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Good Night's thank you. So we're going to start again. Way lost of you in the audience. Hopefully not too many. Because actually, these are the two best talks. So we've gone. You've missed it. So it's a great pleasure to introduce Claire, who is a consultant geriatrician, but more importantly for this audience has been leading on the Zoey app. Now he's going to tell us on enormous amount of out what's happening really out there in terms of symptoms. A lot. Great. Well, I hope you can hear me. All right. Is that working? Okay, So looks like not happy. Yes. So fascinating to being here into here. You'll speak as a geriatrician because, of course, were one of the last sort of bastions of of general medicine. Really? And our approach is very much more disciplinary, and we're really interested in things that affect the whole body on the way we work in geriatric medicine is sort of almost built for long covert. So when Kobe it came around back in March 2020 a suggest attrition was very concerned, obviously, about clinical colleagues and on what's gonna happen in our clinical states because of Kobe, its effect on older people being so just fortunate. But also a zone epidemiologist was really keen to sort of really explore what is covered mean for patients in the community, a lot for people in the community that are getting it across multiple systems. So when we designed the Zodiac right back in March 2020 I put in all of the symptoms that I could think of that might be reflected in a multi disciplinary, a multi system disorder. Um, on. That's hard because I was already seeing patients in the places where I was working. You were already having multi system complaints. So that then led Teo. So I'm just going to disclose that I have consulted Bizarri because since then they've produced the help. Health is very healthy, which were we're doing to try to understand symptoms and how they will because a lot of different diseases on. But also I think you wanted me to disclose that I've got funding sort of a very stupid long coverage studies for from welcome trust in HR and so on. So this is the Zodiac. If you remember it, you might remember it because about 4.5 million people in the UK downtown did that back in 2020 and it's still going on. You can still report your symptoms on. In fact, we're looking at a range of different diseases now on Bright Back then, we were thinking about how could we use this for real time epidemiology, some at the disease over the whole country. Everybody really responded huge me because everybody wanted to do that. And, of course, that was before owner set up studies and so on. And so we were able to report on that before anyone else. But we're also when the first we had a report on wrong Cave in and I want to just tell you a bit of a story of where we've got to on. But we're able to tell right now about the current. Very. It's a swell, but back to our case history, because this is the key thing here that that I heard about a nice store right from the very beginning. This's nurses, finding that some colleagues are highly skeptical about her diagnosis on seem to have lost respect for her on a resentful that she's not returning to work on. I think that's such a prevalent experience of people with lung covert, and it still is today on. Ultimately, that's exactly what I set out to do, right The beginning because we saw that long was happening right from about April because we could see what we were trying to under a dentist. I help back with the incidents of long coat of cove it on to do incidence as opposed to travel. Inssue have to know how long symptoms last fall on. So we saw this big long tail of people like actually after 30 days, and you see that there was a lot of people still having symptoms today. So it was a real problem for us calculating incident. So we knew right from then that the long term it existed. But I spoke to my clinical colleagues and I said, Oh, you know, this is interesting in the patient groups of reporting it. And so my close colleagues said, Well, we know who our patients would be. That would get that we could pick, you know, we could. We could identify them from start off from start off. These are not necessary. This is not necessarily a really phenomenal. It's psychological. It's whatever Onda. I think that's something that we wanted to prove right the beginning. So what we did was we took 4180 individuals and who were reporting on Missouri up that had a positive test result on we compared their symptom reporting two individuals which had got a reason to go and get a covert test, which is that time remember, was based vengeance. They could only get a test if they had a fever, a cough, not even a nausea that time. Or they were admitted to hospital. Yeah, on. So we compared those individuals in terms of the center duration on the whole range of other characteristics. And so you can see that people who are negative have that put that respiratory illness but a negative. Their symptoms drop already quickly. Very, very few of them have symptoms along than 28 days, whereas in the long run, you know, really substantial proportion in our study, 13.3 In other studies, it's much higher than that. Remember, we're doing perspective reporting, you know, at every report. So once they get you know, one healthy report in this analysis, we take them out of analysis that we will show you that we then look at how they relapse, which would be obviously everybody knows about now on a smaller proportion of having symptoms more than 12 weeks. And actually these these figures have remained stable until four. So that two and 2% long coat is what we still see in the APP. It's much smaller of that of that 12 plus symptoms. It's much more than some other studies, but I think it is actually no far off. Actually, in terms of the really prevalence of protocol but syndrome, I think that's really important to understand that this is not something that happens to everybody is not like we've got an absolute tsunami of cases. Otherwise, with in London, we'd have far more than 4000 people going to the C. L. A chocolate nick you on sand. But the thing is, it is definitely real. It's definitely very significantly debilitating on it definitely needs further investigation because it's it's affecting a very large number of people now and so part of that was about it was gaining the evidence to get this cut point of four weeks is being a sort of like relevantly data driven cut point. But it's like describing long. So the second thing that she says is that I picked up on that case was that the's covert 19 s so that she'd had three failed attempts to return to work because she thought she had gotten all the way better. And then she didn't. And we talked about that lots of times today about this cycling's boom and bust thing on. Indeed, within this study, we then looked at how much those people relapse, and we found that individuals that were put cave it positive to start with were much more likely to then go back and get a relapse of symptoms later on. I think people who had got a different disease but still went for a test because of acute illness, um, so just a little bit, because we because there's been a lot of talk about long over here on, I just wanted to sort of like reflect back on these definitions and see how we might be able to moved towards a new definition. So these were formed in 2020 by Nice, based on data available from patient groups and from studies like ours. And they had a number relative they called Long Paper, which is symptoms that continual develop Article 19 for more than four weeks on. Then that's divided into two separate Catch Me is that they look at, which is ongoing symptomatic coated, which is 4 to 12 weeks on post covered syndrome and some of what I mean. So what we've heard about today is probably postcode syndrome rather than long. Paper is more than four weeks because there is this really quite sharp attrition of, of of the of the syndrome and improvement in symptoms that happens over that 4 to 12 week period on, um, you know, that probably partly explains the difference in the numbers that representing two services. So the key risk factors we've heard about them already in our case has some of those. She wasn't severely affected in the initial part, but we saw right at the beginning that the number of symptoms that you have within your first week of symptoms on also, of course, whether or not you need hospitalization, those air really key drivers on some of our sort of new work where we're looking at biomarkers in people who have long coma best. It's not. One of the strongest, very clear indicators is actually their initial immune response to the virus, which is a reflection of the disease severity Nazi. And so I think we've got to No, no, not not Lose sight of that as we move into the heat. But other different risk factors for for long cape it but agent sex have been sort of reeducated now in many different places. So there's a very strong female female second, abundance of long covered on. What's left known about is that is related to age up to about the age of 70 and eso you see if you know white a steep linear incline up to the age of about 70 and then people not coming but not not saying that they have not called it in in either the symptoms study or another longer to know population studies that I'm involved in, um, but actually in longer but services, we're seeing that there is actually very few people that have referred up in this in there sort of sixties and seventies, probably less on Where are those people going? Well, they might be going to someone like me in a complex geriatric assessment clinic. But of course they might then be missing out on long cable service. I think it got a little bit of stuff to do around age as well. In a move on, because you know we want to. We want to serve with through and get questions. So this week we published a study from 10 long shooting A population studies across the UK, including some from you see out many from UCL, the birth cohorts all working together across all these CO. What's try and understand long covitz, which was still doing within the convalescent study on Indeed, the case sort of, you know, was very well picked. Really, because we see this'll relationship with age, that excited with female on we've talked about last month. So that comes out of almost all of the studies that we've looked at that asthma is a respect of the longer that preexisting us that this is not ask for that develops afterwards. Which course happen, but these are actually not a massive risk factors, you know. None of them are more than about 1.6 odds ratio, so I think that's a really important message to take home into your clinics, whatever that you cannot be making judgements on whether or not someone has not improved by whether not there, um, female have asthma and so on because you know, is absolutely possible to have longer, even if your male young and have no people. But she's at all because these risk factors are not very strong. Um, but there's that there's the age difference. So so in 60 of olds, the risk of getting debilitating long covert. So that's long. Hope is that last more than 12 weeks that affects your daily life is 4.8% off all individuals that have court Covitz. This was Prevacid Nation. We've seen in other studies that I might mention that that that reduces prior approximately half half's both those factors when you've been vaccinated, and then there's only crumble come on over to. But they're still that's very large numbers of people that that actually you have a debilitating non capabilities about a set 2% home eso active access. So we've already talked about this and I'm gonna put my or in so when we've looked in these numbers, you know, population studies or indeed in this area. Actually, we've seen no relationship between whether not someone's likely to get to get long coded on index of multiple decoration or education or, um, uh, ethnicity. So we see really flat related ethnicity. Where is when we looked in electric health records? Using open safety, we found a very sharp relationships. That was that If you're if you have it, you're more likely to have long covered. If you live in a high affluence area, you're more likely to get long coat. But if your white, you're more likely to get noncoding. If your educators, of course I'm putting in bed comma is because there's not really I don't think they're really. When we compare these two things side by side, we can see that that must be because of it problems and access to care. Now that's data from March 2021 on. There may well have been improvement since, but I think that's really important to note that and make sure that what we're doing is capturing everybody. And it was really nice to hear ministers of input on that nationally. So here, here's that Here's what I'm talking about. So in in both sort of like electric health records and lung shingle, data analysis from these co warts receive females are high risk. But for ethnicity, we don't see any difference in the long term. You know, studies where as we see a parent, a protective factor if it being South Asian or black, which isn't is not. We don't think Israel. That's because it's not getting into the healthcare record. And likewise, in terms of index of multiple deprivation, it seems like you're more likely to have long covered if you live in a high athletes area. Where is that's probably your morning to be coded with a code in the high chair. So symptoms seem syndromes and what we're doing now with surgery. So I know you wanted to find out about that and look how over the next few weeks, because we'll be pre printing this paper, which is looking at post syndrome, says more than 12 weeks. What are the symptoms and how they cluster? Because we've actually probably in this very study, got the largest study in the world, probably of Perspectively reported long have a symptoms on and So here we can look at each variant. Is that gone through so wild type variant Alpha Delta. And now look at whether someone's been vaccinated or whether they haven't been vaccinated and we can cluster the Simpsons. Okay, so we say, Well, are there detectable from data processing? Is it is It is a data stretchy able to detect different clusters of long paper. And this is what we see. This is Delta and vaccinated people, which is probably what's coming into your clinic. Minute most is panic in the moment, and so most of your clinics will be. But we'll be looking at this. It's changed again with, um, a con on gets changed from example the wild type vaccination. So in the wild type we saw when we see in this paper, consider it you see a big cluster, which is respiratory problems. And that's because the wild type gave you this respectfully problem respiratory scarring until we get that coming out as a separate pastor, once we get vaccinated. And once we moved into Delsym in whatever that's really reduced significantly on now, what you see is a very strong sort of set of people that have ongoing and nausea on what's going really interesting is to see what happens to them and what happens them cognitively. And what happens there that their profiles over time because we know that that may relate to drain changes as well within the old back trouble. Then there's a strong neurological cluster. But then there's one here which has got this red ones, these kind of chest pain or palpitations, which is probably your pots, um, variant off long covert, which, um, has got lots of other symptoms going in. But it's very multi system symptom, but it's actually only about 10% of all the people that we see on the AP was reporting on Cobra. There's no everybody has a subset of the substance, um, on DS. So here is the data that we put out into Lantus Effective diseases, and then Ernest this year further replicated this to show that thankfully vaccination reduces the risk of getting non coated in the first place on. That's you know, that's good news. But of course it's natural 100%. It's only reducing by half, which I've alluded to. We've got another paper that we're working on is not quite ready to submit, which is actually like, really testing properly testing with a control group. Whether know if you've got long came, it does giving you a vaccine change the trajectory of that, and that's actually a very difficult question to answer. Lots of people try to answer it, but, of course, because symptoms get better over time anyway. Thankfully, it's very difficult to map that curve, and you have to do a controlled analysis against people who have the same direction of disease. But it didn't get vaccinated. And so we've done that since study, and we can see that quite a lot of the symptoms certain symptoms are really getting better with vaccination, but some some of them on account for that one a swivel. But I think it's good news that vaccination helps your patients that have a long coat. But if they've not been vaccinated so far on, it's what obviously noncoding groups produced nearly a year ago was, Well, what about, um, a chronic non cable? This is a paper that we just got into Lance. It was a communication a lot, Not not not this last week, but the week before, which shows that I think for military folks running, running long kind of service is that you will find that you will have, um, not the massive increase that you might have expected in. Yeah, and that's what men Estate was also saying that the numbers, they're not going down, they're going up. But they're not going up as exponentially as you might expect. Given the numbers of people that are affected on back with 12 weeks, we just run the data. We're we're putting out something around that that actually, with the 12 weeks or more symptoms, the odds is really much more reduced in in, uh, compared to delta, when you when you come when you make sure you very carefully match these populations to make sure that other things aren't explaining the differences. So I think that's good sort up. But of course, that's think about Oh, my one. This is the A one and two, which one of the reasons why this probably happened was because I wanna be a one or two doesn't really get into the lung tissue very well on. Unfortunately, we've now got be a four and even work, maybe more potentially problematic be a five which do in animal studies get into lung tissue on. Certainly. We've been seeing an uptick of me in hospitalization rates in the UK now and in in Portugal's of increasing death rates. You know, when When the be a five hit. So I think we are in for a bit of a another rollercoaster, so make sure you protect yourselves in family. Um, so that's me for the minute, but I'm happy to say, Yeah, I got a question here, please. Yeah, thanks for Jonathan here and that. We do have some online as well. And so basketball. So I'm going over once. It can be hard to sit here that well that, you know, the crowd is always sitting at this time of the day, isn't it? They were still 350 people joining online watching, so there is still a lot of interest going on. You see, suggest from your colorful flow chart that they're acute symptoms predicted on curve it way. Plenty of people with minimal cove. It go acute care of it. We get really bad longer bit be in peace. Out. Whatever. Just Yes. Is that one? I didn't think that you actually like one thing about that one Centrum or our home. But what we're here talking about what? What Those colorful sort of normal grams that we put into that paper was the number of symptoms that you had in that first week influence. Your risk of going on to get non copay is such that we could produce a prediction algorithm which which separated people off. But But, I mean, remember to get five symptoms which was sort of trigger point base. It was was a sort of a good rule of thumb that you don't have to have that many symptoms across the multi system disorders to get five symptoms. But ultimately you're right. You can you can get along covert if you're asymptomatic. We know that, but it is just much rarer. Think of the interest of time cause I feel like the top timekeeper. There are more questions coming in. I know online. I think they will kill eight all of those answers. But thank you very much.