there were distinct histological differences in lung tissue collected from Mfn1Floxed; CreLysM mice, with less injury and inflammation observed in mice with Mfn1 deficient myeloid cells. There was a significant decrease in lipid peroxidation and ROS production in Mfn1 deficient AM that was associated with increased superoxide dismutase (SOD) and antioxidant activity. Our findings demonstrate that Mfn1 deficiency in myeloid cells decreased inflammation and lung tissue injury during S. pneumoniae infection.

BACKGROUND:The humoral and T-cell responses to booster COVID-19 vaccine types in multidisease immunocompromised individuals who do not generate adequate antibody responses to two COVID-19 vaccine doses, is not fully understood. The OCTAVE DUO trial aimed to determine the value of third vaccinations in a wide range of patients with primary and secondary immunodeficiencies. METHODS:OCTAVE-DUO was a prospective, open-label, multicentre, randomised, controlled, phase 3 trial investigating humoral and T-cell responses in patients who are immunocompromised following a third vaccine dose with BNT162b2 or mRNA-1273, and of NVX-CoV2373 for those with lymphoid malignancies. We recruited patients who were immunocompromised from 11 UK hospitals, aged at least 18 years, with previous sub-optimal responses to two doses of SARS-CoV-2 vaccine. Participants were randomly assigned 1:1 (1:1:1 for those with lymphoid malignancies), stratified by disease, previous vaccination type, and anti-spike antibody response following two doses. Individuals with lived experience of immune susceptibility were involved in the study design and implementation. The primary outcome was vaccine-specific immunity defined by anti-SARS-CoV-2 spike antibodies (Roche Diagnostics UK and Ireland, Burgess Hill, UK) and T-cell responses (Oxford Immunotec, Abingdon, UK) before and 21 days after the third vaccine dose analysed by a modified intention-to-treat analysis. The trial is registered with the ISRCTN registry, ISRCTN 15354495, and the EU Clinical Trials Register, EudraCT 2021-003632-87, and is complete. FINDINGS:Between Aug 4, 2021 and Mar 31, 2022, 804 participants across nine disease cohorts were randomly assigned to receive BNT162b2 (n=377), mRNA-1273 (n=374), or NVX-CoV2373 (n=53). 356 (45%) of 789 participants were women, 433 (55%) were men, and 659 (85%) of 775 were White. Anti-SARS-CoV-2 spike antibodies measured 21 days after the third vaccine dose were significantly higher than baseline pre-third dose titres in the modified intention-to-treat analysis (median 1384 arbitrary units [AU]/mL [IQR 4·3-7990·0] compared with median 11·5 AU/mL [0·4-63·1]; p<0·001). Of participants who were baseline low responders, 380 (90%) of 423 increased their antibody concentrations to more than 400 AU/mL. Conversely, 166 (54%) of 308 baseline non-responders had no response after the third dose. Detectable T-cell responses following the third vaccine dose were seen in 494 (80%) of 616 participants. There were 24 serious adverse events (BNT612b2 eight [33%] of 24, mRNA-1273 12 [50%], NVX-CoV2373 four [17%]), two (8%) of which were categorised as vaccine-related. There were seven deaths (1%) during the trial, none of which were vaccine-related. INTERPRETATION:A third vaccine dose improved the serological and T-cell response in the majority of patients who are immunocompromised. Individuals with chronic renal disease, lymphoid malignancy, on B-cell targeted therapies, or with no serological response after two vaccine doses are at higher risk of poor response to a third vaccine dose. FUNDING:Medical Research Council, Blood Cancer UK.

The chaperone protein EROS (“Essential for Reactive Oxygen Species”) was recently discovered in phagocytes. EROS was shown to regulate the abundance of the ROS-producing enzyme NADPH oxidase isoform 2 (NOX2) and to control ROS-mediated cell killing. Reactive oxygen species are important not only in immune surveillance, but also modulate physiological signaling responses in multiple tissues. The roles of EROS have not been previously explored in the context of oxidant-modulated cell signaling. Here we show that EROS plays a key role in ROS-dependent signal transduction in vascular endothelial cells. We used siRNA-mediated knockdown and developed CRISPR/Cas9 knockout of EROS in human umbilical vein endothelial cells (HUVEC), both of which cause a significant decrease in the abundance of NOX2 protein, associated with a marked decrease in RAC1, a small G protein that activates NOX2. Loss of EROS also attenuates receptor-mediated hydrogen peroxide (H2O2) and Ca2+ signaling, disrupts cytoskeleton organization, decreases cell migration, and promotes cellular senescence. EROS knockdown blocks agonist-modulated eNOS phosphorylation and nitric oxide (NO●) generation. These effects of EROS knockdown are strikingly similar to the alterations in endothelial cell responses that we previously observed following RAC1 knockdown. Proteomic analyses following EROS or RAC1 knockdown in endothelial cells showed that reduced abundance of these two distinct proteins led to largely overlapping effects on endothelial biological processes, including oxidoreductase, protein phosphorylation, and endothelial nitric oxide synthase (eNOS) pathways. These studies demonstrate that EROS plays a central role in oxidant-modulated endothelial cell signaling by modulating NOX2 and RAC1.

### Competing Interest Statement Full COI statement included in the submitted manuscript. ### Clinical Protocols ### Funding Statement This work was supported by a joint funding from the UK Research and Innovation and National Institute of Health Research [grant references: MR/V027859/1 and COV0319]. The views expressed in the publication are those of the author(s) and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Leeds West Research Ethics Committee (20/YH/0225) and is registered on the ISRCTN Registry ([ISRCTN10980107][1]). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The PHOSP-COVID study website () contains an overview of the study, resources, information about people involved, and publications. Research activity using the study is organised across a series of Working Groups ([Figure 3][2]). These were established at the outset of the study to coordinate research, minimise duplication of efforts, and facilitate communication across research and clinical specialties. Researchers interested in undertaking research using PHOSP-COVID are encouraged to contact the relevant Working Group leads () in the first instance. The data are currently held in the Outbreak Data Analysis Platform (ODAP, ). Researchers seeking to access these data are directed to for information and forms. Correspondence to be directed to Dr Rachael A Evans, the Co-Principal Investigator of PHOSP-COVID study phosp{at}leicester.ac.uk. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN10980107 [2]: #F3

Background In patients with coronavirus disease 2019 (COVID-19) requiring supplemental oxygen, dexamethasone reduces acute severity and improves survival, but longer-term effects are unknown. We hypothesised that systemic corticosteroid administration during acute COVID-19 would be associated with improved health-related quality of life (HRQoL) 1 year after discharge. Methods Adults admitted to hospital between February 2020 and March 2021 for COVID-19 and meeting current guideline recommendations for dexamethasone treatment were included using two prospective UK cohort studies (Post-hospitalisation COVID-19 and the International Severe Acute Respiratory and emerging Infection Consortium). HRQoL, assessed by the EuroQol-Five Dimensions-Five Levels utility index (EQ-5D-5L UI), pre-hospital and 1 year after discharge were compared between those receiving corticosteroids or not after propensity weighting for treatment. Secondary outcomes included patient-reported recovery, physical and mental health status, and measures of organ impairment. Sensitivity analyses were undertaken to account for survival and selection bias. Findings Of the 1888 participants included in the primary analysis, 1149 received corticosteroids. There was no between-group difference in EQ-5D-5L UI at 1 year (mean difference 0.004, 95% CI -0.026-0.034). A similar reduction in EQ-5D-5L UI was seen at 1 year between corticosteroid exposed and nonexposed groups (mean +/- SD change -0.12 +/- 0.22 versus -0.11 +/- 0.22). Overall, there were no differences in secondary outcome measures. After sensitivity analyses modelled using a cohort of 109 318 patients admitted to hospital with COVID-19, EQ-5D-5L UI at 1 year remained similar between the two groups. Interpretation Systemic corticosteroids for acute COVID-19 have no impact on the large reduction in HRQoL 1 year after hospital discharge. Treatments to address the persistent reduction in HRQoL are urgently needed.

Increasing rates of autoimmune and inflammatory disease present a burgeoning threat to human health1. This is compounded by the limited efficacy of available treatments1 and high failure rates during drug development2, highlighting an urgent need to better understand disease mechanisms. Here we show how functional genomics could address this challenge. By investigating an intergenic haplotype on chr21q22-which has been independently linked to inflammatory bowel disease, ankylosing spondylitis, primary sclerosing cholangitis and Takayasu's arteritis3-6-we identify that the causal gene, ETS2, is a central regulator of human inflammatory macrophages and delineate the shared disease mechanism that amplifies ETS2 expression. Genes regulated by ETS2 were prominently expressed in diseased tissues and more enriched for inflammatory bowel disease GWAS hits than most previously described pathways. Overexpressing ETS2 in resting macrophages reproduced the inflammatory state observed in chr21q22-associated diseases, with upregulation of multiple drug targets, including TNF and IL-23. Using a database of cellular signatures7, we identified drugs that might modulate this pathway and validated the potent anti-inflammatory activity of one class of small molecules in vitro and ex vivo. Together, this illustrates the power of functional genomics, applied directly in primary human cells, to identify immune-mediated disease mechanisms and potential therapeutic opportunities.

Abstract Recent advances in -omics technologies enable detailed evaluation of the human immune system in the context of important clinical phenotypes. Here, we apply such technologies to investigate predictors of vaccine immune responsiveness in individuals with a range of immunosuppressive conditions who are vulnerable to COVID-19 vaccine failure. Using bulk and single-cell RNA sequencing (scRNA-seq), Olink proteomics and spectral flow cytometry we assessed the pre- and 21 days post-third dose COVID-19 mRNA vaccine immunophenotype of 133 immunocompromised individuals and 22 healthy controls. Machine learning dependent analyses associated these phenotypes with vaccine-induced antibody and T cell responses. We identified distinct pre-vaccination transcriptional signatures which predicted post-vaccine antibody responsiveness across immunosuppressive conditions. Signatures included increased B cell related gene modules and decreased inflammatory and monocyte related modules. These patterns were confirmed by detailed cellular and proteomic immunophenotyping. Persistence of this altered phenotype after vaccination was observed using scRNA-seq, which gave insights into the cellular identity of signatures related to vaccine responsiveness. Through comprehensive immune profiling of pre- and post-vaccine blood samples from immunocompromised individuals we identify novel cellular and molecular signatures that predict vaccine responsiveness, and give insight into mechanisms of vaccine failure.

Whilst SARS-CoV-2 mRNA vaccines generate high neutralising antibodies (nAb) in most individuals, haematopoietic stem cell transplant (HSCT) and chimeric antigen receptor T-cell (CAR-T) recipients respond poorly. HSCT/CAR-T treatment ablates existing immune memory, with recipients requiring revaccination analogous to being vaccine naive. An optimal revaccination strategy for this cohort has not been defined. Factors predicting immunogenicity following three ancestral SARS-CoV-2 vaccines were assessed in 198 HSCT/CAR-T recipients and 96 healthcare workers (HCWs) recruited to multicentre studies. Only 25% of HSCT/CAR-T recipients generated nAbs following one dose, with titres 167-fold and 7-fold lower than that in HCWs after the first and second doses, respectively. Lower post-second dose nAb titres were associated with older age, rituximab use, and previous HSCT. ChAdOx1-S recipients were more likely to generate nAbs compared with mRNA vaccines, with titres comparable to HCWs. In contrast, nAbs were significantly lower in HSCT/CAR-T recipients than HCWs after mRNA vaccination. The poor first-dose immunogenicity in HSCT/CAR-T recipients suggests a minimum licensed dosing interval could limit the period of vulnerability following HSCT/CAR-T. The relative preservation of nAbs with ChAdOx1-S vaccination highlights the importance of evaluating alternative platforms to mRNA vaccination within this highly vulnerable clinical cohort.

Inpatient treatment of hyperkalaemia with insulin and dextrose can be complicated by iatrogenic hypoglycaemia. We sought to assess the incidence of hypoglycaemia in hospitalised patients with renal disease and assess the impact of the introduction of a local guideline incorporating the use of sodium zirconium cyclosilicate (SZC) for patients with moderate hyperkalaemia. After establishing a significant burden of hypoglycaemia in the initial observation period, a requirement for hourly capillary blood glucose monitoring (for up to 6 h) following the administration of insulin for hyperkalaemia was incorporated into the guidelines. The two-fold introduction of SZC alongside changes in patient care after the administration of insulin/dextrose resulted in more appropriate use of insulin/dextrose, as well as a significant (73%) reduction in the iatrogenic burden of hypoglycaemia ( P = 0.04).

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune responses and infection outcomes were evaluated in 2,686 patients with varying immune-suppressive disease states after administration of two Coronavirus Disease 2019 (COVID-19) vaccines. Overall, 255 of 2,204 (12%) patients failed to develop anti-spike antibodies, with an additional 600 of 2,204 (27%) patients generating low levels (<380 AU ml −1 ). Vaccine failure rates were highest in ANCA-associated vasculitis on rituximab (21/29, 72%), hemodialysis on immunosuppressive therapy (6/30, 20%) and solid organ transplant recipients (20/81, 25% and 141/458, 31%). SARS-CoV-2-specific T cell responses were detected in 513 of 580 (88%) patients, with lower T cell magnitude or proportion in hemodialysis, allogeneic hematopoietic stem cell transplantation and liver transplant recipients (versus healthy controls). Humoral responses against Omicron (BA.1) were reduced, although cross-reactive T cell responses were sustained in all participants for whom these data were available. BNT162b2 was associated with higher antibody but lower cellular responses compared to ChAdOx1 nCoV-19 vaccination. We report 474 SARS-CoV-2 infection episodes, including 48 individuals with hospitalization or death from COVID-19. Decreased magnitude of both the serological and the T cell response was associated with severe COVID-19. Overall, we identified clinical phenotypes that may benefit from targeted COVID-19 therapeutic strategies.

Background: Optimal SARS-CoV-2 vaccination strategy in immunocompromised individuals who fail to mount adequate antibody responses to two vaccine doses is unknown. Methods: OCTAVE-DUO was a prospective, open-label, multi-centre, phase III trial investigating humoral and T-cell responses in immunocompromised patients following a third vaccine dose with BNT162b2 or mRNA-1273, and for lymphoid malignancies, NVX-CoV2373. It recruited immunocompromised patients from 11 UK hospitals, aged >18 years, with prior sub-optimal responses to two doses of SARS-CoV-2 vaccine. Participants were randomised 1:1 (1:1:1 for lymphoid malignancies), stratified by disease, previous vaccination type, and anti-spike antibody response following two doses.The primary outcome was vaccine-specific immunity defined by anti-spike SARS-CoV-2 antibody (Roche Elecsys) and T-cell responses (Oxford Immunotec) prior to and 21 days post third dose analysed by a modified intention to treat analysis.ISRCTN 15354495. Trial is closed. Findings: Between 4-Aug-2021 and 31-Mar-2022, 804 participants across nine disease cohorts were randomised to BNT162b2 (n=377), 374 mRNA-1273 (n=374), and NVX-CoV2373 (n=53).The third vaccine dose induced significantly higher anti-spike antibody levels than pre-third dose (baseline) levels. 90% of participants who were baseline low responders increased their antibody levels to above 400AU/mL. Conversely, 54% of baseline non-responders had no response. Detectable T-cell responses following the third vaccine dose were observed in 80% participants.Age >75 years, B-cell targeted therapies, anti-metabolites, or calcineurin inhibitors increased the risk of a serological non-response to the third vaccine. Similarly, a lack of T-cell response post two doses, age >75 years and treatment with calcineurin inhibitors, or corticosteroids reduced the likelihood of a T-cell response. Interpretation: A third vaccine dose improved the serological and T-cell response in the majority of immunocompromised patients. Individuals with chronic renal disease, lymphoid malignancy, B-cell targeted therapies, or an absent response after two vaccine doses are at higher risk of poor response. Trial Registration: The trial was registered on ISRCTN 15354495 (26-Jul-2021) and the EU Clinical Trials Register with EudraCT number 2021-003632-87 (29-Jun-2021). Registration to both was prospective, prior to recruitment of the first patient on 04-Aug-2021.Funding: Medical Research Council [grant number MR/W020653/1]Blood Cancer UK [award reference 21023].Declaration of Interest: DR research funding/honoraria and/or consultancy fees from Novartis, Pfizer, Lily Roche, Astra Zeneca/Diiachi Sankyo, Biotheranostics, RNA diagnostics, and Celgene; EB research funding and/or consultancy fees from Roche, Vaccitech and AZ, holds patents in ChAdOx1 HBV and HCV vaccines; HP honoraria from AZ; IMB research funding and/or consultancy fees from Abbvie, Amgen, BMS, Causeway Therapeutics Cabaletta, Eli Lilly, Evelo, Gilead, GSK, Janssen, Novartis, Pfizer, Sanofi Regeneron, and UCB Pharma; KO royalties to institution from Telix Pharmaceuticals for Radiolabelled anti-CD66 antibody; KLY honoraria from Sanofi Genzyme, Takeda, Amgen and meeting attendance support from Takeda; MJA research funding from Pfizer; MW research funding from Oxford Immunotech; MBCK honoraria from Gilead; MC consultancy fees from VacciTech; PK research funding and/or consultancy fees from Bayer, AZ, Merck and BMS; SM stock or stock options in TCB BioPharm; SHL honoraria from AZ; SS research funding and/or consultancy fees from AbbVie, Amgen (previously Celgene), Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, GSK, Janssen, and UCB; and SOB research funding and/or consultancy fees from CSL Behring, GSK, Baxalta US Inc and Biotest. All other authors declare no conflicts of interest.Ethical Approval: The trial was conducted in accordance with the principles of the Good Clinical Practice (GCP) guidelines and the Declaration of Helsinki. It was approved by the UK Medicines and Healthcare Products Regulatory Agency (MHRA) on the 19-Jul-2021 and the first amendment approved on 23 -Jul-2021 by MHRA and the London and Fulham Research Ethics Committee (REC 302634). Subsequent amendments were approved by MHRA on 13-Oct-2021, 26-Nov-2021 and 14-Jun-2022 and by REC on 01-Nov-2021, 03-Dec-2021, and 06-Jun-2022. A separate CAR T-cell therapy disease cohort was introduced in the November amendment. The trial was overseen by an independent Data Monitoring Committee. All patients gave written informed consent.

Increasing global rates of autoimmune and inflammatory disease present a burgeoning threat to human health 1 . This is compounded by the limited efficacy of available treatments 1 and high failure rates during drug development 2 – underscoring an urgent need to better understand disease mechanisms. Here we show how genetics could address this challenge. By investigating an intergenic haplotype on chr21q22, independently linked to inflammatory bowel disease (IBD), ankylosing spondylitis, primary sclerosing cholangitis and Takayasu’s arteritis 3–6 , we discover that the causal gene, ETS2 , is a master regulator of inflammatory responses in human macrophages and delineate how the risk haplotype increases ETS2 expression. Genes regulated by ETS2 were prominently expressed in affected tissues from chr21q22-associated diseases and more enriched for IBD GWAS hits than almost all previously described pathways. Overexpressing ETS2 in resting macrophages produced an activated effector state that phenocopied intestinal macrophages from IBD 7 , with upregulation of multiple drug targets including TNFα and IL-23. Using a database of cellular signatures 8 , we identify drugs that could modulate this pathway and validate the potent anti-inflammatory activity of one class of small molecules in vitro and ex vivo . Together, this highlights the potential for common genetic associations to improve both the understanding and treatment of human disease.

Chronic Granulomatous Disease (CGD) is an inborn error of immunity characterised by opportunistic infection and sterile granulomatous inflammation. CGD is caused by a failure of reactive oxygen species (ROS) production by the phagocyte NADPH oxidase. Mutations in the genes encoding phagocyte NADPH oxidase subunits cause CGD. We and others have described a novel form of CGD (CGD5) secondary to lack of EROS (CYBC1), a highly selective chaperone for gp91phox. EROS-deficient cells express minimal levels of gp91phox and its binding partner p22phox, but EROS also controls the expression of other proteins such as P2X7. The full nature of CGD5 is currently unknown. We describe a homozygous frameshift mutation in CYBC1 leading to CGD. Individuals who are heterozygous for this mutation are found in South Asian populations (allele frequency = 0.00006545), thus it is not a private mutation. Therefore, it is likely to be the underlying cause of other cases of CGD.

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 50 months (IQR 42-63) 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<00001) and independently associated with COVID-19 status (odds ratio [OR] 29 [95% CI 15-58]; p(adjusted)=00023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=00001; parenchymal abnormalities), brain abnormalities (p<00001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0014; 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 598 years [SD 117] with multiorgan abnormalities vs mean age of 528 years [119] without multiorgan abnormalities; p<00001), more likely to have three or more comorbidities (OR 247 [132-482]; p(adjusted)=00059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 355 [123-1188]; p(adjusted)=0025) 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.

Background and PurposeCardiac glycosides inhibit Na+/K+‐ATPase and are used to treat heart failure and arrhythmias. They can induce inflammasome activation and pyroptosis in macrophages, suggesting cytotoxicity, which remains to be elucidated in human tissues.Experimental ApproachTo determine the cell‐type specificity of this cytotoxicity, we used human monocyte‐derived macrophages and non‐adherent peripheral blood cells from healthy donors, plus omental white adipose tissue, stromal vascular fraction‐derived pre‐adipocytes and adipocytes from obese patients undergoing bariatric surgery. All these cells/tissues were treated with nanomolar concentrations of ouabain (50, 100, 500 nM) to investigate the level of cytotoxicity and the mechanisms leading to cell death. In white adipose tissue, we investigated ouabain‐mediated cytotoxicity by measuring insulin sensitivity, adipose tissue function and extracellular matrix deposition ex vivo.Key ResultsOuabain induced cell death through pyroptosis and apoptosis, and was more effective in monocyte‐derived macrophages compared to non‐adherent peripheral blood mononuclear cell populations. This cytotoxicity is dependent on K+ flux, as ouabain causes intracellular depletion of K+ and accumulation of Na+ and Ca2+. Consistently, the cell death caused by these ion imbalances can be rescued by addition of potassium chloride to human monocyte‐derived macrophages. Remarkably, when white adipose tissue explants from obese patients are cultured with nanomolar concentrations of ouabain, this causes depletion of macrophages, down‐regulation of type VI collagen levels and amelioration of insulin sensitivity ex vivo.Conclusion and ImplicationsThe use of nanomolar concentration of cardiac glycosides could be an attractive therapeutic treatment for metabolic syndrome, characterized by pathogenic infiltration and activation of macrophages.LINKED ARTICLESThis article is part of a themed issue on Inflammation, Repair and Ageing. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.9/issuetoc