I AM DAVID GOFF AND LEAD THE DIVISION OF CARDIOVASCULAR SCIENCES AT THE HEART LUNG INSTITUTE AND I WANT TO WELCOME ALL OF YOU AND THANK YOU FOR AGREEING TO SERVE PUBLIC HEALTH IN THIS CAPACITY. YOU HAVE ALREADY HEARD A LOT OF DISCUSSION ABOUT LONG COVID OR POST-ACUTE COVID, THE LABEL IS EVOLVING. WHAT WE HOPE TO ACCOMPLISH OVER THE NEXT HOUR AND A HALF OR SO IN THIS BREAKOUT SESSION IS TO REALLY DIG A LITTLE DEEPER INTO THE ISSUES RELATED TO THE CARDIOVASCULAR, AND I DO IMMEDIATE CARDIAC AND VASCULAR ASPECTS OF LUNG COVID. SO I AND MY COLLEAGUES ARE NHLEI WILL LARGELY BE IN LISTENING MODE, LISTENING TO YOU, OUR EXTERNAL EXPERTS, WHO WILL GIVE US YOUR INPUT ON ISSUES RELATED TO CARDIOVASCULAR LONG COVID. LEADING THE EFFORT TODAY IS Dr. WENDY POST FROM JOHNS HOPKINS. YOU MAY HAVE HEARD HER PRESENTATION YESTERDAY IN THE FIRST DAY OF THE WORKSHOP. WE'RE DELIGHTED THAT SHE IS HERE TO, YOU KNOW, LEAD AND FACILITATE THIS DISCUSSION AND WE APPRECIATE ALL OF YOU GIVING YOUR TIME. WE KNOW YOU ARE VERY BUSY AND HAVE MANY THINGS YOU COULD BE DOING AND APPRECIATE YOU GIVING US THIS TIME TODAY. I WILL BE LARGELY IN LISTENING MODE. UNFORTUNATELY I WILL HAVE TO DROP OFF IN A FEW MINUTES TO JOIN A SESSION WHERE WE HAVE SOME CLINICAL TRIALS GOING ON IN THE COVID SPACE AND THERE'S SOME ISSUES COMING UP THAT I HAVE BEEN ASKED TO JOIN TO ATTEND TO, WHICH I AM ACTUALLY REALLY DISAPPOINTED ABOUT BECAUSE I WANTED TO HEAR ALL OF THIS TODAY. I WILL BE BACK LATER TO HEAR THE SUMMARY OF THIS AND REALLY JUST APPRECIATE YOU BEING HERE. SO WITH NO FURTHER ADIEU, I WILL TURN THIS OVER TO WENDY POST WHO WILL LEAD THE DISCUSSION. THANKS, WENDY. >> THANK YOU, I REALLY APPRECIATE THE OPPORTUNITY TO BE INVOLVED IN THIS REALLY IMPORTANT WORKSHOP AND TO LEAD THIS BREAKOUT SESSION ABOUT CARDIOVASCULAR CONSEQUENCES OF POST-ACUED COVID OR LONG COVID. WE HAD A REALLY INTERESTING DAY OF LECTURES AND DISCUSSION YESTERDAY. HOPEFULLY MOST OF YOU WERE ABLE TO LISTEN TO IT. I KNOW THAT YOU ARE ALL VERY BUSY SO ON BEHALF OF NIH AND MYSELF, I JUST WANTED TO THANK YOU ALL FOR SPENDING THE TIME TODAY TO TALK ABOUT SOME OF THE BREAKOUT SESSIONS. SO AS YOU HEARD IN THE INTRODUCTION, OUR CHARGE HERE IS REALLY TO IDENTIFY THE KEY KNOWLEDGE GAPS AS IT RELATES TO CARDIOVASCULAR LONG-TERM CONSEQUENCES OF COVID. AND TO DISCUSS POTENTIAL APPROACHES AND CONSIDERATION FOR FILLING THOSE GAPS AND, YOU KNOW, YOU HAVE ALL BEEN CHOSEN BECAUSE YOU HAVE EXPERTISE IN A VARIETY A DIFFERENT TYPES OF EXPERTISE AND UNFORTUNATELY WE DON'T HAVE TIME FOR EVERYBODY TO INTRODUCE THEMSELVES SO WE HAVE THE SLIDE HERE SO PEOPLE CAN SEE WHAT INSTITUTIONS YOU ARE FROM. AND IF WE CAN JUST GO BACK TO THE FIRST SLIDE WHICH HAS THE STRUCTURE FOR THE BREAKOUT SESSION, SO WE'RE SUPPOSED TO PRESENT THE SUMMARY OF THE DISCUSSION -- WELL, NOT WE, I GUESS, I AM PRESENTING THE SUMMARY OF THE DISCUSSION AFTER WE FINISH THIS BREAKOUT DISCUSSION SO THE ULTIMATE GOAL IS TO HAVE A SUMMARY SLIDE THAT WILL HELP TO GUIDE ME WITH THE PRESENTATION. SO THE STRUCTURE OF THE WORKSHOP OR THE BREAKOUT SESSION IS TO DISCUSS THE FIRST SET OF SESSIONS WHICH YOU WILL SEE SHORTLY OVER THE FIRST 40 MINUTES AND THEN THE SECOND SET OF QUESTIONS AND THEN COME TO THE CONSENSUS OF WHAT WE THINK THE KEY POINTS ARE WE WANT TO SHARE WITH THE BROADER COMMUNITY. NEXT SLIDE OR TWO SLIDES FORWARD, PLEASE? SO I WANTED TO THANK SELIN FOR BEING OUR NOTE TAKE AND SHE HAS THE DIFFICULT TASK OF TRYING TO SUMMARIZE OUR CONVERSATION SO WE HAVE A GUIDE TO USE TO COME UP WITH THE SLIDES WE WILL BE PRESENTING LATER. AND I ALSO WANTED TO THANK SHAWN CODY FOR ALL HE HAS DONE TO HELP ME IN PREPARING FOR THIS SESSION. SO THE FIRST SET OF QUESTIONS, REALLY THE FIRST ONE IS A VERY BROAD QUESTION WHICH IS WHAT ARE THE MOST IMPORTANT QUESTIONS TO ADDRESS REGARDING POST-ACUTE CARDIOVASCULAR COMPLICATIONS OF COVID. SO I WANT THE GROUP TO KEEP IN MIND WE COULD COME UP WITH A LIST OF 100 QUESTIONS, I AM SURE SO WE WANT TO COME UP WITH THE TOP THREE OR FOUR BROAD THEMES OF QUESTIONS THAT YOU WANT TO PRESENT TO THE GROUP. AND THEN THE SECOND QUESTION IN THE FIRST SET OF QUESTIONS, WHICH IS ACTUALLY A GROUP OF QUESTIONS, IS WHAT ARE THE MOST IMPORTANT CARDIOVASCULAR OUTCOMES TO EVALUATE AS POST-ACUTE SEQUELAE COVID-19, WHAT ASSESSMENTS SHOULD BE CONSIDERED TO EVALUATE CV SEQUELAE ACROSS THE LIFE.INCLUDING CHILDREN AND ADULTS AND HOW CAN REMOTE TELEMEDICINE TECHNOLOGIES BE EMPLOYED. AND SO THE FIRST QUESTION IS WHAT ARE THE MOST IMPORTANT OUTCOMES AND WHAT ASSESSMENT SHOULD BE USED AND SHOULD WE CONSIDER REMOTE/TELEMEDICINE -- WEARABLE TECHNOLOGIES AND THE SECOND SET OF QUESTIONS, WHAT ARE THE MOST APPROPRIATE PROGRAMMATIC STRUCTURES AND PLATFORMS TO SUPPORT THE DATA, WHAT EXISTING ASSETS CAN BE LEVERAGED TO SUPPORT STUDIES OF CV AND OTHER OUTCOMES, HOW CAN WE ENGAGE THE COMMUNITY AND WHAT FACTORS MAY CONFOUND, MEDIATOR MODIFY CARDIOVASCULAR OUTCOMES AFTER COVID OR SARS-COV-2 INFECTION AND I JUST GOT A NOTE SAYING MY INTERNET IS UNSTABLE. CAN YOU HEAR ME OKAY? >> YES. >> OKAY, SO LYNN IF YOU CAN GO BACK TO THE FIRST SET OF QUESTIONS AND SO AGAIN, THIS BROAD QUESTION OR WHAT ARE THE MOST IMPORTANT QUESTIONS TO ADDRESS REGARDING POST-ACUTE CV COMPLICATIONS OF COVID. SO AS I WAS PUTTING TOGETHER MY SLIDES, IT SEEMS TO ME INHERENT THAT ONE OF THE MOST IMPORTANT DISCUSSIONS SHOULD BE AROUND THE FINDINGS OF CARDIAC MRI SO I WOULD LIKE TO START WITH MAYBE A BRIEF DISCUSSION ABOUT CARDIAC MRI AND THERE WAS A QUESTION THAT I ACTUALLY HUNTED BECAUSE I KNEW THAT THERE WOULD BE OTHERS WERE MORE EXPERTISE ABOUT CARDIAC MRI IN THIS DISCUSSION GROUP. SO THE CHARGE HERE IS REALLY NOT FOR US TO BE ANSWERING THE QUESTIONS BUT MORE POSING THE QUESTIONS BUT I THOUGHT THAT MAYBE IF WE COULD START WITH A BRIEF DISCUSSION ABOUT WHAT PEOPLE THINK ABOUT -- [INDISCERNIBLE] -- FINDINGS AND POST ACUTE COVID AND WHAT QUESTIONS NEED TO BE ADDRESSED TO TRY AND UNDERSTAND THEM BETTER. SO I AM HAVING A LITTLE DIFFICULTY SEEING THE VIEW I WANT TO SEE WHICH WAS TO BE ABLE TO SEE WHO IS RAISING THEIR HAND, BUT DAVID, ARE YOU ABLE TO SEE THAT? >> HELLO WENDY, YES, I AM HERE AND -- >> OKAY, I SEE IT NOW. SO I THINK Dr. FA YED WOULD PROBABLY -- >> NO, I AM TRYING TO RAISE MY HAND AND FIND A WAY TO DO IT. I WILL DO IT LIKE THIS. >> OKAY, PERFECT, I SEE IT NOW AND I ASSUME YOU WILL BE THE ONE TO RESPOND AND ADDRESS THIS ISSUE. >> YES, I WILL BE HAPPY TO ADDRESS THAT AND THANK YOU SO MUCH FOR BRINGING FORWARD THIS WORKSHOP. SO LET ME GO TO THE QUESTIONS YESTERDAY PRESENTED TO THE FINDINGS OF DIFFERENTIATING MINOR CARDITIS AND FROM THE DIFFERENT STUDIES THAT HAVE BEEN DONE. SO OBVIOUSLY THIS IS NOT A SIMPLE THING TO DO AND SO FAR THE STUDIES THAT HAVE DONE THIS ARE NOT UTILIZED THE FULL CAPABILITIES OF CARDIAC -- [INDISCERNIBLE] SO MY PROPOSAL IS TO EXPAND A LITTLE ON THE CURRENT TECHNIQUES BEING USED SO TECHNIQUES SUCH AS CHARACTERIZATION OF T1 AND T2 WILL OBVIOUSLY NEED TO BE PUT INTO PERSPECTIVE WHICH I THINK IS DEFINITELY FEASIBLE. MOST PEOPLE CAN DO THIS. AND IF YOU WANT TO STICK JUST WITH CARDIAC MR, THE PROTOCOL NEEDS TO INCLUDE DELAYED ENHANCEMENT AS WELL AS T1 AND T2 MAPPING -- [OVERLAPPING SPEAKERS] >> GO AHEAD. >> OH, I AM SORRY, I WAS ASKING IF YOU COULD ANSWER THE QUESTION THAT WAS POSED YESTERDAY BECAUSE I KNOW YOU WERE ON FOR MOST OF YESTERDAY OF WHAT IS YOUR INTERPATION OF WHAT THE FINDINGS ARE DESCRIBED SO FAR AS IT RELATES TO LATE ENHANCEMENT OR CHANGES IN T1 AND T2 AND HOW WOULD YOU INTERPRET THAT IN THE SETTINGS THAT THE STUDIES WERE PERFORMED? >> I THINK WENTY WHAT I HAVE SEEN SO FAR IS AGAIN THE CONNECTIVITY IN T1 AND T2 ASPECTS AND NONE OF THE STUDIES HAVE FULL COMPREHENSIVE ASPECTS SO FAR. SO LOOKING AT CARDITIS, NEED TO DO FURTHER ASSESSMENT AND I THINK A LITTLE MORE OF WHAT WE DO WITH DIAGNOSIS, TO SUPPLEMENTS THAT WITH ANOTHER TECHNIQUE WITH FEG PATH TO LOOK AT THE INFORMATION. BUT IF YOU HAVE THE CAPABILITY, TODAY IF YOU LOOK AT HOW WE DO THIS, WE ARE RELYING ON BOTH MRI AND -- [INDISCERNIBLE] SO THE IDEAL PROTOCOL WOULD BE YOU KNOW THE ASSESSMENT. FULL CARDIAC PROTOCOL AS WELL AS SUPPLEMENTATION. >> SO CAN I SUMMARIZE TO SAY THE RESULTS SO FAR ARE INCONCLUSIVE BECAUSE THE MOST COMPREHENSIVE MRI IMAGING PROTOCOLS HAVE NOT YET BEEN PERFORMED? >> YES. >> AND THAT ADDING A MORE COMPREHENSIVE MRI PROTOCOL IN ADDITION TO OTHER IMAGING MODALITIES SUCH AS FTC WOULD HELP TO DEFINE THE SIGNIFICANCE OF THE PREVIOUS FINDINGS. >> RIGHT, AND I -- >> REPRESENT INFLAMMATION OR I GUESS MY INTERPRETATION OF THE ENHANCEMENT IS THAT WAS A SCAR OR -- >> CORRECT. >> IS THAT SOMETHING THAT NEEDS FURTHER DEFINITION OR WERE YOU REFERRING PRIMARILY TO -- [INDISCERNIBLE] FINDINGS. >> I DIDN'T HEAR WHAT YOU SAID AT THE END, WENDY? >> IS IT CLEAR WHAT THE ENHANCEMENT MEANS OR DOES THAT NEED FURTHER DEFINITION AS WELL? >> NO, I THINK WE KNOW THE SENSITIVITY OF THE LGE TO DETECT MYOCARDITIS IS LOWER FOR T1 AND T2 MAPPING SO WE NEED TO SUPPLEMENT THAT FOR SURE AND I ALSO WOULD LIKE TO MAKE SURE WE ARE NOT COMING UP WITH A NEW PARADIGM HERE, WE NEED TO DRAW FROM OUR EXPERIENCE WITH SIMILAR CARD I DON'T WANT THESE. SO - - C A R D I O PATHIES SO WHAT I AM SPEAKING ABOUT IS ALONG THOSE LINES AND FROM EXPERIENCE, WE HAVE 50 PROTOCOLS USING THAT SO FAR SO WE ARE TALKING FROM SPECIFIC EXPERIENCE AT OUR SITE SO FAR. >> THAT IS REALLY HELPFUL. SO Dr. ROSENBURG FROM NHL BI PUT IN THE CHAT WHAT IS THE BEST POPULATION TO STUDY, AN IMPORTANT GROUP, AND AS I MENTIONED, THE HARRISON GROUP IS REALLY IMPORTANT AS WELL AND Dr. FAYED IF YOU WANT TO DISCUSS THAT OR ANYONE ELSE -- >> IF I UNDERSTOOD THE QUESTION, YEAH, WE HAVE BEEN PONDERING QUITE A BIT ABOUT THE CONTROL GROUP, RIGHT, AND THERE HAVE BEEN MANY IDEAS ON THE TABLE. I LOOKED AT THE TWO UK STUDIES THAT HAD BEEN PERFORMED. THEY HAVE BEEN MUCH MORE AHEAD OF US IN TERMS OF POST-COVID WORK UNFORTUNATELY OR FORTUNATELY FOR THEM. AND THEY HAVE USED MATCH CONTROL SO THEY REALLY USE THE POPULATION THAT IS CONSIDERED NORMAL AND MATCH TO THEIR POST-COVID PATIENTS. BUT THERE HAVE BEEN SOME OTHER IDEAS IN TERMS OF CONTROLS IF YOU USE MAYBE A SPECIFIC TYPE OF OTHER CARDIOMYOPATHY BUT I AM NOT SURE WE SHOULD GO THERE, THAT MAYBE GOING THROUGH THE CLEAN CONTROL MATCH WOULD BE MOST APPROPRIATE AT THIS STAGE. BUT WE ARE STILL SCRATCHING OUR HEADS ON THAT ONE ALSO. >> WELL, DOCTOR NEWTON -- SORRY, GO AHEAD? >> I WAS GOING TO SAY, WENDY, I SEE A COUPLE OF RAISED HANDS. >> OKAY, WHY DON'T WE START WITH Dr. NEWTON-SHAY. >> THANKS, I WONDER IF WE COULD JUST TALK BRIEFLY ABOUT THE TIMING IN WHICH IMAGING, LIKE WHAT YOU HAVE DESCRIBED, MIGHT BE PERFORMED? I THINK PART OF MY CHALLENGE FOR ALL THE QUESTIONS THAT WE HAVE HERE IS I DON'T REALLY KNOW WHAT ACUTE COVID AND THE HEART ARE AND SO I HAVE A BIG CONCERN ABOUT JUST TESTING RELATIVELY ASYMPTOMATIC PEOPLE WHO ARE POST-COVID AND I AM NOT SURE THAT IS A BURNING QUESTION FOR THE FIELD, EVEN THOUGH IT HAS BEEN WIDELY DONE IN ATHLETES. AND I WONDER WHETHER WE COULD JUST DISCUSS SHOULD WE BE TALKING ABOUT WHAT PEOPLE'S COVID ILLNESS INCLUDED, WHETHER IT INCLUDED ANY EVIDENCE OF A MYOCARDIAL DYSFUNCTION OR ARHYTHMIAS OR REASONS TO BE CONCERNED ABOUT THE HEART, AND HOW MUCH DO WE KNOW -- I THINK WE WILL NEVER KNOW MUCH ABOUT THE PRE-MORBID STUDIES WITH PROTOCOL IMAGING DONE WHERE JUST OUT OF CONVENIENCE WHEN THEY DEVELOP COVID, THEY MAY BE REIMAGED. BUT I HAVE A LOT OF CONCERN ABOUT THE CURRENT CLINICAL APPLICATION THAT HAS LED TO PRETTY WIDESPREAD CONCERNS ABOUT MYOCARDIAL INVOLVEMENT IN THE HEART AND I WONDER, WHAT DO YOU THINK OF LIMITATIONS OR ADVANTAGES ARE OF IDENTIFYING SUBGROUPS, FOR EXAMPLE, OUTPATIENTS OR INPATIENT WHO HAVE THEIR ACUTE COVID ILLNESS AND THEN DO CONVALESCENT STUDIES FOUR OR SIX WEEKS LATER? I THINK I REMAIN VERY UNCERTAIN BASED MOSTLY ON PORT MORTEM AUTOPSY WHAT IS EXACTLY GOING ON IN THE HEARTS OF PEOPLE WHO HAVE OVERT AND RECOGNIZED MYOCCARDIAL DYSFUNCTION DURING THEIR ACUTE ILLNESS. THAT SEEMS LIKE A UPSTREAM QUESTION BEFORE DOING OUTPATIENT APPARENTLY ASYMPTOMA ITIC SCREENING THAT HAS BEEN DONE IN SEVERAL OF THE ATHLETE SERIES. >> SO THAT IS REALLY HELPFUL. I GUESS WE COULD PUT IT AS A BROAD STATEMENT THAT WE NEED TO DO MYOCARDIAL OR MRI ASSESSMENTS OF THE HEART IN VARIOUS POPULATIONS AT VARIOUS TIMES TO BE ABLE TO UNDERSTAND IT. SO WHETHER IT IS PEOPLE WHO WERE ASYMPTOMA TIC AS WHAT HAS BEEN DONE IN AT SKPHRAOETS NOW THAT THE QUESTION HAS BEEN RAISED, WE WILL HAVE TO ANSWER WHAT IT MEANS OR WHETHER IT WAS PEOPLE WHO HAD SEVERE COVID AND HAD THE TIMING OF THE MRI RELATIVE TO THAT, AND ACTUALLY DOING A MRI WHEN SOMEONE IS IN SESSION MAY BE DIFFICULT BUT AFTERWARDS, WHEN YOU WOULD DO IT. IN TERMS OF THE LONGITUDINA ASPECT. THERE ARE SEVERAL STUDIES THAT ARE AVAILABLE. I MENTIONED C4 YESTERDAY WHICH IS A LARGE COLLABORATION OF COHORT STUDIES AND MANY OF THEM HAVE AN INCLUDED BASELINE CARDIAC MRI SO WE CAN GET A PRE- AND A POST AND ANOTHER DOCTOR HAD MENTIONED BRIEFLY IN THE CHAT THAT THERE WERE PLANS TO DO STUDIES AS WELL IN REPRIEVE SO WE CAN DISCUSS THAT AS WELL. BUT I REMEMBER Dr -- [INDISCERNIBLE] -- WHAT IS BEING PLANNED FOR THAT. >> YOU WANT ME TO START, WENDY, YOU SAY? >> IF WE COULD START WITH Dr. KHAN, I AM SORRY. >> THANK YOU SO MUCH, I THINK ONE OF THE QUESTIONS IN TERMS OF CONTROVERSY AROUND THE MRI AND HOW MUCH IMAGING WE SHOULD BE DOING IN ASYMPTOMATIC PEOPLE IS HOW MUCH OF WHAT WE ARE SEEING IS RELATED TO THE ILLNESS IN WHAT IS RELATED TO THE ILLNESS AND HOW DO WE USE THAT TO BETTER UNDERSTAND THE VIRUS AND THAT LEADS TO THE LONGITUDINAL MRI. >> SO WHAT WOULD YOU SUGGEST, Dr. KHAN WOULD BE APPROPRIATE COMPARISON GROUP TO THE PATIENTS WITH COVID? >> I THINK THIS WAS ONE OF THE POINTS YOU MADE WHERE YOU SHOWED IN THE PAPER THAT AMONG INDIVIDUALS WHO HAD ARDS THAT WAS NOT COVID, THEY HAD THE SAME DEGREE OF INJURY COMPARED TO INDIVIDUALS WHO HAD COVID SO IDENTIFYING POTENTIALLY MATCHED FOR SEVERITY OF ILLNESS, WHETHER THAT IS RELATED TO INFLUENZA OR ADRS OR SIMILAR POP-UP PHYSICAL KWROLGS PHYSIOLOGY WHERE WE START TO SEE MORE HEART FAILURE WITH THE HEART ECHOS, NOT A HEALTHY CONTROL BUT WE WANT TO MATCH FOR THE MORBIDITY COMING INTO THE COVID ILLNESS IN THE COURSE. >> EXACTLY, SO HAVING A COMPARISON GROUP OF PEOPLE WHO SURVIVED A VERY SEVERE ILLNESS WHETHER ARDS OR ANY OTHER ILLNESS THAT REQUIRED PROLONGED HOSPITALIZATION WOULD BE IMPORTANT. DOCTOR GRINSPIN, TELL US ABOUT YOUR PLAN. >> YES, THANKS, FIRST OF ALL, IT IS A GREAT DISCUSSION AND I THINK OTHERS HAVE SAID THIS AS WELL, I WOULD MENTION A PLUG-IN FOR THE GROUP -- [INDISCERNIBLE] AND YOU WILL KNOW WHO HAS THE DISEASE AND DOESN'T BUT YOU WON'T KNOW WHO MIGHT HAVE BEEN PREDICTED TO HAVE THE DISEASE IN THE LARGER GROUP WHO GOT COVID SO I WOULD URGE US ALL TO BE CAREFUL ABOUT THAT AND HARVESTING ANY CLINICAL DATA THAT IS AVAILABLE AND PAIRING THAT WITH IMAGING FOR EXAMPLE FOR SPECIFIC COMORBID CONDITIONS, GENETICS, BIOMARKERS, ET CETERA. BECAUSE IF WE JUST FOCUS ON SOME OF THE FANCIER IMAGING WHICH IS PHENOMENAL, AS I HAVE USED IT, WE MIGHT MISS SOMETHING IN OUR STUDY. WE HAVE 7000 PEOPLE WITH THE BEFORE AND AFTER AND WILL SEE IF THERE ARE SPECIFIC PATTERNS OF PROTEINS OR INFLAMMATORY PATHWAYS THAT MIGHT PREDICT SUPERIOR DISEASE. WE ARE GOING TO REPEAT CT SCANS TO LOOK AND SEE WHETHER THERE IS ANY DIFFERENCE IN ATHLEROSCLEROSIS WHICH I KNOW WE WILL TALK ABOUT AND LOOK AT COCONDITIONS IN GENETICS. SO I THINK THE COHORT STUDIES HAVE BEEN AN ADVANTAGE AS YOU SAID VERY NICELY BUT NONETHELESS, WE SHOULD KEEP THAT IN MIND WHEN WE TALK ABOUT THIS. >> AND Dr. MORRIS, I SEE YOU HAVE YOUR HAND RAISED? >> YES, I WANTED TO JUST SORT OF HIGHLIGHT AS WE'RE THINKING ABOUT THESE IDEAS FOR IMPLEMENTATION SCIENCE, IT IS VERY EASY TO THINK ABOUT THE TECHNOLOGY AND HOW WE CAN USE THAT. WE ARE ALL AWARE IN THE PANDEMIC WE HAVE SEEN A MUCH HIGHER MORTALITY RATE AND MORE RURAL VERSUS URBAN BECAUSE OF THE LACK OF RESOURCES. AND AS I THINK ABOUT THE AVAILABILITY OF FOR EXAMPLE C MR AS MODALITY FOR IMAGING PARTICULARLY WITH FOLLOW UP IN RURAL LOCATIONS VERSUS OUR PRIMARY CARE CENTERS, WHAT DOES THAT LOOK LIKE FOR PATIENTS WHO EXIST IN THOSE LOCATIONS AND WHO NEED THAT SORT OF FOLLOW UP. CERTAINLY THE LITERATURE IN THE HEART FAILURE STAGE AS WELL AS OTHER SPACES SHOW THAT THEY ARE MUCH LESS LIKELY TO BE CARED FOR BY SPECIALISTS SO IF THEY ARE BEING CARED FOR BY INTERNISTS, YOU KNOW, IN TERMS OF CARE FOR POST-COVID SEQUELAE, ARE WE GOING TO PUT OUT VERY CLEAR GUIDELINES THAT SAYS WHO NEEDS TO BE REFERRED, HOW OFTEN THEY NEED TO SEE A SPECIAL AND HAVE THIS CARE. BECAUSE WE CAN'T NECESSARILY ASSUME THOSE PATIENTS ARE GOING TO BE REFERRED TO CARDIOVASCULAR SPECIALISTS TO HAVE THIS DONE BECAUSE THAT IS NOS NOT HAPPENING WITH CONDITIONS LIKE HEART FAILURE AND OTHER THINGS. >> THESE ARE INCREDIBLY IMPORTANT POINTS AND I APPRECIATE YOUR RAISING THEM. IN OUR STUDIES THAT ARE, YOU KNOW, SYSTEMATICALLY DOING IMAGING, MAYBE THERE WILL BE LESS OF AN ISSUE BUT IN TERMS OF THE ROUTINE CARE PEOPLE ARE RECEIVING, THERE ARE DIFFERENCES IN WHAT KIND OF TESTS AND CARE INDIVIDUALS ARE GETTING. SO THE WE WILL NEED TO BE VERY COGNIZANT OF THAT. AND C MR WAS DESIGNED TO INCLUDE A VERY DIVERSE GROUP OF PEOPLE IN TERMS OF GEOGRAPHIC AND RACIAL AND ECONOMIC BACKGROUNDS. SO I KNOW THERE ARE A LOT OF PEOPLE WITH THEIR HANDS UP AND Dr. MIRAQUEZ, THERE WAS SOMETHING YOU WANTED TO SAY? >> YES, HI, I AM THE COMMUNITY REPRESENTATIVE HERE ON THIS WORKSHOP -- >> OH, I MADE YOU A DOCTOR. I FIGURED I WAS SAFER THAT WAY THAN NOT. [OVERLAPPING SPEAKERS] >> THAT IS OKAY, I FEEL LIKE I HAVE GOT TEN MY HONORARY DOCTORATE WITH COVID. I GOT SICK WITH COVID IN MARCH IN LOS ANGELES AND HAVE BEEN SICK FOR ALMOST NINE MONTHS INCLUDING LONG-TERM COMPLICATIONS OF SEVERE BLOOD CLOTS TWO MONTHS INTO MY INFECTION SO JUST WANTED TO MAKE A COMMENT ABOUT TIMING AND I AM IMAGING. WHEN I FIRST GOT SICK, ONE OF MY FIRST SYMPTOMS TACK WERE TACK CARD I TACHYCARDIA AND ARREST, SOME SKIPPED BEATS BUT BASICALLY AFTER AN ECHO CARDIOG RAM, I WAS TOLD I WAS PERFECTLY FINE AND ALL OF MY SYMPTOMS WERE RELATED TO ANXIETY. IT WASN'T REALLY TILL EIGHT OR NINE WEEKS POST MY POST-ACUTE INFECTION THAT I SHOWED UP TO THE EMERGENCY ROOM WITH SYMPTOMS OF EITHER -- I DIDN'T KNOW, EITHER DEEP VEIN THROMBOSIS OR PULMONARY 'EM EMBOLISM, WAS TOLD I WAS SEVERELY ANXIOUS, I DEMANDED A V DAIMLER LAB AND FOLKS WHO MEN STRUATE ARE INFINITELY FAMILIAR WITH THE CONSISTENCY OF THEIR MENSES AND FOR ME MINE WERE EXTREMELY CLOTTED WITH VERY LITTLE LIQUID SO I KNEW IN MY BONES I WAS SEVERELY CLOTTED AND WHEN I FINALLY GOT THE LAP, I WAS 5324NANOGRAMS PER MILLILITER SO TEN TIMES WHAT IT SHOULD BE AND I WAS TOLD THAT WAS BECAUSE OF PANDEMIC STRESS. SO I WAS ABLE TO DEMAND A CT SCAN OF MY CHEST, WAS CLEARED FOR PULMONARY EMBOLISM, SO NO PE BUT WAS NEVER ASSESSED FOR DEEP VEIN THROMBOSIS ELSEWHERE. I HAD STROKE, LOST MY ABILITY TO SPEAK FOR AN HOUR, CONFUSED, NOW I AM LEARNING I HAD MASSIVE AMOUNTS OF MICROTHROMBOSIS EVERYWHERE AND WAS NOT REALLY ASSESSED FOR ALL OF THESE SORT OF MICROVASCULAR IMPACTS AFTER THAT FULL CARDIAC WORKUP VERY EARLY INTO MY ILLNESS. SO MY ILLNESS CRESCENDO'D OTHER THE COURSE OF TWO MONTHS AND IT IS NOT REALLY SORT OF IN THE LAST SIX MONTHS, I HAVE SEEN -- A LOT OF MY SYMPTOMS ARE RELATED TO THE DAMAGE I BELIEVE I SUSTAINED BY UNTREATED CLOTTING. >> I AM SO SORRY THAT YOU EXPERIENCED SUCH A DIFFICULT COURSE WITH COVID AND REALLY APPRECIATE YOUR PARTICIPATION. AND THE REALLY IMPORTANT POINTS YOU BROUGHT UP, I CERTAINLY HOPE YOU ARE FEELING BETTER NOW. I THINK TO SUMMARIZE, SOME OF THE MANY IMPORTANT POINTS YOU MADE IS, YOU KNOW, THERE ARE CLEARLY ASSESSED DIFFERENCES IN HOW PATIENTS ARE PERCEIVED AND WOMEN ARE OFTEN FELT TO BE ANXIOUS AND NOT NECESSARILY TO BE APPROPRIATELY EVALUATED MORE THAN MEN. AND SO UNDERSTANDING THE DIFFERENCES BETWEEN SYMPTOMS THAT CAN APPEAR TO BE RELATED TO ANXIETY AND SYMPTOMS THAT ARE TRULY SOME CARDIOVASCULAR OR PULMONARY OR OTHER ORIGINAL BEGIN ARE REALLY IMPORTANT TO CONSIDER AND -- [INDISCERNIBLE] -- BECAUSE SOMETIMES THE SYMPTOMS ARE SIMILAR AND IT MAY NOT ALWAYS BE POSSIBLE FOR CLINICIANS TO TELL THE DIFFERENCE BUT THE IMPORTANCE OF THE AWARENESS IN THOSE DIFFERENCES AND HOW THAT IS PERCEIVED IS REALLY IMPORTANT. AND THERE WAS AN EFFECT YESTERDAY ON THE EFFECTS OF THE MENSTRUAL CYCLE -- [INDISCERNIBLE] Dr. REYNOLDS WHO HAD YOUR HAND UP FOR A LONG TIME, THANK YOU SO MUCH FOR YOUR PATIENCE. >> I AGREE. WE HAVE TO LISTEN TO WHAT THE PATIENTS ARE TELLING US AND I THINK THAT TAKES A LOT OF DIFFERENT FORMS. SO ONE THING TO KEEP IN MIND IS WE ARE GOING TO NEED LONG-TERM FOLLOW UP WITH A BROAD RANGE OF TESTING NOT ONLY THE ADVANCED TESTS OF MRI BUT SIMPLE THINGS, EXERCISE, 6-MINUTE WALK, EKG, TELEMETRY MONITORING IN ORDER TO UNDERSTAND WHAT IS GOING TO EMERGE. FOR EXAMPLE LONG-TERM HEART FAILURE, HOW EXERCISE CAPACITY IS GOING TO RECOVER. EXERCISE IS A VERY IMPORTANT RISK FOR CORONARY DISEASE AND IS THAT GOING TO HAVE LONG-RANGING IMPACT. AND THERE IS A LOT TO IT AND WHAT WE NEED TO LEARN FROM THE WORLD TRADE CENTER EXPERIENCE NEW THINGS NOT EXPECTED WERE UNCOVERED LIKE ASTHMA, SINUSITIS, THINGS THAT DIDN'T PEAK PEOPLE'S INTEREST INITIALLY BUT EMERGED BECAUSE PATIENTS WERE BEING FOLLOWED FOR A NUMB OF ASSESSMENTS AND I WONDER IF THIS WILL LEAD TO LATER CORONARY DISEASE. THERE IS SOME VASCULAR RISK WITH THIS DISEASE AND HOW WILL THAT PRESENT IN RISK. THOSE ARE SOME OF THE THINGS I AM WORRIED ABOUT. >> SO I WILL HAVE YOU SLOW DOWN A LITTLE BIT AS THAT WAS EXCELLENT SO WE CAN GET THE NOTES, WHAT ARE THE ASSESSMENTS WE SHOULD INCLUDE ON RESEARCH STUDIES SO SAY THAT A LITTLE MORE SLOWLY. >> I THINK WE NEED EXERCISE ASSESSMENTS, STANDARDIZED THINGS. THE 6-MINUTE WALK TEST, EASY TO DO NO MATTER WHERE YOU ARE. I THINK WE SHOULD GET RISK PULMONARY TESTING AND THAT IS EASY TO DO THAT BUT LOTS OF -- >> SO EXERCISE TEST, 6-MINUTE WALK, STRESS TESTS, THREE SO FAR AND YOU ALSO MENTIONED TELEMETRY, LIKE ANDOMYOCARDIC EKG MONITORING? >> YES, WONDERING HOW LONG TACHYCARDIA EXISTS AND -- [OVERLAPPING SPEAKERS] [INDISCERNIBLE] >> AND THEN WHILE WE'RE WRITING DOWN A LIST OF THINGS WE MIGHT WANT TO MEASURE, WE HAVE ALREADY TALKED ABOUT CARDIC MRI, CT SCANS AND BIOMARKERS SO Dr. LONGSTEIN WILL BE A GREAT ONE TO TELL US ABOUT BIOMARKERS. BUT I THINK Dr. ROSENBUR WANTED TO COMMENT AS WELL. DOCTOR ROSENBURG, I KNOW YOU PUT A COUPLE OF THINGS IN THE CHAT. >> NO, IT WAS JUST A COMMENT RELATED TO THE HISTORY. WE HEARD THAT WE NEED TO MAKE SURE THAT WE DIFFERENTIATE BETWEEN THE COMPLICATIONS THAT ARE CONSEQUENCES OF THE ACUTE PHASE THAT ARE NOT TREED LIKE IN TERMS -- TREATED LIKE THOSE THAT APPEARED EARLY ON THAT MAYBE IF TREATED COULD HAVE BEEN PREVENTED, BETWEEN THE REALLY LONG-TERM COMPLICATIONS THAT EMERGED GIVEN THE STANDARD TREATMENTS GIVEN. >> YES, THANK YOU FOR THAT IMPORTANT POINT. SO WE DO NEED TO DIFFERENTIATE THAT OUR CHARGE HERE IS LONG-TERM CONSEQUENCES OF COVID AND LOTS OF RESEARCH THAT CAN BE AND WILL BE DONE ABOUT ACUTE COVID AND WE WANT TO TRY TO EMPHASIZE THE LONG-TERM COMPLICATION. SO Dr. LOWENSTEIN, TELL US MORE ABOUT WHAT YOU THINK THE KNOWLEDGE GAPS ARE AND HOW WE CAN TRY TO ADDRESS THEM RELATED TO ENDOTHIOLITIS AND WHICH IS IT. >> THANKS, WENDY. I HAVE ONE MINUTE. FIRST OF ALL IT IS IMPORTANT TO LISTEN TO ANGELA'S STORY, WHETHER AN MD OR HONORARY BECAUSE I AM HEARING OF COMPLICATIONS TWO, THREE MONTHS AFTER THE ACUED PHASE OF COVID AND THAT GOES TO WHAT Dr. ROSENBURG IS SAYING, THAT THERE ARE THINGS THAT LAST A LONG TIME. SO A LOT OF US FEEL THAT IT IS PNEUMONIA WITH AN IMMUNE RESPONSE BUT SEVERE, IT IS A VASCULAR DISEASE. SO ONE OF THE QUESTIONS THAT HE IS ASKING IS HOW LONG DO THE CONSEQUENCES LAST AND IS THERE AN INITIAL VASCULAR INSULT WITHENDOTHELIALITIS THAT TURNS INTO THROMBOSIS AND OTHER THINGS. SO WE NEED TO DEFINE THIS AS BEST WE CAN AND IN ADDITION TO HISTORY, WE NEED GREAT IMAGING INCLUDING THIS INFORMATION IMAGING OF THE HEART AND BIOMARKERS ESPECIALLY VASCULAR BIOMARKERS IN THE LONG-TERM BECAUSE WE REALLY NEED TO FIND OUT WHAT IS CAUSING THIS POST COVID SYNDROME AND I THINK WHAT WE'RE ALL TALKING ABOUT WITH IMPLEMENTATION AND SETTING UP COHORTS IS REALLY THE WAY TO DO IT, MORE LONG-TERM IMAGING AND MORE BIOMARKERS IN PARTICULAR, INFLAMMATORY BIOMARKERS AND VASCULAR THROMBOSIS IMAGING. I AM DONE. >> SO WITH REGARD TO SPECIFIC BIOMARKERS, ARE THERE ONES YOU WANT TO TELL US WE SHOULD BE STUDYING? >> SAY IN THE HOSPITALS, EVERYONE IS GETTING D DAIMLERS AND CSVS BUT LOTS OF PEOPLE THINK THERE ARE SPECIFIC ONES FOR VASCULAR THAT INCLUDE D-DAIMLER T SELECTION, VWF FACTORATE AND THERE ARE A COUPLE OF OTHERS, THE CLASSIC INFLAMMATORY ONES WHICH MOST IMPORTANT ARE -- [INDISCERNIBLE] THERE ARE OTHERS THAT MIGHT ULTIMATELY PROVE TO BE MORE VALUABLE BUT THOSE ARE SORT OF THE LARGE -- [INDISCERNIBLE] [ TRAILING OFF ] >> GREAT, AND YOU MENTIONED SPECIFICALLY THE ONES RELATED TO VASCULAR DISEASE AND INFLAMMATION AND Dr. REYNOLDS MENTIONED VMT WHICH IS MORE RELATED TO THE MYO CARDIAL ABNORMALITIES WE HAVE DISCUSSED. SO MY COMPUTER IS SAYING FOUR PARTICIPANTS HAVE RAISED HANDS BUT I AM NOT SURE IF THE PEOPLE WHO ALREADY RAISED THEIR HANDS TOOK THEM DOWN SO THIS IS CHALLENGING TO ME. WHO WANTS TO GO NEXT, JUST SPEAK UP. >> I WOULD JUST LIKE TO ADD FOR -- OH, SORRY, I JUST WANTED TO ADD FOR THE RECOMMENDATION AROUND STRESS TEST AND STRESS IMAGING TO JUST BE MINDFUL OF PATIENTS. ONE OF BODY POLITICS, OUR POST COVID RESEARCH IS SHOWING THAT MALAISE IS EXTREMELY COMMON IN OUR COHORTS PRETTY MUCH FROM THE BEGINNING OF THE INFECTION AND FOR MONTHS ON INCLUDING MYSELF. I WAS A RUNNER AND CAN NO LONGER GO FOR A RUN WITHOUT EXPERIENCING HUGE SETBACKS IN MY RECOVERY SO WANT TO BE MINDFUL WHEN TALKING ABOUT PROTOCOLS THAT ANYTHING STRETCHING OUT THE CARDIOVASCULAR SYSTEM COULD POTENTIALLY CAUSE REGRESSION OR INCREASED SYMPTOMS. >> YES, AN IMPORTANT POINT THAT THE SYMPTOMS ARE CARDIOVASCULAR IN ORIGIN BUT DIFFICULT TO DETERMINE WHAT IS VASCULAR AND WHAT ISN'T SO THAT IS AN IMPORTANT QUESTION AND Dr. FAYED, YOU HAD SOMETHING ELSE TO SAY? >> I HOPE WE WILL HAVE THE CHANCE, I DON'T KNOW HOW WE ARE GOING TO DO THIS BUT LET ME BRING A FEW THINGS THAT RESONATED WITH ME AND LET ME START WITH THE LAST ONE THAT WAS MENTIONED THAT HAS NOT BEEN TOUCHED UPON AT ALL, THE HEART RATE VARIABILITY HAS BEEN MENTIONED AND WE TALKED ABOUT REMOTE MONITORING AND SO WE HAVE ACTUALLY LAUNCHED A STUDY USING THE APPLE WATCH TO LOOK AT VULNERABILITY. WE CALL IN THE WARRIOR WATCH BECAUSE IF YOU LOOK AT HEALTHCARE WORKERS AT MOUNT SINAI, AND WE ALREADY SUBMITTED A PAPER LOOKING AT PREDICTION OF INFECTION BEFORE SOMEBODY BECOMES SYMPTOMATIC AND LOOKING AT THE EFFECT THAT COVID HAS ON THE HEALTHCARE WORKERS RELATED TO STRESS. AND SO THAT IS ANOTHER -- IT IS A VERY EASY MEASURE. THERE ARE MANY DEVICES THAT CAN DO THIS TODAY SO YOU COULD DO THIS WITH A GARMIN, WITH A FITBIT, YOU COULD DO IT WITH A LOT OF THE WEARABLE WATCHES OR DEVICES OUT THERE. SO THAT IS POINT NUMBER ONE. POINT NUMBER 2, I MEAN, A LOT OF THESE THINGS YOU MENTIONED, YOU KNOW, WE CREATED A POST-COVID FREQUENT PROGRAM, AND EVERYTHING THAT YOU MENTIONED, YOU KNOW, IS BEING COLLECTED. SO IT IS A FULL CLINICAL ASSESSMENT THAT THE PATIENTS ARE GETTING, THE 6-MINUTE WALK, THE SPIROMETRY, THE C-PATH ALSO AND EVALUATING HOW IMPORTANT THIS IS GOING TO BE. OBVIOUSLY THE MARKERS, YOU KNOW, ALL THE TYPING THAT IS DONE, BUT ALSO SOME REMOTE ALSO MONITORING, LOOKING AT, YOU KNOW, OXIMETRY, PULSE, TEMPERATURE WITH THESE DEVICES. AGAIN, WE SHOULD TRY TO TAKE ADVANTAGE OF THE NEW TECHNOLOGY ESPECIALLY DESIGNED TO GET INTO THE ASPECT OF EMOTION. AND FINALLY ONE POINT THAT WAS RAISED, THE ASPECT OF TYING THAT DATA AND ENRICHING WITH THE DATA YOU HAVE AVAILABLE. WE CREATED -- WE HAVE A 10,000-PLUS PATIENTS REGISTRY WITH COVID WHERE WE ARE ALL INTEGRATED UNDER ONE SINGLE DATA ENCLAVE SO WE ARE ABLE TO LOOK AT THE PATIENTS COMING BACK TO US, LOOK RETROSPECTIVELY AT ALL THE DATA OF WHEN THEY PRESENTED THEMSELVES TO MOUNT SINAI. SO I THINK THE MORE WE CAN ENRICH FROM THE DATA SET, THE BETTER IT IS GOING TO BE. >> THAT IS A WONDERFUL POINT. GO AHEAD. >> ONE FINAL POINT I WANT TO MAKE ON THE ASPECT OF THE TIMING, I THINK WE ARE -- I MEAN LET'S ASSUME WE WANT TO LAUNCH A STUDY NOW, MAYBE SOON IN TERMS OF LOOKING AT POST WOE INDIVIDUAL EFFECT OF PEOPLE PRESENTING TO THE CLINIC. WE ARE GOING TO MISS QUITE A BIT OF THREE MONTHS AND SIX MONTHS POST-COVID. WE ARE A LITTLE BIT COMING IN LATE IN THE GAME I WOULD SAY. AND I AM ACTUALLY VERY CONCERNED THAT THIS EARLY TIME OF CATCHING THESE PATIENTS, UNLESS SOMETHING HAPPENED MIRACULOUSLY AND WE'RE ABLE TO LAUNCH THESE STUDIES NOW, AND I KNOW ANGELA IS VERY INTERESTED IN THIS, I THINK WE ARE GOING TO MISS A BIT ON THE SHORT-TERM ASSESSMENTS. >> WELL, UNFORTUNATELY THERE IS A LOT NEW COVID COMING IN SO WE WILL HAVE THE OPPORTUNITY BUT WE DID MISS THE EARLY PHASE OF THE ACUTE. THANKS FOR THOSE IMPORTANT POINTS. IT REMINDS ME OF THE QUESTION ABOUT REMOTE MONITORING AND YOU DID MENTION THE APPLE WATCH AND OF COURSE THERE ARE LOTS OF DIFFERENT APPROACHES TO REMOTE MONITORING SO IF WE WERE DESIGNING A STUDY, YOU COULD BE COMPLETELY REMOTE AND DOING A SURVEILLANCE STUDY WHERE YOU ARE ASSESSING RESPONSES TO -- [INDISCERNIBLE] TO INCLUDE DIVERSE GROUPS OF PEOPLE WHO HAVE AQUITE COVID, BUT YOU COULD BE COST EFFECTIVE AND NEVER ACTUALLY SEE ANYONE IN PERSON, BUT BE ABLE TO DO MONITORING REMOTELY AMONG PEOPLE WHO ALREADY HAVE DEVICES OR SEND DEVICES OUT TO PEOPLE SO THOSE ARE POTENTIAL WAYS TO DO POPULATION STUDIES. WE COULD DO VERY INTENSE HIGHLY SPECIALIZED PHENOTYPING THAT HAS BEEN PROPOSED, WE CAN'T DO THE ADVANCED PULMONARY TESTING IN EVERYBODY BECAUSE IT IS VERY EXPENSIVE AND LABOR INTENSIVE BUT WE DEFINITELY HAVE A NEED FOR VERY EXTENSIVE DETAILED PHENOTYPING IN SOME GROUPS OF COVID AND WE WILL HAVE TO FIGURE OUT WHO GETS TARGETED FOR THOSE STUDIES. AND THEN, YOU KNOW, CAPITALIZING ON EXISTING STUDIES, AND I SEE Dr. GREENSTEN HAS A HAND UP AND WANTED TO DISCUSS THE IMPORTANT QUESTION ABOUT ATHLEROSCLEROSIS SO I APPRECIATE THE COMMENTS FROM Dr. FAYED WHO DISCUSSED THE VARIOUS WAY WE SHOULD DESIGN THE STUDIES. >> YES, I AGREE WITH EVERYTHING. IN TERMS OF SPECIFIC BIOMARKERS AT LEAST IN THE HIV SPACE WHICH HAS SOME SIMILARITIES, WE HAVE FOUND MARKERS OF INFLAMMATION AT BEING VERY GOOD IN PICKING UP ARTERIAL INFLAMMATION AND CORRESPONDING TO SOME OF THE STUDIES AND FUNCTIONAL IMAGING AGENTS. SO I WOULD RECOMMEND THAT. I WOULD ALSO RECOMMEND A DEEP PHENOTYPING ON ARTERIAL INFLAMMIVE MARKERS SPECIFICALLY ON THE NEURAL PATHWAYS SO THE IL-6 AND CRP ARE SOME WE CAN DO. ALSO WITH WOMEN, THERE ARE MARKERS WITH OVARIAN AGING THAT WE COULD USE TO STRAT GUY DISEASE ACROSS THAT SPECTRUM IN WOMEN TO SEE WHETHER THERE IS A DIFFERENT, IF WOMEN, OLDER WOMEN BECOME LESS PROTECTED BECAUSE THEY HAVE LESS ESTROGEN, IE THEY ARE FURTHER ALONG IN THEIR -- TOWARDS MENOPAUSE, ALH LEVELS ARE VERY INTERESTING IN PREDICTING CARDIOVASCULAR DISEASE HIV. SO THERE ARE EXPERIENCES FROM VARIOUS POPULATIONS, THEY MAY NOT BE EXACTLY ON POINT BUT OFFER SOME SOLUTIONS OR AREAS TO FOCUS ON AND YOU YOURSELF WENDY HAVE PUBLISHED SOME VERY GREAT WORK ON SPECIFIC BIOMARKERS, MANY OF US HAVE, AND I THINK THAT MAY BE GOOD MARKERS FOR THAT AS WELL. >> GREAT, THANK YOU. WHO ELSE WOULD LIKE TO -- Dr. COOPER, ARE YOU STILL ON? DID YOU WANT TO COMMENT BEFORE YOU HEAD ON? OKAY, HE JUST SENT ME AN E-MAIL BUT -- SO ANYONE WHO HAS NOT SPOKEN YET WHO WOULD LIKE TO ADD SOME COMMENTS? I DON'T WANT TO PUT ANYONE ON THE SPOT BUT FEEL FREE. WHY DON'T WE GO TO THE SECOND SET OF QUESTIONS, PLEASE. SO WHAT ARE THE MOST APPROPRIATE PROGRAMMATIC STRUCTURES AND DATA PLATFORMS THAT CAN BE DEPLOYED EFFICIENTLY TO SUPPORT COLLECTING AND ANALYZING DATA? WHAT EXISTING ASSETS CAN BE LEVERAGED TO SUPPORT STUDIES OF CARDIO VAS RARE AND OTHER OUTCOMES. WHAT NEW OR EMERGING ASSETS ARE NEEDED AND HOW CAN WE ENGAGE THE COMMUNITY IN AN INCLUSIVE FASHION TO DESIGN A CARDIOVASCULAR FOLLOW UP PROGRAM. WHAT FACTORS CAN CONFOUND, MEDIATOR MODIFY ASPECTS AFTER COVID AND WHAT SHOULD BE PRIORITIZED. LOTS OF QUESTIONS THERE. LET'S SEE, MAYBE WE CAN -- I CAN ASK MY NIH COLLEAGUES TO TELL ME A LITTLE BIT MORE ABOUT THIS WORD ASSETS. WHAT NEW AND EMERGING ASSETS ARE NEEDED? WHAT EXISTING ASSETS CAN BE LEVERAGED? WHO FROM NIH WANTS TO GIVE US A LITTLE MORE DETAIL ON HOW EXACTLY TO INTERPRET THAT QUESTION? >> I THINK THEY ARE LOOKING AT ME. SO THE IDEA, I THINK THE WORD ASSETS WAS MEANT TO CONVEY, YOU KNOW, A VARIETY OF PROBABLY LARGELY CLINICAL STUDIES BUT MAYBE NOT NECESSARILY. SO WAS A WAY OF TRYING TO DEFINE RATHER BROADLY WHAT CAN WE -- WHAT CAN WE DO TO LEVERAGE BOTH NEW AND EXISTING PROGRAMS, STUDIES, IN ORDER TO UNDERSTAND BETTER, ESPECIALLY, YOU KNOW, AS WHAT I AM HEARING TODAY, KIND OF THE WHAT IS THE ACUTE PHASE VERSUS WHAT IS THE POST-ACUTE PHASE. DOES THAT HELP AT ALL? >> YEAH, SO I MEAN THERE ARE A NUMBER OF EXISTING STUDIES THAT HAVE ALREADY BEEN ENGAGED IN SUPPLEMENT TO ALLOW FOR ADDITIONAL STUDY OF COVID. SOME HAVE BEEN MENTIONED SKPHR-RD SOME ARE -- MENTIONED ALREADY AND SOME ARE LISTED IN THE CHAT AND LEAST OF ALL WE KNOW AGING IS ASSOCIATED WITH THEM. SO IT WOULD BE HELPFUL IF THERE ARE PEOPLE IN THE GROUP WHO KNOW ABOUT EXISTING ASSETS THAT HAVEN'T YET BEEN ENGAGED THAT COULD BE ENGAGED IN ORDER TO HELP ANSWER SOME OF THE QUESTIONS. DOES ANYONE HAVE ANY SUGGESTIONS? >> SO I THINK SAYED WAS THE FIRST TO RAISE HIS HAND. [INAUDIBLE] >> -- DEFINITELY BE LEVERAGED AND ANY STUDY THAT IS GOING TO BE ONGOING SHOULD DEFINITELY BE THINKING OR HAVE A TASK TO LINK TO -- [INDISCERNIBLE] AND I KNOW THAT THERE HAVE BEEN SOME INITIAL WORK IN TERMS OF INGESTING SOME COVID DATA. AND THERE ARE OTHER NIH ASSETS OR PLATFORMS, DATA PLATFORMS, NCAS AND NIAID THAT ARE ALSO COLLECTING COVID DATA THAT CAN BE INTEGRATED WITH THE OTHER DATA THAT IS EITHER COLLECTIVELY OR -- >> CAN YOU EXPLAIN WHAT THE BIODATA CATALYST IS? >> SHAWN MAY KNOW MORE THAN I THERE. >> IT IS MEANT TO BE A CLOUD-BASED PLATFORM FOR PRIMARILY DATA SHARING. CURRENTLY THEY HAVE BEEN WORKING ON ADJUSTING THE TOP MED GENOMIC DATA BUT TRYING TO RAPIDLY EXPAND ESPECIALLY FOR COVID-RELATED RESEARCH, YOU KNOW, THOSE PROJECTS ONGOING IN THE COVID SEVERE FOR ESSENTIALLY WIDE SHARING. BUT THAT IS, I GUESS, KIND OF LIKE THE $50,000 VIEW OF BIOCATALYST. >> SO THAT REMINDS ME THAT GENETICS IS ONE OF THE TOPICS WE WANTED TO COVER SO WHEN WE SPOKE ABOUT BIOMARKERS, WE CAN ADD TO THAT LIST WHEN WE REPORT OUT THAT WE OBVIOUSLY WANT TO ASSESS GENETIC PREDICTORS OF A VARIETY OF DIFFERENT OUTCOMES AND THAT CAN BE STUDIES FROM EXISTING DNA DATA WHICH IS A NICE THING ABOUT THE DNA, IS THAT IT IS RELATIVELY STATIC. BUT THERE ARE ALSO INTERESTING QUESTIONS THAT CAN BE RAISED ABOUT OMICS, WHETHER EXPRESSION PROFILE OR METABOLOMICS, SOMEONE MENTIONED TOP MED AND THERE IS EXPRESS INTEREST IN TOP MED TO LOOK AT HOW THE OMIC MIGHT CHANGE OR BE MARKED WITH COVID. DOES ANYONE ELSE IN THE GROUP TO WANT MENTION ANYTHING ABOUT GENETICS OR GENUINE MOMENT MIX? >> I THINK HARMONY WAS NEXT WITH HER HAND RAISED. >> OKAY, HARMONY, YOU WANT TO SAY SOMETHING? >> SURE, NOT WITH GENETICS OR GENOMICS BUT IT WILL BE VERY IMPORTANT TO USE SELF REFERRAL AND COMMUNITY OUTREACH TO GET PATIENTS IN THESE STUDIES. IF WE USE EXISTING CLINICAL TRIAL STUDIES, AND WE SHOULD, WE KNOW THOSE A BIASED INFORMATION. BUT WE SHOULD HAVE A STANDARDIZED ASSESSMENT, DID THEY HAVE COVID IN THE OUTCOMES THEY ARE CONTINUING TO COLLECT. ALSO KEEP IN MIND THE AMERICAN HEART ASSOCIATION IS COOPERATING WITH ANOTHER AGENCY AS A PLATFORM FOR PEOPLE INTERESTED AND WONDER FOR THAT COULD BE A PLACE TO REFER FOR PEOPLE WHO HAVE HAD COVID. >> SO THERE ARE SO MANY TOPICS TO COVER IN THIS AMOUNT OF TIME. SO Dr. REYNOLDS MENTIONED HOW DO WE INCLUDE COVID PATIENTS INTO OUR STUDIES AND CAPITALIZE ON EXISTING -- [INDISCERNIBLE] -- WHAT BECAME C4 R, ARE WE GOING TO HAVE ENOUGH PEOPLE WITH COVID TO HAVE POWER TO ANSWER QUESTIONS AND FORTUNATELY FOR OUR RESEARCH AND UNFORTUNATELY FOR THE POPULATION, IT LOOKS LIKE WE WON'T HAVE ANY TROUBLE FINDING ENOUGH PEOPLE WHO HAVE EXPERIENCED COVID WITH THE WAY THINGS ARE GOING RIGHT NOW. SO IT MAY BE THAT AS DOCTOR REYNOLDS MENTIONED, EXISTING CLINICAL TRIALS COULD BE LEVERAGED TO ASCERTAIN EFFECTS OF COVID IN THOSE POPULATIONS. SO THAT IS REALLY HELPFUL, Dr. KHAN, I SEE YOU PUT A BUNCH OF THINGS IN THE CHAT AND IT IS HARD FOR ME TO KEEP UP WITH THEM BUT DID YOU WANT TO ADD ADDITIONAL COMMENTS? >> SURE, THANK YOU. I THINK THAT CONVERSATION AROUND THE E MR DATA BEING GENERATED FROM THE CTSA AND N3 SOUNDS WONDERFUL BECAUSE SOME OF THE LONG-TERM FOLLOW UP WITH REHOSPITALIZATION AND HOW DO WE BEST CAPTURE WHAT IS BRINGING PEOPLE BACK, WHAT ARE THEY BEING HOSPITALIZED FOR AND WHAT IS THE TIME COURSE WHEN THAT IS HAPPENING. AND ON A BROADER SCALE, HOW DO WE BETTER HARMONIZE ACROSS DIFFERENT PLATFORMS AND ARE THERE WAYS TO INTERACT WITH THAT OUTSIDE OF THE CTSA THAT WOULD BE MORE BROAD AND REACHING IN HARMONIZING THAT DATA. >> YEAH, GOOD POINT. WHO ELSE HAS SOMETHING THEY WANT TO ADD? I GUESS THERE IS A REALLY BROAD QUESTION AT THE END HERE ABOUT WHAT FACTORS MAY CONFOUND, MEDIATOR MODIFY CARDIOVASCULAR OUTCOMES AND WHAT EXPOSURES SHOULD BE PRIORITIZED FOR STUDYING CARDIOVASCULAR OUTCOMES? WHO WANTS TO TACKLE THAT ONE? DON'T ALL VOLUNTEER AT THE SAME TIME. I SEE HARMONY, YOU STILL HAVE YOUR HAND RAISED OR SADIA OR WAS THAT FROM BEFORE? >> I WILL COMMENT. I THINK CLEARLY AGAIN SORT OF THINKING BACK TO THE EPI OF THE INFECTION, WE KNOW THAT OUR PATIENTS ARE HAVING HIGHER RATES OF INFECTION THAT ALREADY HAD HIGHER RATES OF COMORBIDITIES TO BEGIN WITH SO IF WE SORT OF THINK ABOUT THE FACT THAT INCIDENT HEART FAILURE IS ALREADY MORE COMMON IN THOSE POPULATIONS, HOW IS THAT RISK DECELERATING EXACERBATED BY THE HIGHER INS INCIDENCE OF COVID-19, WHAT DOES IT LOOK LIKE AND HOW ARE WE TRACKING THAT SO IT IS THIS SORT OF PERFECT STORM OF THE DISEASE AS WELL AS ARE WE GOING TO SEE ACCELERATED RATES OF HYPERTENSION IN AFRICAN-AMERICAN PATIENTS AND SO MANY QUESTIONS THAT COVID-19 MIGHT EXACERBATE AND ACCELERATE THE COMORBIDITIES THAT ARE ALREADY THERE SO I THINK THAT IS SOMETHING THAT NEEDS TO BE PRIORITIZED IN TERMS OF STUDYING THIS. >> THANK YOU AND THERE IS THE RACIAL ETHNIC DISPAINTERS AND PARTS -- DISPARITIES AND MAY BE OF THOSE TRACK WITH OF COURSE OBESITY, ADVANCING AGE, DIABETES, LUNG DISEASE, ALL RISK FACTORS AND ALSO AFFECTED BY DISPARITIES THAT EXIST IN OUR SOCIETY AND SO TRYING TO TEASE APART ALL THESE DIFFERENT FACTORS IS REALLY IMPORTANT AND WHILE YOU HAVE THE FLOOR, MAYBE YOU CAN MAKE SOME SUGGESTIONS, Dr. MORRIS, ABOUT HOW DO WE ASSESS SOME OF THE -- I AM TRYING TO FIGURE OUT THE RIGHT WORDS, BUT IF WE'RE DOING A STUDY TO TRY TO LOOK AT RISK FACTORS FOR SEVERE COVID, HOW DO WE TEASE OUT THE DISPARITIES RELATED TO SYSTEMIC RACISM AND, YOU KNOW, WHAT KIND OF QUESTIONS SHOULD WE BE ASKING TO MAKE SURE THAT WE'RE GETTING ALL THE DATA THAT WE NEED TO ASSESS VARIOUS RISK FACTORS FOR OUTCOME AND INCLUDE THOSE RELATED TO STRUCTURAL RACISM, HOW SHOULD QUESTIONS BE PHRASED AND WHAT ARE THE IMPORTANT DOMAINS THAT NEED TO BE INCLUDED. >> YEAH, AND I THINK WE NEED TO BE SURE WE THINK ABOUT ALL THE DIFFERENT FACTORS THAT IMPACT PATIENTS' RISK FOR INFECTION AGAIN BEFORE THEY EVER INTERACT WITH THE HEALTHCARE SYSTEM. SO WE LOOK AT, FOR EXAMPLE, NEIGHBORHOOD ACCESS TO, YOU KNOW, RESOURCES FOR PHYSICAL ACTIVITY, ACCESS TO RESOURCES FOR HEALTHY DIET. YOU KNOW, WE DON'T NECESSARILY THINK ABOUT THE VARIOUS SORT OF STRUCTURES AND SOCIAL DETERMINANTS THAT WE DON'T SEE WHEN WE'RE ACCESSING PATIENTS IN A CTSA OR OUR HEALTHCARE SYSTEM BUT CERTAINLY FACTORS AND DRIVERS THAT WE ACTUALLY SEE IN RESEARCH STUDIES AS WELL AS WHAT OUR PATIENTS ARE ABLE TO COMPLY WITH ONCE THEY NEED OUR HEALTHCARE OR RESEARCH SETTINGS. SO I THINK TRYING TO GET A BETTER, MORE COMPREHENSIVE LOOK AT WHAT THE RESOURCES LOOK LIKE. WE TALKED ABOUT THE IDEA THAT THE CARDIAC OR LUNG COMPLICATIONS MIGHT LEAD TO A MORE SEDENTARY LIFESTYLE WHICH MIGHT MAKE PATIENTS MORE SUSCEPTIBLE IN CERTAIN NEIGHBORHOODS AND THAT MIGHT AMPLIFY FACTORS FOR OBESITY AND HOW DO WE TRACK THAT DEPENDING ON WHERE THEY LIVE AND DO THEY HAVE ACCESS TO CARDIOVASCULAR EXERCISE OR A GYM FACILITY. THEY SEEM LIKE VERY BASIC THINGS BUT THEY ARE WIDE DEPENDING ON WHERE THE PATIENTS LIVE SO IF THEY TRACK THOSE THINGS IN RESEARCH STUDIES IN ADDITION TO ALL THEE BIOMARKERS, I THINK THOSE TYPES OF RESOURCES ARE INCREDIBLY VALUABLE. >> GREAT, THANK YOU. AND WE HAVE SEEN SEVERAL PATIENTS THAT RECOVER WELL AND SOME DON'T, WHY. SO THAT IS ONE OF THE FUNDAMENTAL QUESTIONS THAT GETS TO THE INITIAL QUESTION WE ASKED AND SO MAYBE WE CAN PUT THAT IN THERE AND WILL NEED TOE REPORT OUT WHAT ARE THE KNOWLEDGE GAPS AND THAT SEEMS TO BE ONE OF THE MAJOR KNOWLEDGE GAPS THAT WE WANT TO TRY TO UNDERSTAND. >> AND LARGELY AN ASPECT OF LONGITUDINAL ASPECT THAT IS CRITICAL. I CAN SHOW YOU PATIENTS WHO STARTED AT THE SAME DISEASE LINE AND OVER THE COURSE OF, YOU KNOW, SEVERAL STUDIES LONGITUDINALLY, ONE IS FINE, RECOVERED PRETTY NICELY, THE OTHERS ONES HAVE NOT RECOVERED. AND THAT IS A MYSTERY WE HAVE NOW, WHY. AND I THINK SHAWN MENTIONED IN THE COMMENTS, THIS ASPECT OF RESILIENCE, WE NEED TO UNCOVER THAT RESILIENCE. AND I ALSO THINK THERE IS A MENTAL ASPECT TO THIS, RIGHT, IN TERMS OF THE STRESS EXPOSURE. THAT IS WHY LINKING THE ASPECT OF THE STRESS, YOU KNOW, THIS WHOLE MIND-BODY CONNECTION NEEDS TO BE ALSO PUT IN CONTEXT. I KNOW IT MAY GO OUTSIDE NHL BI'S PURVIEW, YOU START TO CROSS NOW FROM HERE UP TO THE GRAIN BUT THE ISSUE WE ARE DEALING WITH THIS, UNFORTUNATELY. >> YEAH. AND AS I PUT IN MY LAST SLIDE, THIS IS GOING TO HAVE TO BE A COLLABORATIVE APPROACH BECAUSE EVERYTHING WE ARE TALKING ABOUT IS INVOLVING NOT JUST CARDIOVASCULAR BUT HOW IS INTERACTS WITH OTHER SYSTEMS. SHAWN, I AM SORRY I INTERRUPTED YOU AND I THINK YOU PUT IN A QUESTION OR A COMMENT. >> YES, THAT HAD COME FROM THE PUBLIC, ESPECIALLY IN TERMS OF POTENTIAL COST EFFECTIVE MEASURES BUT JUST TO RESPOND TO SAHID, WITH RESPECT TO COGNITIVE FUNCTION, ONE THING ABOUT HEART LUNG AND BLOOD, WE SPAN A LOT OF DIFFERENT DOMAINS SO IT IS HARD TO GET SOMETHING OUTSIDE OF OUR INTERESTS. >> NO, NO, I KNOW THIS AND I APPRECIATE IT. I AM THE BOLD DER OF A PROGRAM PROJECT LOOKING AT MIND-BODY INTERACTION FUNDED BY NIH WHICH I AM HOPEFUL FOR. >> SO MIND-BODY INTERACTION IS AN IMPORTANT KEY TO PUT IN OUR SLIDES BECAUSE IT WILL BE IMPORTANT TO THE MANY THINGS WE DISCUSSED. SORRY, I INTERRUPTED YOU. >> SORRY, IF I COULD ADD AROUND ASSETS, I WANT TO ELEVATE THIS IDEA OF PATIENTS THEMSELVES AS ASSETS. YOU KNOW, BODY POLITIC AND OTHER LONG-TERM COVID SUPPORT GROUPS ARE REALLY THE REASON IN MY OPINION THAT WE ARE ALL HERE TODAY. IT IS THE PATIENT ADVOCACY THAT HAS UPLIFTED THIS IDEA OF LONG COVID. WHEN I WAS FIRST EXPERIENCING, YOU KNOW LONG-TERM SYMPTOMS POST, YOU KNOW, THIS TWO-WEEK AND DONE ILLNESS FRAMING THAT WAS IN THE MEDIA AND THAT MY PROVIDERS WERE MARRIED TO, IT WAS OTHER PATIENTS WHO, YOU KNOW, CAME TOGETHER AND REALLY STARTED OFFERING THIS, YOU KNOW, SUPPORT BASED ON HISTORICAL MUTUAL AID STRATEGIES THAT HAVE BEEN IN THE COMMUNITY, YOU KNOW, LONG BEFORE COVID WAS HERE AND SO I WANT TO MAKE SURE THAT AGAIN AS WE'RE DEVELOPING RESEARCH PROTOCOLS AND STUDIES THAT PATIENTS THEMSELVES ARE INVOLVED IN THOSE PROCESSES, THEY HAVE -- WE HAVE A LOT TO OFFER BY WAY OF NOT JUST OUR DIRECT EXPERIENCE BUT SO MANY OF US INCLUDING THE FOLKS WHO ARE LEADING BODY POLITICS PATIENT-LED RESEARCH ARE PATIENTS THEMSELVES, ARE DOCTORS AND HAVE DONE THEIR OWN DIGGING INTO THE SORT OF HISTORICAL INDICATORS OF WHAT WE'RE GOING THROUGH AND ALSO TRYING TO LEAD THE WAY IN FIGURING OUT WHAT IS HAPPENING TO LONG COVID PATIENTS. SO REALLY JUST WANT TO UPLIFT TO THE EXTENT THAT YOU CAN HAVE PATIENT ADVISORY COMMITTEES, PATIENTS INVOLVED IN THE DESIGN OF QUESTIONS AND STUDIES, IS GOING TO BE REALLY IMPORTANT. THE OTHER PIECE I WANTED TO SAY AROUND SORT OF COMMUNITY ASSETS, THIS IS FOR ME REALLY IMPORTANT TO THINK THROUGH, IF THERE IS ANY OPPORTUNITY TO PARTNER WITH LOCAL PUBLIC HEALTH AGENCIES, THE REALITY IS THAT BLACK AND BROWN FOLKS ARE MUCH MORE LIKELY TO BE SERVED BY PUBLIC HEALTH CLINICS AND ON MEDICAID SO TO THE EXTENT IF YOU WANT TO HAVE A TRULY REPRESENTATIVE STUDY OF YOUR COMMUNITIES, PARTNERING WITH PUBLIC HEALTH AGENCIES ARE WHERE YOU ARE GOING TO GET A LOT OF THAT DIVERSITY FROM DIFFERENT EXPERIENCES. AND FOR ME, ALSO, YOU KNOW, I HAVE PRIVATE INSURANCE BUT I WILL BE HONEST, I RECEIVED MUCH BETTER CARE, MUCH MORE COMPASSIONATE AND CURIOUS CARE FROM THE LARGE UNIVERSITY THAT RUNS OUR PUBLIC EMERGENCY ROOM FOR THE COUNTY AS COMPARED TO THE OTHER UNIVERSITY ON THE WHITE WEALTHY SIDE OF TOWN. SO I THINK ALSO THERE IS POTENTIAL FOR I THINK LONG STANDING COMMUNITY PARTNERSHIPS. THIS IS A GLOBAL PANDEMIC, BLACK AND BROWN FOLKS ARE THE GLOBAL MAJORITY AND IF WE WANT TO FIGURE OUT WHAT IS HAPPENING TO BLACK AND BROKEN BROWN FOLKS WITH COVID WE NEED TO THINK ABOUT HOW WE ENGAGE WITH THOSE PATIENTS IN THE COMMUNITY. >> THANKS FOR THOSE REALLY IMPORTANT COMMENTS AND THE FACT YOU ARE HERE IS A GOOD INDICATION OF THE INPUT OF THE COMMUNITY AND PATIENTS WHO ARE EXPERIENCING LONG COVID ARE REALLY VALID AND WE APPRECIATE YOUR CONTRIBUTION. Dr. LEWIS? >> ACTUALLY WHAT I WANTED TO SAY HAS BEEN SAID ALREADY BUT I WOULD LIKE TO ADD TO THE IMPORTANCE OF ASSESSING MIND-BODY INTERACTIONS, PARTICULARLY AS YOU THINK ABOUT BLACK AND BROWN COMMUNITIES, MANY OF WHOM HAVE PREEXISTING HIGH LEVELS OF CHRONIC STRESS, TRAUMA, POVERTY, SO THINGS NOT JUST AT THE NEIGHBORHOOD LEVEL BUT THE INDIVIDUAL LEVEL RISK FACTORS THAT MAKE THEM -- MY WORK IS FUNDED BY NHL BI AND FOCUS ON CARDIOVASCULAR DISEASE AND WE KNOW THERE ARE PATTERNS OF RELATIONSHIPS THAT THESE MINORS ARE EXPOSED TO EVERY SINGLE STRESS YOU CAN THINK OF. YOU SUPER-IMPOSE COVID ON TOP OF THAT AND I THINK THAT WILL CONTRIBUTE TO VASCULAR AGING IN WAYS WE ARE NOT NECESSARILY THINKING ABOUT. WE KNOW THERE IS A LINK BETWEEN STRESS AND IMMUNE FUNCTION. WE KNOW THERE IS A LINK BETWEEN BEREAVEMENT AND LATER LONG OUTCOMES AND COMMUNITIES ARE IMPACTED BY COVID-RELATED BEREAVEMENT AND THESE ARE ALL THINGS WE SHOULD BE THINKING ABOUT. AND A POINT THAT WAS RAISED EARLIER, WE CANNOT ASSUME WHEN HAVING THESE CONVERSATIONS ABOUT THE VACCINE THAT BLACK AND BROWN COMMUNITIES ENTER THE MEDICAL CENTER AND RECEIVE THE SAME QUALITY OF CARE EVEN IF THEY ARE AT MEDICAL CENTERS THAT HAVE HIGH QUALITY CARE AND THERE IS A LARGE BODY OF RESEARCH IN THAT AREA. SO THESE ARE ALSO THINGS WE NEED TO BE THINKING ABOUT WHEN WE THINK ABOUT CROSS CUTTING ISSUES, NOT JUST THE VASCULAR SYSTEM BUT WHAT SOCIAL DETERMINANTS, HOW THOSE THINGS IMPACT THE BODY AND HOW THOSE THINGS IMPACT THE CARE THAT THESE PATIENTS WILL FIND THEMSELVES IN. >> THANK YOU THOSE ARE REALLY IMPORTANT COMMENTS. SO Dr. LOWENSTEIN, I AM GOING TO PUT YOU ON THE SPOT. SO WE TALKED A LOT ABOUT MYOCARDIAL ABNORMALITIES AND BRIEFLY ABOUT THROMBOSIS ANDENDOTHELITIS SO IS THERE MORE YOU WANT TO TALK ABOUT WHAT THE POTENTIAL KNOWLEDGE GAPS ARE TO ANSWER QUESTIONS YOU HAVE BEEN THINKING ABOUT A LOT? >> I DON'T HAVE A LOT TO ADD. THERE ARE LOTS OF GREAT -- FIRST OF ALL, WENDY, THANKS FOR RUNNING THIS. YOU ARE DOING SUCH AN AMAZING JOB ABOUT MULTITASKING, IT IS REALLY GREAT. [LAUGHTER] >> I DON'T KNOW ABOUT THAT BUT I AM TRYING. >> AND ALL THESE VIEWPOINTS, IT IS LIKE APPROACHING AN ELEPHANT AND DEFINE WHAT IT IS ON ALL THESE DIFFERENT TYPES SO WE NEED PHYSICIAN CONTROL GIFTS, COHORTS, CENTER YOU CAN SURE AND THEN RELYING ON GREAT PATIENT IMAGING AND BIOMARKERS AND THERE IS A HEALTHY DEBATE ABOUT WHAT ARE THE COMMON BIOMARKERS THAT EVERYONE GETS AND WHAT ARE THE SPECIALIZED BIOMARKERS THAT WOULD GIVE US ADDED INSIGHT INTO THE CAUSE BUT I DON'T HAVE ANYTHING ELSE TO ADD AND THINK THIS IS A REALLY VALUABLE CONVERSATION. THAT IS ALL. >> AND WE APPRECIATE YOUR CONVERSATION. >> ONE THING WE HAVEN'T TALKED ABOUT YET THAT JUST OCCURRED TO ME, LIKE A LOT OF PATIENTS HAVE BEEN ON NIH AND NONNIH FUNDED TRIALS OF THERAPEUTICS WHICH HAVE HAD VARIABLE EFFECTS ON ACUTE COVID BUT MIGHT HAVE DIFFERENTIAL EFFECTS ON LONG COVID. SO IT MIGHT BE INTERESTING TO TALK TO NIH TO GET SOME KIND OF ORGANIZED EFFORT TO GET LONG-TERM ASSESSMENTS IN PEOPLE WHO HAVE GOTTEN ACUTE THEIR B OOT -- THERAPEUTICS AND LONG-TERM EFFECTS. >> SO I CAN ADD TO THAT. >> GO AHEAD. >> WITH ALL THE STUDIES, WE ARE ALREADY IMPLEMENTING THAT PLAN, MEANING THAT WE ARE MAKING SURE THAT IT INCORPORATES THE STATEMENT TO FOLLOW THE PATIENTS FOR LONG-TERM -- [INDISCERNIBLE] >> BUT THAT COULD ALSO BE CARRIED OVER TO PHARMACEUTICAL TRIALS AS WELL AND I DON'T KNOW IF THEY ARE DOING THE SAME THING BUT THAT IS A GREAT POINT. >> SO NOW WE HAVE THE VERY DIFFICULT TASK OF TRYING TO CONSOLIDATE ALL THIS DISCUSSION INTO A 10-MINUTE PRESENTATION BY ME, UNFORTUNATELY. SO-- [LAUGHTER] -- I REALLY APPRECIATE THE EXCELLENT NOTE TAKING AND MAYBE WE CAN NOW USE THIS TIME TO GET THE CONSENSUS ABOUT WHAT THE MAJOR POINTS ARE. AND I AM TRYING TO FIGURE OUT HOW BEST TO DO THIS BUT I AM THINKING THAT MAYBE IF I TYPE, IT MIGHT BE EASIER FOR ME SINCE I AM GOING TO NEED TO ACTUALLY PRESENT, BUT I WONDER IF YOU COULD E-MAIL THE NOTES OUT TO THE GROUP BECAUSE WE'RE NOT GOING TO BE ABLE TO DISPLAY THEM ALL BECAUSE THERE'S MULTIPLE PAGES, LOOKS LIKE THERE'S SEVEN. AND THEN WE CAN TRY TO SUMMARIZE THEM SUCCINCTLY INTO WHAT WE THINK ARE THE MAJOR COMPONENTS -- [INDISCERNIBLE] I DON'T KNOW, DO YOU HAVE THE E-MAIL LIST OR YOU CAN E-MAIL IT TO SHAWN WHO HAS IT? >> I ACTUALLY DON'T HAVE THE LIST SO I WILL E-MAIL TO YOU AND SHAWN AND YOU CAN SHARE IT. >> AND THEN SHAWN CAN E-MAIL IT TO EVERYONE, FINE. AND THEN IF YOU CAN STOP SHARING, THEN MAYBE I CAN -- NOW, I AM JUST GOING TO DO IT AS A WORD DOCUMENT NOW AND CHANGE IT AS A POWERPOINT LATER. JUST GOING TO REVIEW FOR MYSELF THE AGENDA HERE. SO WE ARE SUPPOSED TO FINISH BY 12:10 WHICH IS A LITTLE LESS THAN HALF AN HOUR. THEN WE GET A BREAK AND THEN I AM SUPPOSED TO PRESENT AT 12:37. OKAY, SO I AM GOING TO JUST LOOK AT A COUPLE MORE COMMENTS. I AM GOING TO SHARE MY SCREEN WITH A WORD DOCUMENT -- NO, THAT IS NOT THE RIGHT ONE. OKAY, SHARE SCREEN. OKAY, CAN YOU ALL SEE THIS THAT SAYS THIS IS WHAT I WANT TO SHARE? YES? >> YES. OKAY, SO I THINK THE FIRST MOST IMPORTANT PART IS WHAT ARE THE KEY KNOWLEDGE GAPS. WE HAVE BEEN HAVING A DISCUSSION WHICH HAS BEEN DETAILED AND REALLY HELPFUL BUT IF PEOPLE CAN HELP ME SYNTHESIZE SUCCINCTLY WHAT THE KEY KNOWLEDGE GAPS ARE, MAYBE WE CAN START WITH EXACTLY HOW IT IS WRITTEN. I CAN'T SEE THE PICTURES RIGHT NOW SINCE I AM TYPING SO ANYONE START WITH ONE KEY KNOWLEDGE GAPS THAT SHOULD BE ON THE LIST, WHAT IS THE MOST IMPORTANT ONE. >> LONG-TERM RISKS OF CARDIOVASCULAR EVENTS. >> OKAY, YOU CALL IT EVENTS BUT CARDIOVASCULAR, IT DOESN'T HAVE TO BE AN EVENT IT, COULD BE A LONG-TERM RISK OF CARDIOVASCULAR PATHOLOGY -- >> OR COMPLICATIONS -- >> YEAH, I -- [OVERLAPPING SPEAKERS] >> HOW ABOUT SEQUELAE? >> WHAT ARE THE LONG-TERM SEQUELAE -- LONG-TERM CARDIOVASCULAR DISEASE SEQUELAE OF COVID-19. OKAY. WHAT IS THAT? >> RELATED TOE THAT, WHAT IS THE RELATIONSHIP BETWEEN ACUTE CARDIOVASCULAR SEQUELAE OF COVID-19 AND LONG-TERM CARDIOVASCULAR SEQUELAE BECAUSE I THINK IT IS UNCLEAR. >> SAY IT AGAIN? >> THE RELATIONSHIP BETWEEN ACUTE CARDIOVASCULAR ILLNESS AND LONG-TERM CVD SEQUELAE. >> YOU MEAN HOW DO THEY DIFFER? [OVERLAPPING SPEAKERS] >> CERTAINLY MANY OF THE LONG-HAUL PATIENTS SR-R HAD RELATIVELY MILD UPFRONT ACUED COVID ILLNESS, SOME HAVE HAD QUITE SEVERE SO I AM SAYING THE RELATIONSHIP BETWEEN ACUTE COVID ILLNESS AND THE LONG-TERM CONSEQUENCES IS UNDEFINED. >> I WILL CALL IT LONG COVID BECAUSE IT IS EASIER TO TYPE, PREDICTORS OF LONG COVID ASYMPTOMATIC, MILD OR SEVERE DISEASE, RIGHT? >> YEAH, JUST CALLING IT ACUTE BECAUSE THE PHENOTYPING OF ACUTE COVID NEEDS TO BE CONNECTED TO THE PHENOTYPE OF LONG COVID. >> OKAY, NEEDS TO PHENOTYPE ACUTE COVID TO DETERMINE RISK RELATIONSHIP WITH LONG COVID, RIGHT? >> YES. >> I THINK THIS GOES TO THE POINT OF WHAT EXACTLY IS THE LONG-TERM SEQUELAE, SOMETHING THAT COULD HAVE BEEN AVOIDED THROUGH, YOU KNOW, PROPER TREATMENT OR SUPPORT DURING THE ACUTE PHASE. >> SO HOW DOES TREATMENT DURING ACUTE COVID ASSESS LONG-TERM COVID? SO I GUESS WHAT I AM THINKING IS NONE OF THIS IS REALLY SPECIFIC TO CARDIOVASCULAR SO I AM ASSUMING THAT THE OTHER BREAKOUT GROUPS WILL COME OUT WITH VERY SIMILAR QUESTIONS. BUT IF WE CAN ALSO THINK ABOUT SPECIFIC CARDIOVASCULAR THINGS. >> RIGHT, BUT YOU ARE WRITING LONG COVID AS SHORTHAND FOR THE POTENTIAL MANIFESTATIONS BUT MAYBE YOU SHOULD PUT IN MORE SPECIFIC EVENTS, AS THERE ARE A NUMBER OF DIFFERENT THINGS IN THE COVID FINDINGS. >> OKAY, SO THROMBOTIC, MYOCARDIAL, VASCULAR AND AUTONOMIC -- WE DIDN'T REALLY TALK ABOUT THAT. >> IF I COULD ADD TO THAT, I THINK THE RELATION BETWEEN VASCULAR AND OTHER SYMPTOMS AND BODY SYSTEMS, SO CERTAINLY AUTONOMIC DYSFUNCTION AND COMPLICATIONS BUT A LOT OF MY PATIENTS CONTINUE TO LOOK LIKE POTENTIAL NERVOUS SYSTEM VASCULARITIS. AND THINKING THERE, THERE IS DATA TO SUGGEST IN PATIENT SURVEYS THAT IT IS RELATED TO GASTRO INTESTAL SYMPTOMS SO MICROVASCULATURE OF DIFFERENT ORGANS IS IMPACTED AND WHERE DOES THE RESEARCH OF THAT LIE, IS IT IN MYOCARDIAL RESEARCH OR GASTROINTESTINAL FOR EXAMPLE. >> SO HOW DO WE DIFFERENTIATE CARDIOVASCULAR IS IT SYMPTOMS THAT ARE RELATED TO -- I AM TRYING TO FIGURE OUT ANGELA HOW TO PHRASE THIS IN A WAY THAT IS SENSITIVE TO THE -- WHAT YOU EXPERIENCED AND MANY PEOPLE DO AS WELL WHICH IS THERE IS A LOT OF STRESS RELATED TO HAVING ACUTE COVID AND SOME PEOPLE DO GET ALMOST POSTTRAUMATIC STRESS DISORDER RELATED TO THE FACT THEY WERE SO SICK. SO HOW DO YOU DIFFERENTIATE THOSE SYSTEMS TO PARALLEL SYMPTOMS YOU COULD HAVE FROM THROMBOTIC OR CARDIOVASCULAR OR SOMETHING THAT COULD BE MORE PHYSIOLOGICALLY DEFINED. >> I THINK SOMETHING ABOUT THE ORGANIC NATURE OF SYMPTOMS. SO I WILL BE HONEST, I AM A PTSD SURVIVOR AND THE ANXIETY AND DEPRESSION THAT I EXPERIENCED AS A PTSD SURVIVOR IS SIMILAR BUT ENTIRELY DIFFERENT FROM THE AUTONOMIC DYSFUNCTION AND ADRENALINE DUMPS I GET IN THE MIDDLE OF THE NIGHT. SO FOR ME IT IS ABOUT SORT OF RUNNING DOWN ALL OF THE POSSIBLE ORGANIC NATURE OF -- >> NO, I UNDERSTAND THAT, I GUESS -- SO THE PTSD-RELATED SYMPTOMS, THEY ARE THEY ARE PHYSIOLOGIC AND I AM TRYING TO FIGURE OUT HOW TO DIFFERENTIATE BETWEEN THE ORGANIC AND THE OTHER PART OF THAT, THE NEUROPSYCHIATRIC PTSD TYPE SYMPTOMS FROM THE -- WHAT IS THE NEXT PART OF THAT PHRASE, FROM THE CARDIOVASCULAR DAMAGE TO -- FROM THE DAMAGE TO THE CARDIOVASCULAR SYSTEM. IS THAT RIGHT? OKAY, SO SO FAR WE HAVE WHAT ARE THE LONG-TERM CARDIOVASCULAR SEQUELAE WITH PREDICTORS THAT INCLUDE ASYMPTOMATIC, PHENOTYPE ACUTE COVID, WHAT IS THE TREATMENT, THERE IS THE RELATIONSHIP BETWEEN COVID AND EFFECTS, WHAT IS THE RELATIONSHIP BETWEEN CARDIOVASCULAR EFFECTS AND OTHER BODY SYSTEM EFFECTS OF COVID, HOW DO WE DIFFERENTIATE CARDIOVASCULAR SYSTEMS RELATED TOLL -- TO NEUROPSYCHIATRIC SYMPTOMS FROM THE DAMAGE BY COVID TO THE CARDIOVASCULAR SYSTEM. AND THEN ALSO WHAT BIOMARKERS PREDICT LONG-TERM COVID? SO WE TALKED ABOUT GENETICS AND GENOMICS, ILLNESS, WE TALKED ABOUT IMAGING AND BLOOD BIOMARKERS. THERE'S ALSO, YOU KNOW, WE TALKED ABOUT WHETHER YOU ARE ASYMPTOMATIC, MILD OR HAD SEVERE DISEASE AND THEN OTHER CARDIOVASCULAR MEASURES SUCH AS EKGS OR MOBILE ASSESSMENTS. >> PREDICT OR MEDIATE TO GET AT SOME OF THE BIOLOGY? BECAUSE THERE IS SOME QUESTION WE'RE SEEING PREDICTORS THAT ARE INFLAMMATION BUT WHAT IS THE MECHANISM OF WHAT IS DRIVING THE COMPLICATION, SO WHAT BIOMARKERS PREDICT OR MEDIATE THE COMPLICATIONS? >> OKAY, WHICH THEN I GUESS GETS TO HOW DO WE PREVENT THE COMPLICATIONS OF LONG COVID AND IT WAS MENTIONED THE LONGITUDINAL FOLLOW UP OF RANDOMIZED AND NONRANDOMMIZED TREATMENT STUDIES FROM THE ACUTE PHASE TO THE LONG COVID PHASE. >> WEPT DE, I THINK HOW WILL RACIAL DISPARITIES IN ACUTE COVID INFECTIONS EXACERBATE PREEXISTING DISPARITES IN CARDIOVASCULAR DISEASE. >> OKAY, CAN YOU SAY IT MORE SLOWLY? OKAY SO ARE THOSE THE MAJOR QUESTIONS? ANYTHING ELSE WE SHOULD -- >> I THINK YOU COULD EMBELLISH -- >> -- IN THE CHAT -- [OVERLAPPING SPEAKERS] SORRY, I WAS SAYING I SEE PEOPLE PUTTING THINGS IN THE CHAT BUT I AM NOT REALLY MONITORING THE CHAT SO IF YOU COULD SPEAK OUT INSTEAD OF THE CHAT, THAT WOULD BE HELPFUL. WHO WAS SPEAKING? >> THAT WAS ME, HARMONY. ONE OF THE THINGS THAT CHRIS AND I WOULD LIKE TO WORKSHOP THE SECOND POINT IN YOUR SECOND SET OF QUESTIONS SO PREDICTORS AND MEDIATORS. THE SECOND PART OF THAT, WOULD YOU PLEASE REPLACE THAT WITH HOW DO ACUTE COVID CV OR NONCV PHENOTYPES CONTRIBUTE TO LONG COVID CV AND NONCV PHENOTYPES. >> WHAT DO YOU MEAN BY PHENOTYPES, ALL THE THINGS I LISTED HERE, IMAGING, BIOMARKERS AND ET CETERA AND ALSO YOUR CLINICAL SITE LIKES HOW SICK YOU WERE -- [OVERLAPPING SPEAKERS] >> YEAH, RECOGNIZABLE CARDIOVASCULAR INVOLVEMENT IN THE ACUTE PHASE. IT IS CERTAINLY POSSIBLE THAT MAYBE MOST OF IT IS LUNG DISEASE BUT THAT IT CONTRIBUTES TO A VARIETY OF SYSTEMIC MANIFESTATIONS THAT MANIFEST LONG-TERM. IT IS HARD TO ANTICIPATE THAT. >> GREAT, SO WE WILL REFINE THIS A LITTLE BIT WHEN WE ARE DONE BUT ARE THESE THE MAJOR QUESTIONS PEOPLE FEEL NEED TO BE ADDRESSED? >> CAN WE ADD SOMETHING ABOUT WHY CERTAIN PEOPLE RECOVER, WHY CERTAIN OTHERS DON'T? >> WHY DO SOME PEOPLE WITH SYMPTOMATIC COVID RECOVER AND OTHERS DEVELOP LONG COVID? >> YEAH. >> AND THEN I THINK AN IMPORTANT QUESTION IS WHAT IS THE CLINICAL SIGNIFICANCE OF SUBCLINICAL IMAGING ABNORMALITIES THAT HAVE BEEN IDENTIFIED ON CARDIAC MRI AND ECHO CARDIO GRAB DURING THE RECOVERY PHASE OF COVID. IS THAT THE RIGHT WAY TO PHRASE IT? [INAUDIBLE] >> MOST OF THESE WE WOULD CONSIDER SUBCLINICAL. SOME OF THE STUDIES ARE DONE IN PEOPLE WHO PRESENT WITH SYMPTOMS IN THE RECOVERY PHASE BUT MOST OF THEM, LIKE ATHLETES, WERE PEOPLE WHO WERE COMPLETELY ASYMPTOMATIC, DIDN'T HAVE SYMPTOMS. >> CORRECT. >> SO TO BE MORE SPECIFIC ABOUT YARD YO -- ABOUT CARDIOVASCULAR, SHOULD WE PUT IN MORE SPECIFIC QUESTIONS RELATED TO MRI THINGS? >> THE BIG QUESTION IS REALLY THE ASPECTS OF HOW SEQUELAE AND INJURY, HOW OFTEN IT IS, RIGHT, REACHING THE HEART? SO WE STILL, AGAIN, DON'T KNOW WHAT PROPORTION OF PATIENTS ARE GOING TO HAVE THAT MYOCARDIAL JOURNEY. >> I THINK THERE IS ALSO A QUESTION OF WHAT IS THE CLINICAL SIGNIFICANCE OF TROPONIN ELEVATIONS AS THAT IS THE LONG-TERM EFFECT OF THAT IN SEVERE MANIFESTATIONS. >> YEAH, IF YOU WANT TO PUT IT IN A LAY CONTEXT, I HAD COVID, DO I NEED TO WORRY THAT I CAN'T EXERCISE BECAUSE I AM AT RISK OF HAVING HAD UNRECOGNIZED MYOCARDITIS? I THINK A LOT OF US WHO ARE CLINICALLY ACTIVE ARE SEEING PEOPLE SELF-REFERRING AND INCREDIT PLEA STRESSED OUT TRYING TO RESOLVE THE UNCLEAR BODY OF LITERATURE. >> YEAH. >> CORRECT ARE. >> SO AGAIN I AM JUST GOING TO TRY TO GET QUESTIONS THAT ARE SPECIFIC TO CARDIOVASCULAR AND SOME OF THE QUESTIONS WE HAVE YOU COULD SUBSTITUTE PULMONARY OR WHATEVER. THEY ARE IMPORTANT QUESTIONS BUT GIVEN THAT THERE IS GOING TO BE AN HOUR OF THESE TYPE OF PRESENTATIONS, WE SHOULD FOCUS ON THE CARDIOVASCULAR. SO THIS IS HELPFUL -- [OVERLAPPING SPEAKERS] >> I KNOW WE MENTIONED PTSD BUT MAYBE GO BACK TO THE MIND-BODY CONCEPT AND STRATEGIES TO PROMOTE RESILIENCE IN ANY WAY. >> SO CAN WE DEVELOP STRATEGIES, CAN WE DEVELOP -- ARE YOU LOOKING AT THE EFFECTS OF RESILIENCE ON OUTCOME OR HOW TO DELIVER DELIVER RESILIENCE? CAN WE CREATE STRATEGIES TO PROMOTE RESILIENCE AND I AM KEEPING THE RESILIENCE OPEN HERE BECAUSE WE STILL NEED TO FIGURE OUT WHAT IS RESILIENCE BUT THERE ARE STRATEGIES OF MIND-BODY INTERACTION THAT COULD BE IMPORTANT. WOULD HE KNOW FOR EXAMPLE THE IMMUNE SYSTEM IS AFFECTED BY THE STRESS DISORDER, RIGHT? SO IF WE CAN DEAL WITH THE STRESS, MAYBE WE CAN HELP THE IMMUNE SYSTEM AND PREVENT LONG-TERM INJURY. >> IT CAN POTENTIALLY AFFECT HOW THE IMMUNE SYSTEM DEALS WITH THE STRESS OF COVID. >> ONE OF THE OTHER THINGS OF PROMOTING RESILIENCE, YOU COULD EVEN LOOK AT IT FROM A INTRAPERSONAL AND COMMUNITY STRUCTURE, SO KIND OF A MULTILEVEL APPROACH FOR IT. >> ABSOLUTELY AND AS YOU KNOW VERY WELL, TAKING IT FROM A NEUROPSYCHIATRY POINT OF VIEW, THE MOST IMPORTANT THING IS HAVING THE COMMUNITY SUPPORT, LIKE IT COULD BE FAMILY SUPPORT BUT THAT SUPPORT ASPECT IS CRITICAL TO THE ASPECT OF BUILDING RESILIENCE IN GENERAL. >> GREAT, SO SHAWN, OTHER QUESTIONS THAT YOU HEARD IN THE DISCUSSION THAT YOU THINK SHOULD BE LISTED HERE AS HIGH PRIORITY? SORRY IF THIS IS PUTTING YOU ON THE SPOT HERE. >> YOU KNOW I AM NOT SURE IF IT IS FOR THIS PART HERE BUT, YOU KNOW, IN TERMS OF ESPECIALLY COMMUNITY PARTNERSHIPS, HOW DO WE REACH DIVERSE COMMUNITIES? IF THOSE ARE HERE OR MAYBE FOR SOMEWHERE ELSE, BUT THAT IS SOMETHING I AM KIND OF SEEING. >> OKAY. >> AND WENDY, THE THOUGHTS YOU HAD ON ENDOCRINOLOGY, TO THE EXTENT THAT COVID AFFECTS THE PANCREAS AND RELATES TO LONG-TERM DIABETES OR EXERCISE DYSFUNCTION AND THEN ULTIMATELY HIGHER WEIGHT, THERE WILL BE SORT OF MORE PERHAPS TRADITIONAL CARDIOVASCULAR LONG-TERM THAT MAY IMPACT THE HEART. IN OTHER WORDS THERE IS THE COVID, INFLAMMATORY, YOU KNOW, STUFF THAT IS NEAR TERM ACUTE, PERHAPS LONGER BUT THEN THERE IS THE WHOLE OTHER THING IS THAT IF IT AFFECTS OTHER CRITICAL METABOLIC SYSTEMS THAT MAY ELM SELVES IMPACT IN -- THEMSELVES IMPACT IN A NONTRADITIONAL WAY. >> BUT WHAT DO YOU HAVE IN MIND IN TERMS OF MULTIORGAN ASSESSMENT? THE UK STUDY HAS DONE THAT. THEY HAVE ALREADY PUBLISHED ON THE ASPECTS OF -- YOU KNOW, I DON'T KNOW IF YOU GUYS KNOW ABOUT THIS STUDY BUT THEY PICKED ONLY A MRI PROTOCOL BECAUSE THEY WANTED TO KEEP THINGS FROM THAT POINT OF VIEW SIMPLE. AND THEY DID AN ASSESSMENT OF MULTIORGAN THAT INCLUDES THE LIVER, SPLEEN, PANCREAS, KIDNEY, BRAIN, HEART. SO DEFINITELY THE MULTIORGAN -- >> YEAH, THAT IS A BETTER WAY TO CAPTURE IT, I LIKE THAT. THAT IS A GOOD IDEA, A GREAT WAY TO SAY IT, THANK YOU. BUT THAT IS IMPORTANT I THINK, SUPER IMPORTANT. >> ABSOLUTELY. >> SO NOW WE'RE GOING TO MOVE ON TO WHAT ARE SOME OF THE ASSESSMENTS WE'RE GOING TO DO AND WE HAD THREE E-MAILS OUT FOR NOTES FOR THE WONDERFUL THINGS THAT HARMONY SAID AND I AM JUST TRYING TO FIND WHERE IT IS. OKAY, HERE IT IS. OKAY, SO WE NEED A LONG-TERM SET OF TESTS, NOT ONLY ADVANCED TESTS BUT SIMPLE TESTS SUCH AS -- OKAY, SO WE NEED EXERCISE ASSESSMENT COULD BE SUCH AS A 6-MINUTE WALK, DO WE WANT TO PUT ACTUAL STRESS TEST IN HERE AS POTENTIAL -- >> YES, THEY ARE VERY DIFFERENT, ONE IS MAXIMAL EXERCISE CAPACITY VERSUS ONE YOU ARE DOING AT A NATURAL PACE. >> AND THEN WE TALKED ABOUT CARDIO PULMONARY TESTING WHICH IS-- [INDISCERNIBLE] -- INVENTORY EKG MONITORING, HEART RATE VARIABILITY, PULSE WAVE VELOCITY, ECHOCARDIOGRAPHY, CMR, CORONARY CT CALCIUM AND ANT YOGRAPHY. >> CAN WE ADD THE FDG -- >> OH, YEAH, THAT IS GREAT. SO THAT GETS US TO THE NEED TO DEFINE THE IMPORTANCE OF CARDIAC MRI ABNORMALITY IDENTIFIED AND WIDELY PUBLICIZED. AND SO YOU SUGGESTED WE NEED MORE -- HOW TO YOU WANT TO PHRASE IT, MORE DETAILED OR SPECIFIC CARDIAC MRI DETAIL? [INAUDIBLE] >> YES, WHICH INCLUDE -- >> MYO CARDIAL TISSUE CHARACTERIZATION WITH T1 AND T2 MAPPING IN ADDITION OBVIOUSLY TO THE LGE. >> AGAIN, I AM NOT A DOCTOR BUT JUST WANTED TO MAKE SURE SORT OF LIKE WHETHER IT IS ANG IOGRAPHY OR ULTRASOUND, SOMETHING THAT GETS AT LIKE THE MICROVASCULAR EFFECTS THAT I HAVE BEEN TOLD ARE REALLY DIFFICULT TO SEE ON IMAGING. >> SHOULD RETINAL IMAGING BE SOMETHING? >> TO LOOK FOR 'EMBO ALMOST I? >> YEAH, AT THE MICROVASCULAR LEVEL. >> CARDIAC MRI DOES THAT ALSO AND I THINK SOMETHING WE HAVEN'T SPECIFICALLY TOUCHED ON BUT MANY OF US ARE SEEING THERE IS A LOT OF PERSISTENT CHEST PAIN AND SHORTNESS OF BREATH. WHAT IS CAUSING THAT? >> OH, ABSOLUTELY. >> THAT IS UNDER THE QUESTIONS AND IS A GOOD ONE, WHAT IS CAUSING CHEST PAIN FOR LONG COVID? >> SO YOU KNOW ONE THING -- I AM PERHAPS GETTING A LITTLE CONFUSED AND COULD BE MY NAIVETE, THE COMPLICATIONS VERSUS OUTCOMES POST-COVID, DO WE KNOW ENOUGH TO ESSENTIALLY DEFINE THE PHENOTYPE WE'RE LOOKING FOR? >> SO TO DEFINE THE PHENOTYPE OF LONG COVID CARDIOVASCULAR DISEASE AS THE FIRST QUESTION? >> YEAH, OF THE QUESTIONS WE HAVE LISTED, HOW MUCH ARE OUTCOMES THAT HELP US DEFINE WHAT IT IS. >> I SEE WHAT YOU ARE SAYING, SO LIKE I HAVE A CARDIAC ABNORMALITY ON MY MRI, IS THAT THE PHENOTYPE OR THE OUTCOME, IS THAT THE PREDICTOR OF SOMETHING IN THE FUTURE? WELL, THAT IS SORT OF LIKE -- YEAH, TRYING TO FIGURE OUT HOW TO PHRASE THAT BUT YOU KNOW LIKE IN MESA, WE HAVE ALL THESE SUBCLINICAL MEASURES SO IT COULD BE AN OUTCOME OR A PREDICT TORE, TO PREDICT THE MARKER OF -- [INDISCERNIBLE] >> YES. >> WE DIDN'T TALK ABOUT OTHER METHODS TO ASSESS WITH END OTHELIAL DYSFUNCTION, HRI, DIDN'T TALK ABOUT CHRONIC ET BUT PERHAPS THOSE WOULD BE MORE SYMPTOMATIC IN PEOPLE EXPERIENCING -- >> AND I AM GLAD YOU BROUGHT THAT UP AS THAT IS ANOTHER THING WE'RE LOOKING AT WITHIN THE PATIENT, THERE COULD BE OTHER MRI TECHNIQUES THAT -- [INAUDIBLE] >> SO THERE IS ENDOPATH, BRACHIAL, MRI -- >> YES, ALL OF THESE COULD -- >> YES, CAROTID ULTRASOUND, PWV I THINK MENTIONED AS WELL. >> I ALSO DIDN'T WANT TO LOSE, RETALKED ABOUT REPRODUCTIVE HEALTH AND SEX GENDER DIFFERENCES. >> SO THE REPRODUCTIVE HEALTH ISN'T SPECIFICALLY CARDIOVASCULAR BUT WITH LONG COVID -- >> WELL, I WILL SAY AGAIN THERE IS A LOT OF EMERGING RESEARCH FROM THE PATIENT-LED RESEARCH THAT MANY OF THE CARDIOVASCULAR SYMPTOMS SEEM TO EBB AND FLOW TO ONE'S MENSTRUAL CYCLE. >> I AM GOING TO THROW THIS OUT THERE, TOO, YOU KNOW, SOME OF THE THINGS THAT MIGHT BE POTENTIAL GENDER BIAS AND DIAGNOSES WITH RATIO ETHNIC BIASES THAT ARE SET TO EMERGE. >> SO GENDER AND RACE ETHNICITY BIASES IN TREATMENT AND DIAGNOSIS? >> YEAH. YOU KNOW I MAY NEED TO ASK BRIAN -- YEAH, IF WE HAVE TO BREAK OR WHAT IS -- IF HE HAS GOT TEN WORD ON WHAT EXACTLY OUR SCHEDULE -- >> THE BIOMARKERS, WE TALKED ABOUT A LOT OF BIOMARKERS. >> OKAY, THAT ON HERE? BIOMARKERS AND GENOMIC -- THIS IS REALLY HARD TO DO, I AM SORRY. >> YOU ARE DOING GREAT. [LAUGHTER] >> WENDY, I THINK ONE THING WE DID NOT DISCUSS WAS THE AGE. WE SAW YESTERDAY THAT EVEN A YOUNG PATIENT HAD COVID LONG HAUL AND THERE ARE REPORTS SAYING OLDER PATIENTS, THERE ARE MORE PERCENTAGES OF LONG HAULERS IN THEM BUT IS IT BECAUSE OF COMORBIDITIES AND HOW DOES IT AFFECT THE YOUNG AND HEALTHY CHILD HAVING THE -- BE DETERMINED AS LONG HAUL? I THINK THE AGE MIGHT BE ANOTHER THING THAT WE MIGHT HAVE TO ADDRESS. >> YEAH, YOU MAY WANT TO MOVE TO THE SECOND SET OF QUESTIONS GIVEN THE TIME. >> YES. SO IF ANYONE NEEDS TO SIGN OFF, SINCE WE'RE SUPPOSED TO FINISH AT 12:10, OBVIOUSLY FEEL FREE. SO THE SECOND SET OF QUESTIONS, WHAT ARE THE -- DO YOU HAVE IT THERE? PROGRAMMATIC STRUCTURES AND DATA PLATFORMS, EXISTING ASSETS, IMMUNITY, WHAT ARE THE CONFOUNDERS, EXPOSURES AND THE VARIOUS -- OKAY WE TALKED ABOUT THE NEED FOR APPROPRIATE CONTROL POPULATION AND PRE-COVID ASSESSMENT AND LONGITUDINAL -- WE TALKED ABOUT ENGAGING THE POPULATION WITH MOBILE DEVICE DATA COLLECTION THROUGH APPLE AND OTHER PLATFORMS. >> WENDY, MAYBE THIS MAKES SENSE WHEN YOU MEAN PRECOVID AND LONGITUDINAL, IT IS ALSO DURING THE COVID PRESENTATION BUT MAYBE THAT IS MEANT IN THE LONGITUDINAL. >> PRECOVID, ACUTE COVID AND LONGITUDINAL SHORT TERM OR LONG-TERM LONGITUDINAL -- >> IT IS VERY RICH DURING THE ACUTE PHASE OF SOME OF THESE PATIENTS, AS YOU KNOW, SOME OF THEM RECEIVE UP TO EIGHT CHEST X-RAYS DURING THEIR HOSPITALIZATION SO THERE IS A LOT OF TEMPORAL DATA THAT CAN BE USED NOW. >> SO USE EXISTING CLINICAL SET AND OBSERVATIONAL RESEARCH OR STUDIES. SO IF SOMEONE CAN BE SCROLLING THROUGH SELINE'S REALLY HELPFUL NOTES AND SEE WHAT WE LEFT OUT FOR THE SECTION YOU WANTED TO MAKE SURE ARE INCLUDED. >> WE ALSO TALKED ABOUT LEVERAGING PATIENTS IN EXISTING CLINICAL TRIALS AND SEEING IF WE CAN ADD DATA COLLECTION RELATED TO COVID. >> ADD DATA COLLECTION TO EXISTING CLINICAL TRIALS. >> YOU KNOW THAT MIGHT BE UNRELATED TO COVID LIKE ISCHEMIA FOLLOW UP. >> RIGHT. >> AND WITH COMMUNITY ENGAGEMENT, WE TALKED ABOUT THE IMPORTANCE OF SELF REFERRAL WHO MIGHT OTHERWISE NOT BE CAPTURED. >> REFERRAL INTO RESEARCH STUDIES, YOU MEAN? >> YEAH, YEAH. >> PARTNERSHIP WITH PUBLIC HEALTH. >> SO SELF REFERRAL INTO RESEARCH STUDIES TO ENGAGE THE COMMUNITY INCLUSION OF PATIENT REPRESENTATIVES TO HELP WITH STUDY QUESTIONS AND DESIGN, RIGHT? >> AND TO THE POINT OF CHRONIC STRESS, ROLE OF BEREAVEMENT AND HOW THAT AFFECTS THE MIND-BODY INTERACTION AND HOW THAT MIGHT DIFFER IN -- >> WHICH ASSET, WHICH PROGRAM PLATFORM WOULD WE USE FOR THAT, THAT IS THE QUESTION I AM ASKING. >> SO THE QUESTION IS WHAT PLATFORM DO WE USE TO STUDY MIND-BODY -- SORRY, I AM HAVING TROUBLE FOLLOWING. >> YES, CAN YOU TELL US MORE? I DIDN'T UNDERSTAND WHERE YOU ARE GOING WITH THIS. >> WELL, I THINK WE ALREADY RECOGNIZE AND ACCEPT THAT WE NEED TO STUDY THAT SO THE QUESTION IS HERE WE NEED TO MAKE -- YOU NEED TO MAKE A RELATION ABOUT HOW YOU ARE GOING TO GO ABOUT STUDYING, WHICH STRUCTURE, WHICH DATA SETS CAN WE LEVERAGE TO DO THAT OR WHAT DO WE NEED TO CREATE. >> SO MOST OF THE STUDIES IN POST COVID YOU KNOW HAVE ALSO DONE PATIENT QUESTIONNAIRE, SELF-ASSESSMENT. YOU COULD DO THIS DURING THE PRESENTATION AND THEY HAVE BEEN -- THERE ARE A LOT OF INSTRUMENTS IN FORMENTAL ASPECT YOU CAN MEASURE. YOU CAN ALSO DEPLOY SOME OF THEM WITH AN APPLE OR AN APP SO THEY CAN EVERY WEEK OR EVERY DAY TELL YOU HOW THEY FEEL AND WITH HEALTHCARE WORKERS WE WILL BE SUBMITTING VERY SOON, EXTREMELY POWERFUL DATA THAT CAN BE COLLECTED THERE. AND THAT IS ONE ASPECT. THE SECOND ONE IS SPECIFIC ASPECT RELATED TO THE AUTONOMIC SYSTEM WITH VARIABILITY AND MENTIONED -- [INDISCERNIBLE] -- TO DO THIS AND FINALLY IF YOU COULD GO A LITTLE MORE SOPHISTICATED AND DO BRAIN IMAGING WORK BUT THEN IT MIGHT BE OUTSIDE THE PURVIEW OF THIS GROUP. >> I AM AFRAID WE'RE GOING TO HAVE TO REALLY WRAP UP HERE AT SOME POINT. >> YEAH, WELL THANK YOU ALL SO MUCH. THIS HAS BEEN REALLY ENLIGHTENING, VERY FUN FOR ME AND I AM SURE REALLY HELPFUL TO THE NIH TO HEAR YOUR EXPERT OPINIONS. I KNOW THERE'S LOTS IN THE CHAT. IS THERE A WAY TO PULL THAT STUFF OUT LATER I THINK -- >> YEAH, I WILL TRY TO SAVE THAT TO -- FILE IT AND SAVE IT AND I GUESS FROM THE NHL BI SIDE, I WANT TO EXPRESS MY THANKS TO YOU AS WELL. AS THESE THINGS ARE, THERE ARE A LOT OF COMMON FLAWS AND DIFFERENT DIRECTIONS AND WHAT WE WILL BE TRYING TO DO OVER THE NEXT FEW DAYS IS SYNTHESIZE EVERYTHING IN KIND OF A COHESIVE STORY, PROBABLY MAINLY FOR US BUT I REALLY DO WANT TO THANK YOU VERY MUCH. >> AND THANK YOU TO SHAWN FOR ALL YOU HAVE DONE TO HELP. THIS IS REALLY FABULOUS. THANKS, EVERYONE, STAY WELL, HOPEFULLY WE'LL SEE EACH OTHER IN PERSON SOMETIME SOON. NICE TO SEE THE FACES OF SOME OF MIGHT HAVE FRIENDS I HAVEN'T SEEN IN A LONG TIME AND THANK YOU AGAIN. AND IF YOU CAN, LOG IN WITH THE OTHER ZOOM LINK SO THAT YOU CAN HEAR THE PRESENTATIONS. BUY, EVERYONE.