OUR GOALS HERE ARE HIGH LEVEL IDENTIFICATION OF KEY KNOWLEDGE GAPS WHICH BY THE WAY SPOILER ALERT SEEMS TO BE EVERYTHING. GIVEN WHERE WE ARE IN THE PANDEMIC BUT WHAT ARE KEY QUESTIONS. WHAT IDEAS DO WE HAVE ABOUT HOW TO QUICKLY MOVE FORWARD, HOW CAN WE LEVERAGE EXISTING STRUCTURE AND LET'S TRY TO HAVE A FINITE LIST OF SOLUTIONS AN IDEAS HOW TO MOVE FORWARD AT THE END OF THIS HOUR AND A HALF. SO THAT'S THE LARGER CHARGE. I THOUGHT IT MIGHT BE HELPFUL TO START JUST WITH A BIT OF CONVERSATION AROUND HOW ARE WE GOING TO ORGANIZE OUR THINKING BECAUSE PULMONARY OUTCOMES AFTER RESPIRATORY SYNDROME THAT AFFECTS THE ENTIRE BODY AND OUR ENTIRE SOCIETY SEEMS A LITTLE BIT AMORPHOUS. SO I DON'T KNOW IF ANYONE WANTS TO TAKE A FIRST STAB THINKING ABOUT HIGH LEVEL WHAT DO WE THINK WILL SOME OF THE KEY DOMAINS THAT WE NEED TO SLATE HERE. -- INVESTIGATE HERE. HOPEFULLY NOT STARTING OFF WITH TOO HARD A QUESTION. BUT THINKING OF A FEW BOXES. HOW DO WE ORGANIZE THIS? >> TERRY, WHAT DO YOU THINK ABOUT USING THE ICF MODEL AS A FRAME WORK? >> YOU MUTED YOURSELF. CAN YOU TELL US WHAT YOU MEAN WITH THAT? >> SURE. SO THIS IS JUST A STRAW PERSON IDEA BUT WHAT JUMPED TO MIND. SO THE WHO INTERNATIONAL CLASSIFICATION FUNCTIONING HELPS US UNDERSTAND THINGS BY THINKING OF STRUCTURE AND FUNCTION, MEASURES OR DOMAINS AND SEPARATE FROM THAT ACTIVITY AND SEPARATE FROM THAT PARTICIPATION SO STRUCTURE AND FUNCTION MIGHT BE LUNG IMAGING, RESPIRATORY MUSCLE STRENGTH, SPIROMETRY, ACTIVITY MIGHT BE EXERCISE TESTING OR SIX MINUTE WALK TEST AND PARTICIPATION WOULD BE PATIENT'S PERCEPTION SAYING THE REAL WORLD SETTING LIKE A DYSNIA SCORE FOR INSTANCE. >> GOING TO FLESH OUT THE STRUCTURE FUNCTION, I WOULD ARGUE WE THINK ABOUT PARYNCHEMAL ABNORMALITIES, AIRWAY ABNORMALITIES AND VASCULAR ABNORMALITIES AS A STARTING PLACE. >> IF YOU TALK AIRWAYS LET'S TALK LOWER AND UPPER SINCE THAT'S SITE OF INFECTION AND INVASION OF THE NERVOUS SYSTEM, COULD BE RESERVOIR, THAT SORT OF THING. >> WE CAN ALSO OVERLAY ON TOP OF THAT THINKING ABOUT THE PATIENT JOURNEY BOTH THROUGH THE ACUTE CARE SYSTEM BUT ALSO AS MENTIONED HERE NON-HOSPITALIZED PATIENTS. >> WE ARE ALREADY SAYING NOT A TWO BY TWO TABLE BUT GRID WHERE WE HAVE OUR LEVELS ACROSS THE ICF MODEL AND MAYBE DIFFERENT PATIENT POPULATIONS AND MAYBE THOSE WILL MARKED THEN BY WHERE THEY Q. THE COVID -- WHERE THEY ENTER THE COVID JOURNEY. MAYBE USE MY ICEBERG MODEL YESTERDAY FROM THE TALK I GAVE BUT THOSE WITH ACUTE RESPIRATORY FAILURE AND THE TIP OF THOSE PLEA LONGED ACUTE RESPIRATORY FAILURE, THE HOSPITALIZED PATIENT POPULATION AND THEN THAT COULD BE CONNECTED TO THE SYMPTOMATIC OVERALL COVID POPULATION AND THEN I THINK BELOW THAT WE HAVE THE ASYMPTOMATIC POPULATION AND EVEN JUST GENERAL POPULATION THINKING ABOUT POPULATION HEALTH IMPACTS. I DON'T KNOW IF THAT APPEALS OR IF OTHERS HAVE SOMETHING TO ADD ACROSS WHAT MAYBE OUR POPULATIONS MIGHT BE. >> MAYBE I CAN INTERJECT TOO, TERRY, AND JUST ADD TO PAT'S COMMENT ABOUT PATIENT JOURNEY THROUGH CARE AND IN KEEPING WITH THE CONCEPT OF CONTINUUM OF CARE IMPORTANT TO FOCUS ON PRE-ILLNESS TRAJECTORY AS WELL AS THIS IS GOING TO BE MAJOR DETERMINANT OF OUTCOME AND HOW THE COVID INFECTION INTERACTS WITH PRE-EXISTING ILLNESS. >> THANK YOU. >> THINKING ABOUT ANOTHER PARADIGM, I LIKE THIS, WE TALKED ABOUT ANATOMY, WE TALKED PATIENT JOURNEY, WE TALKED ABOUT ILLNESS SEVERITY IS WHAT I SEE. THE OTHER PARADIGM COULD THINK ABOUT ARE WHAT IS AVAILABLE AS IMMEDIATE TARGETS FOR INTERVENTION OR IN AN EMERGENCY THINKING QUICKLY HOW WE CAN START TO PREVENT LONG TERM PULMONARY DYSFUNCTION IS ANOTHER PARADIGM TO THINK ABOUT. >> THIS IS WHY YOU HAVE TO INVITE EMERGENCY MEDICINE COLLEAGUES THEY GET US LIGHT INTO WHERE WE NEED TO ACT. THANK YOU,. I LOVE THAT. I THINK ANOTHER WE HAVE A THIRD DIMENSION ON OUR GRID. BUT WE HAVE OBSERVATIONAL STUDIESNA ARE BIOLOGIC OR MORE CLINICAL RESEARCH BASED. THINKING OPPORTUNITIES FOR EARLY INTERVENTION, MAYBE THE SECOND STRATUM AND IMPLEMENTATION AND HEALTHCARE DELIVERY ACROSS ALL OF THOSE. >> ONE THING. I THINK THIS IS LUKE. SO I THINK THE COPD ASTHMA PATIENT PARTICULARLY IN THE MIDDLE OF PANDEMIC IF THEY WILL THE PATIENT WHO GETS A LOT OF EXACERBATIONS AND THEY TWO TO ER OR I THINK THAT'S A PARTICULARLY TROUBLESOME GROUP BECAUSE IT IS PULMONARY YET IN THE MIDDLE OF PACK DETERMINIC THEY GO TO ER AND GETTING RULED OUT FOR STUFF AND THAT CAN BE TROUBLESOME SO I THINK A PLAN AROUND THOSE KINDS OF PATIENTS WITH CHRONIC LUNG DISEASE WITH DYSMIA AS A PRESENTING SYMPTOM IS A PARTICULAR FOCUS WE HAVE TO THINK ABOUT CAREFULLY. >> WE DIDN'T LIST SYMPTOMS AS DOMAIN BUT IT'S WORTH GOING BACK AND LISTENING P THE SYMPTOMS PROMPTING THIS WHOLE TO BEGIN WITH. >> CHRONIC BECAUSE WE KNOW THEY ARE DIFFERENT. THIS IS RUN CHIMING IN ABOUT THE DISEMEA PIECE. , CRISIS WE COINED IT FROM THE ATS IN THE EMERGENCY ROOM AND EVEN IN ACUTE HOSPITALIZATION THERE'S BEEN ONE STUDY I FOUND WHERE THERE HAVE BEEN TRIALS OF LOW DOSE OPIOIDS FOR THOSE PATIENTS PRESENTING ACUTELY. IMPORTANT TO ADDRESS THOSE SYMPTOMS, ACUTE AND LONG TERM. >> AND TERRY, THIS IS GEORGE. THE QUESTION YOU MENTIONED ALSO PATIENT POPULATIONS. I WANT TO ASK WHAT IS OUR REMIT? I DON'T THINK IT WOULD BE SURPRISING TO SAY THAT A SUBSET OF PEOPLE WITH PULMONARY RESPIRATORY FAILURE DO NOT COMPLETELY RECOVER. ARE WE SEEKING TO SAY IS THIS IN EXCESS OF WHAT WOULD BE EXPECTED AS COMPARED TO CONVENTIONAL ARDS? OR HOW ARE WE FRAMING THIS? >> THIS IS ANN FROM HOPKINS AND PARKER. I WANTED TO CHIME IN WITH THAT AS WELL. IT'S GOING TO BE IMPORTANT TO HAVE NON-COVID ICU PATIENTS, AS CONTROLS AND COMPARING A LONG BASED ON SEVERITY OF DISEASE AS WELL WOULD BE HELPFUL. >> THIS IS BILL, I WOULD ECHO THAT. EARLY ON WE WERE TOLD THIS IS VERY -- A VERY DIFFERENT DISEASE AND I THINK IN MANY WAYS IT'S SIMILAR TOP -- TO ARDS THAT WE STUDIED FOR DECADES SO WE SHOULDN'T FORGET THE THINGS WE LEARNED PRIOR TO THIS. >> I WONDER IF WE WANT TO INCLUDE IN HERE NOT JUST -- BUT PATIENT MANAGEMENT FROM A HEALTHCARE INFRASTRUCTURE STANDPOINT. I HAVE BEEN TAKING A LOT OF CALL LATELY AND WE ARE ACTUALLY STARTING TO SEE A LOT OF THESE POST COVID POST ARDS PATIENTS CALLING. WITH ALMOST SORT OF CAP LIKE FASHION WITH ALL SORTS OF THINGS AND I KNOW WE HAVE GOT THESE POST COVID CLINICS BUT WONDER WHETHER BECAUSE OF THE SHEER NUMBER OF PATIENTS THAT WE HAVE GOT COMING THROUGH THE SYSTEM WHETHER WE ARE GOING TO BE MORE PERMANENT INFRASTRUCTURE. >> THANK YOU. I TOTALLY AGREE. THIS SORT OF THE HELP SYSTEM SCIENCE OF WHAT WE ARE DOING HEALTHCARE DELIVERY IS REALLY IMPORTANT AS WELL. I APPRECIATE THIS DISCUSSION ABOUT MAYBE USEFUL TO PARSE OUT HOW MUCH OF THIS IS POST COVID AND HOW MANY IS RECOVERY FROM SORT OF THE FINAL COMMON PATHWAYS OF LUNG INJURY. I WOULD LOVE TO PUSH BACK THOUGH. I WOULD LOVE TO KEEP THAT AS A PIECE OF OUR CHARGE. I FEEL LIKE WE ARE HAVING AN EPIDEMIC OF ARDS AND REASON CHRONIC CLINICAL ILLNESS AND THIS IS THE TIME I THINK TO REALLY LEARN ABOUT POTENTIALS FOR INTERVENTION FOR THAT PATIENT POPULATION AND BEST CARE AND SO I WORRY A LITTLE BIT IF WE SAY LET'S TAKE THAT, LET'S CALL IT AND THEY'S NOT OUR CONCERN, THAT WE BOTH DO A DISSERVICE FOR LOTS, HUNDRED THOUSAND SUR SURVIVORS, I WOULD LOVE TO KEEP A PIECE OF THAT MAYBE BECAUSE THAT'S WHAT I DO. >> I AGREE, TERRY. WHATEVER WE LEARN WITH COVID, MOST WE WANT RELEVANT FOR ARDS IN THE DECADES TO COME, AFTER COVID IS NO LONGER THE MAJOR CAUSE OF ARDS >> THIS IS KRISTINA CARUTHES VA PEW GENT SOUND. I DIDN'T SEE THAT AS A DETRACTION FROM THE IMPORTANCE OF WHAT OF THIS SYNDROME BUT WHAT MIGHT BE UNIQUE TO COVID. AND I THINK ALSO GOING BACK TO THE COMMENT SOMEBODY HAD ABOUT LOOKING AT OUTPATIENTS OR PEOPLE WHO DID NOT HAVE CRITICAL ILLNESS. THINKING ABOUT ARE THERE APPROPRIATE COMPARE TORR -- COMPARE TORR GROUPS FOR THOSE PEOPLE. INFLUENZA OR OTHER CAUSES OF PNEUMONIA OR OTHER RESPIRATORY FAILURE OR DISTRESS THAT DIDN'T RESULT IN ICU AND INTO BASEMENT -- INTO BASEMENT >> A QUICK COMMENT ON THAT. I'M MICHAEL PALUSSO UCSF, I MANAGE THE COVID RECOVERY COHORT. TWO-THIRDS WERE NOT HOSPITALIZED. WHAT I HEAR FROM THOSE WHO HAVE PERSISTENT PULMONARY SYMPTOMS IS THEY ARE REALLY FEELING >> POST COVID CLINIC TAKING PEOPLE WHO WERE HOSPITALIZED. I WILL CONTINUE TO ADVOCATE FOR SPECIFICALLY ACKNOWLEDGING THAT POPULATION HAVING PERSISTENT ISSUES, WORK TO BE DONE THERE BUT THE MIX PIECE IS VERY IMPORTANT FOR UNDERSTANDING ARDS OVERALL. >> >> IS IT PART OF THE CHARGE TO ALSO ADDRESS TREATMENT THAT PREVENT LONG-TERM DISABILITY? >> ABSOLUTELY. I THINK IT'S ONE OF THE HARDEST PARTS, WHEN I TRY TO CONCEPTUALIZE WHAT THE COHORT LOOK LIKE, I THINK THAT THE DATA STREAMS WHEN WE MOVE TO OUR NEXT STEPS OF THIS CONVERSATION THEY GET REALLY COMPLICATED, IF WE WANT TO UNDERSTAND HOW THESE ACUTE THERAPIES MAYBE IMPACTING THE LONGER TERM OUTCOMES. >> (INDISCERNIBLE) NORTHWESTERN PITCHING IN FOR SCOTT WHO IS NOW DOING NIGHT CALLS. OLDER PEOPLE DOING ONLY TELEMEDICINE THAT'S WHY I'M HERE. LOOKING A LITTLE BIT AT THE DISTINCTION BETWEEN THE RESPIRATORY FAILURE IN COVID AS OPPOSED TO VIRAL PNEUMONIA, IT SEEMS IN COVID MECHANISTICALLY ALSO THE MACROPHAGES GET INFECTED. THE AL VIE OWELITIS IS PROLONGED. I WILL INCLUDE A PAPER NOW IN REVIEW AND BY ARCHIVES. THAT MAKES THAT -- MORE FIBROSIS AND ALSO TO THE DISTAL ORGANS. FOR EXAMPLE, TERRY IN THE PAPER THAT YOU MENTIONED YESTERDAY THAT WAS PUBLISHED IN SCIENCE MEDICINE THIS WEEK OF THE TRANSPLANT PATIENTS THAT WE HAVE DONE 8 THEY HAVE VERY SEVERE FIBROSIS, THE SAME ALMOST LIKE PEOPLE END STAGE FIBROSIS. WHAT WE SEE ALSO IN RECOVERY CLINIC IS PATIENTS COME WITH PERSISTENT DISPNIA. SOME OF THE THINGS WE NEED TO LOOK AT IS WHAT ARE CONSEQUENCES, PREVENTING FOCUSING ON FIBROSIS. PULMONARY EMBOLISM PART OF THE -- AND WHAT -- INTRODUCE US, SOMETIME AGO IS MUSCLE DYSFUNCTION WHICH IS PROLONG END STAGE LONG TIME. WE ALSO KNOW NOW VIRAL INFECTION PATHWAY TO DESTROY MUSCLES. NOT BECAUSE PEOPLE REST, IT'S OR ARE INACTIVE, IT'S VIRAL ACTIVATION OF SIGNAL TRANSDUCTION PATHWAYS LEADS TO MUSCLE DESTRUCTION RAPIDLY. WE KNOW IN OLDER PATIENTS THAT TAKES FOR LONG TIME TO RECOVER BECAUSE OF THE INABILITY TO EXPAND SATELLITE CELLS OR REGENERATIVE CELLS. SO LEARNING FROM THE MECHANISTIC ASPECT THAT A WE CAN HAVE FIBROSIS AND WE CAN LOOK AT HOW TO PREVENT THAT, B THERE'S THIS SYMBOLIC EVENTS THAT CAN ALSO CAUSE PULMONARY HYPERTENSION AND DISTAL EFFECTS WHICH CAN MANIFEST AS MUSCLE DYSFUNCTION BUT ALSO DELIRIUM AND COGNITIVE. SEVERAL THINGS THAT AREN'T ONLY FOCUSED ON LUNGS BUT INTERACT AND WE SEE THAT IN THE PATIENT RECOVERING. I THINK MECHANISM TO UNDERSTAND HOW TO INTERVENE AND LOOK AT THOSE ASPECTS WOULD BE INTERESTING. >> THANK YOU. A LOT OF IMPORTANT COMMENTS THERE. A PIECE OF OUR CHARGE IS NOT JUST MAPPIN PULMONARY DOMAIN BUT ALSO HOW THIS INTERACTS AND WHERE CROSS CUTTING THEMES WITH THE OTHER AREAS SYMPTOMTOLOGY AND LUNG COVID. CERTAINLY I THINK THE SEQUEL LAY AFTER ACUTE ILLNESS WILL MAP TO EVERY DOMAIN AND I FEEL LIKE WE OWN THEM BECAUSE IT STARTS WITH THE RESPIRATORY INFECTION SO I THINK THAT CERTAINLY FITS WITHIN WHAT WE ARE TALKING AS WELL. I ALSO VERY MUCH LIKE THIS IDEA UNDERSTANDING MECHANISMS OF HOW PROFOUND RESPIRATORY FAILURE AND HOW PROLONGED IN COVID WILL HELP US UNDERSTAND WHAT IS HAPPENING WITH SARS COV-2 BUT MAYBE NOW WE HAVE LARGE ENOUGH POPULATION TO UNDERSTAND HOW TO TREAT THAT. FOR LARGER AREA OF POPULATION TOO. MOST STUDIES OF THAT POPULATION HISTORICALLY HAVE BEEN TOO SMALL AND SLOW IN ENLOWELLING TO FIGURE OUT WHAT WE HAVE TO DO RIGHT. >> HI, TERRY. THIS IS BRAD AT UNC CHAPEL HILL. I THINK ANOTHER THING TO CONSIDER IS WHETHER WE WANT TO VIEW OR SHOULD WE VIEW THE CRITICALLY ILL COVID PATIENT AS ENTIRELY DIFFERENT PHENOTYPE THAN THE MILDER OUTPATIENT WITH DIFFERENT SYMPTOM ON SETS. I THINK THERE ARE -- THERE ARE MAYBE AN ASSUMPTION OR REASONABLE HYPOTHESIS IT'S THE SIMILAR MECHANISM OF DISEASE BUT ONE IS LESS SEVERE THAN THE OTHER. BUT THE FACT THESE PHENOTYPES IN RECOVERY STATE ARE DIFFERENT AND RESPOND DIFFERENTLY TO DIFFERENT INTERVENTIONS. ONE OF THE CHALLENGES IS THE THE PREVALENCE OF THE MILDER PATIENTS WITH CHRONIC SYMPTOMS, IS GOING TO BE LARGER SO THINKING ABOUT AS WAS MENTIOND BY DR. PALUSO HOW WE TREAT THOSE PATIENTS DIFFERENTLY OR CONSIDER THEM DIFFERENT THAN THOSE WHO HAVE MORE SEVERE CRITICAL ILLNESS PATHWAY AND THINK ABOUT TWO BUCKETS THERE. >> BLOOD FOLLOW-UP ON THAT, HIGHER RESOLUTION CHARACTERIZATION OF THE ACUTE PHASE OF DISEASE. THAT MAYBE BEST INFORM TRAJECTORIES PEOPLE ARE TRAVELING ON SO NOT JUST A FOLLOW-UP POST HOSPITALIZATION BUT DATA COLLECTION DURING ACUTE EVENT. >> AGREE GEORGE. TALKING TO PROVIDERS HERE SEEING PATIENTS MILDER -- NEVER IN THE ICU THEY ARE DEALING WITH DO THEY HAVE PNEUMONIA, CHRONIC COUGH MAYBE WE NEED TO BE TREATING THEM WITH INHALED OR SYSTEMIC CORTICOSTEROIDS. THERE'S NO DATA IN THAT, THAT'S A DIFFERENT POPULATION THAN THOSE RECOVERING FROM A CRITICAL SEVERE ILLNESS. >> ANOTHER DATA GAP BUT THIS IS AREA WE HAVE DATA GAPS WITH LIMITED AMOUNT OF IMAGING DATA IN PARTICULAR WHICH IS AN INTEREST OF MINE. FOR IN PATIENTS BUT ALMOST NONE WE HAVE FROM THE OUTPATIENT SECTOR. >> JUST AS ANOTHER PERSPECTIVE I'M WONDERING ABOUT USING THESE STICKING TO THE MILD AND SEVERE H MILD BEING OUTPATIENT SEVERE BEING HOSPITALIZED BECAUSE WE ARE STARTING TO HEAR STORIES YESTERDAY OF PEOPLE THAT WERE NOT HOSPITALIZED. AND ENDED UNDERSTOOD WITH SUBSTANTIAL LIMITING SYMPTOMS THAT OCCURRED MONTHS DOWN THE ROAD AND HAD IMPACT WHEREAS OTHER PEOPLE IN THE HOSPITALLY COVERED AND RETURNED TO WORK. SO NOT SURE IF MAYBE IT'S MORE A TIME LINE AS OPPOSED TO JUST PUTTING TWO BATCHES MILD AND SEVERE BASED ON WHERE YOU WERE TREATED. >> BILL JANSON, MILD AND SEVERE MIGHT BE MISNOMERS, HOSPITALIZED AND OUTPATIENT MIGHT BE A BETTER DESCRIPTOR. YOU CAN BE OUTPATIENT AND STILL BE CRIPPLED BY YOUR DISEASE. AND WE DON'T WANT TO DIMINISH THAT. BUT IN THE HOSPITAL WE HAVE DIFFERENT THERAPIES WE USE AND THAT MIGHT ACTUALLY CAUSE LONG TERM SEQUEL LAY PARTICULARLY IN THE ICU PATIENTS SO I THINK WE SHOULD LUMP OUTPATIENT AND HOSPITALIZED. >> I LIKE THE IDEA OF TAXONOMY. >> I THINK SORRY, I THINK IT'S HARD FROM EPI PERSPECTIVE TO STUDY PEOPLE TO SORT OF EASIER TO DEFINE MILD EQUALS OUTPATIENT. AND MORE SEVERE IS HOSPITALIZED BUT I AGREE WITH COMMENTS IN THE CHAT THERE'S DIFFERENT CRITERIA FOR HOSPITALIZATION AND ALSO HOSPITALIZED FOR REASONS NOT NECESSARILY DUE TO SEVERITY OF COVID BUT TO OTHER CIRCUMSTANCES. SO FIGURING HOW TO MEASURE THAT. TO BRAD'S COMMENTS THERE MAYBE SOME PHENOTYPES OR PHENOTYPES THAT EMERGE FROM THIS BUT I THINK APPLYING A MEASUREMENT OF THESE PATIENTS TO UNDERSTAND THE SPECTRUM OF ILLNESS WE SHOULD DO MORE CONSISTENTLY ACROSS THE SPECTRUM OF SEVERITY SO WE DON'T MISS THINGS THAT MAYBE HAPPENING AND PEOPLE WHO WILL MORE MILD OUTPATIENT CASES WE SEE PATIENTS IN POST CLINIC WHO WERE TREATED AS OUTPATIENTS FOR COVID BUT HAVE SIGNIFICANT GROUND DA OPACITIES ON CHEST CTs THAT PERSISTING BUT THEY ARE NOT HOSPITALIZED AND THEY HAVE PERSISTENT RESPIRATORY SYMPTOMS. >> AGREE. 'S IMPORTANT TO RECOGNIZE DISCONNECT BETWEEN SEVERITY OF INFECTION AND SEVERITY OF SEQUEL LAY. >> SO I APPRECIATE THIS CONVERSATION DO WE NEED SOMETHING BEYOND WHAT WE HAVE ALREADY, MU CLASSIFICATION FOR EXAMPLE THAT'S USED AT PRESENTATION OF DISEASE THAT GOES EVERY WHETHER FROM ASYMPTOMATIC TO HOME WITH SYMPTOMS DOES THAT WORK FOR US OR DO WE NEED SOMETHING BEYOND THAT? >> THIS IS RENEE. HI, EVERYBODY BY THE WAY. ONE THING THAT IS ALSO HAPPENING IS THAT I THINK THERE IS A VERY LARGE NUMBER OF PATIENTS WHOSE INITIAL DISEASE MIGHT SPAN A CONTINUUM BUT THEY HAVE THESE LONG HAUL PULMONARY SYMPTOMS LIKE SHORTNESS OF BREATH AND COUGH AN CHEST PAIN WITHOUT ANY OBJECTIVE MEASURE OF DISEASE THAT WE CAN FIND. EVEN IN A PLACE LIKE VERMONT WHERE WE HAVE BEEN SUPER LUCKY TO HAVE PRETTY MINIMAL COVID SO FAR, WE HAVE SEEN A LOT OF PATIENTS IN OUR CLINIC WHO HAVE CONTINUED DYSMIA WITH NOTHING ON WHOLE BATTERY OF PFTs AND CHEST CT AND EVEN CARDIO PULMONARY EXERCISE TEST. AND MY HUNCH IS THAT THESE ARE SOME PRETTY UNIQUE SENSOR NEURAL EFFECTS FROM THE VIRUS ITSELF. SO THEY ARE PERCEIVING THEIR NERVE RECEPTORS ARE SAYING THEY ARE DISMIC BUT WE DON'T KNOW HOW TO MEASURE IT. I THINK WE WILL BE FLOODED IN PULMONARY CLINIC WITH THESE SYMPTOMS LONG TERM THAT WE DON'T HAVE ANY ALLO PATHIC WAY TO CARE FOR. AND THE PATIENTS SEEM TO BE SUPER LIMITED AND I THINK WE NEED SOME -- WE NEED SOME INVESTIGATION INTO SOME ALTERNATIVE THERAPIES. LIKE ACUPUNCTURE AND AM TRIP LIEN, THINGS FOR NEUROPATHIC PAIN, THOSE KINDS OF THINGS THAT I DON'T THINK WE HAVE A TON OF EXPERIENCE WITH IN MOST PULMONARY CLINICS. >> THANK YOU, RENEE. I HEARD TWO THINGS I WOULD LIKE TO UNDERLINE FIRST IS TAKING ON DISOMY YEAH. AND SYMPTOM SCIENCE HOW WE TREAT IT CLASSIFY IT HOW WE WORK IT UP AND TREAT THAT IS INCREDIBLY IMPORTANT. WE'RE GOING TO SEE MILLIONS OF PEOPLE POTENTIALLY, THE NUMBERS ARE MIND BOGGLING. THE SECOND THE WHO CLASSIFICATION AS A FIRST IDEA, ACTUALLY THINK IT WORKS TERRIBLY IF WE ARE THINKING ABOUT DEFINING THE EXPOSURE OF INITIAL INSULTS. DR. PIOT'S STORY YESTERDAY WAS A PERFECT EXAMPLE HOW YOU MIGHT SHOW AT THE BEGINNING AND MAYBE HAVE A FEVER AND NOTHING ELSE AND THEN BUT THE INITIAL INSULT CAN GO ON FOR WEEKS OR MONTHS HOW DO YOU CHARACTERIZE THAT. >> I'M SORRY TO HAVE JOINED LATE. IF MY COMMENTS ARE OFF TARGET FORGIVE ME BUT AS WE ARE TALKING ABOUT DISEMEA AND LACK OF OBJECTIVE MEASURES, AND THERE WERE GREAT PRESENTATIONS YESTERDAY BY SOME OF THE FOLKS ON THIS CALL ABOUT OTHER CO-MORBIDITIES, IT'S HARD TO LOOK AT PULMONARY COMPLICATIONS IN ISOLATION SO THE PSYCHOSOCIAL STRESS FACTORS IN PARTICULAR HAVE LARGE PART HOW PATIENTS PERCEIVE SYMPTOMS AND HOW THEY PERCEIVE DISEMEA AND WE SEE THIS A LOT IN OUR COPD STUDIES. IF THEY ARE DEPRESSED OR HAVE STRESS THEY MIGHT REPORT SYMPTOMS DIFFERENTLY. SO I THINK THE OVERLAP OF PULMONARY COMPLICATIONS HAVE TO BE TAKEN INTO CONSIDERATION. AND HOW PULMONARY OVERLAPS WITH OTHER E SEQUEL LAY. >> I THINK PARTICULARLY IN THE POST COVID SPACE CHRONIC FATIGUE SYNDROME WHATEVER THEY ARE CALLING IT, I THINK WORKING UP DISEMEA IS SOMETHING WE NEED TO BE ABLE TO HAVE THERAPEUTIC OPTIONS FOR AND APPROACHES FOR OFTEN PFTs AND THINGS ARE NEGATIVE. THEY MAY JUST HAVE CHRONIC FATIGUE SYNDROME. WHAT DO YOU DO FOR THAT SO OVERLAPS ARE NAME AND WE SHOULD BE ABLE TO HAVE A WORK APPROACH FOR THOSE THINGS AS WELL. >> HI, THIS IS -- IN THAT WILL WANT I THINK IT'S IMPORTANT TO HAVE A GOOD DEFINITION THAT WILL HELP US IN TERMS OF RESEARCH AS WE TRY AND UNDERSTAND THESE. BUT ALSO THERE ARE A LOT -- PATIENTS HAVE A LOT OF SYMPTOMS THAT DON'T HAVE A LOT OF OBJECTIVE PHYSIOLOGIC OR RADIO LOGIC OUTCOMES THAT WE CAN PUT WITH THEM. HAVING A CLEAR DEFINITION I THINK WILL BE HELPFUL. >> THIS IS ANN PARKER HOPKINS. I WANT TO PIGGY BACK ON WHAT IN THE YEAH SAID. IN OUR PAST CLINIC WE IN PULMONARY PARTNERED WITH COLLEAGUES IN PHYSICAL REHABILITATION SO PATIENTS HAVE ACCESS TO CARE BY REHABILITATION PSYCHOLOGISTS TO HELP WITH THAT HOLISTIC APPROACH TO CARE FOR DISEMEA. I ALSO -- THIS IS MAKING ME THINK OF ALLISON'S WORK IN EXPECTATIONS AN RECOVERY, I PUT ANYTIME THE CHAT BUT PATIENTS WHO WE ARE SEEING WHO ARE PRESENTING MANY MONTHS OUT FROM THEIR ACUTE ILLNESS AND SAYING I'M STILL SHORT OF BREATH MAY PERHAPS BE YOUNGER SOME OF THEM ARE ATHLETES. WHEN THEY REALLY TRYING TO PUSH THEMSELVES TO GET BACK TO WHERE THEY WERE BEFORE THEY HAD COVID, IT IS A DIFFERENT SET OF EXPECTATIONS THAN PERHAPS SOME OF OUR 80-YEAR-OLD PATIENTS WHO WAS ALREADY ON OXYGEN BEFORE SHE CAME INTO THE HOSPITAL. >> WONDERFUL POINT. >> I JUST SPEAK THIS IS MARGARET FROM TORONTO. WONDERFUL POINTS. I WANT TO INTRODUCE THE TOPIC OF STIGMA. AND JUST TALK A LITTLE BIT ABOUT OUR EXPERIENCE HERE IN TORONTO WITH SARS. WHICH ARE RELATED BUT NOT EXACTLY THE SAME PROBLEM. MORE AN OUTBREAK THAN PANDEMIC AS YOU FOLKS MAY OR MAY NOT REMEMBER, IT WAS HERE IN TORONTO AND HONG KONG AND OTHER PLACES IN 2003. AND VERY SIMILAR TRAJECTORIES OF ILLNESS, A LOT OF FATIGUE, A LOT OF NON-SPECIFIC SOMATIC COMPLAINTS, THAT SADLY WERE LARGELY ATTRIBUTED TO SOMATIZATION DISORDERS. AND NOT VERY ALTERED PHYSIOLOGY. BOTH IN MOSTLY OUTPATIENTS IN THE HOSPITALIZED NON-ICU PATIENTS AND HUGE ELEMENT FOR THESE FOLKS WAS THE STIGMA OF HAVING HAD SARS. AND HOW THAT PLAYED OUT IN TERMS OF THE PSYCHOLOGICAL BURDEN AND INTERACTED WITH RECOVERY. SO I WANT TO SPRUE DUTIES THAT, SOMEONE ALLUDED BUT ORTHIAN WAS ALLUDING TO THIS IS JUST DIFFERENTIAL EXPECTATIONS BUT ALSO RESILIENCE. SO NOT JUST PHYSICAL RESILIENCE BUT PSYCHOLOGICAL RESILIENCE AS WELL AFTER A TRAUMATIC EPISODE LIKE THIS. >> THAT LOSE US TO THINK ABOUT EFFECT MODIFIERS INCLUDING ENVIRONMENT. THE PATIENT OWNED THINGS AS MARGARET SAID AND THE ENVIRONMENT THAT THEY SIT IN WHICH TIES INTO THE DISPARITIES THAT WE ARE SUPPOSED TO COVER. >> FOR SURE. FOR SURE. SO >> ONE QUESTION WE HAD IN THE FIRST SET IS WHAT KNOWLEDGE EXTRAPOLATED FROM OTHER AREAS AND I THINK WE HAVE TALKED ABOUT ARDS AND THE MIX EXPERIENCE, MARGARET, THANK YOU FOR BRINGING UP THE SARS EXPERIENCE. FROM THOSE IN THE GROUP WHO STUDY VIRAL PNEUMONIA, THERE ARE A NUMBER OF YOU WHO HAVE MAYBE MORE EXPERIENCE IN THAT DOMAIN, CAN YOU THINKABLE OF OTHER PAST EXPERIENCES OR INFORMATION THAT MAYBE RELEVANT HERE WE SHOULD BE THINKING ABOUT AS WELL? >> IN THE CHAT IT WAS RAISED THAT THE FOCUS ON TO LOOK AT INNATE VERSUS ADAPTIVE RESPONSE. BROADLY RESPONSIBLE FOR THE IMMEDIATE WHETHER IT'S AT CAT OR NOT TO CONTROL INFECTION. ADAPTIVE IS A LITTLE BIT ALSO TO THE DEVELOPMENT OF ADEQUATE ANTIBODIES. NEUTRALIZING ANTIBODIES AN T-CELLS. THIS IS COMING FROM MECHANISM TO CONTROLLING DISEASE AND CONTROLLING THE LATER MAYBE FIBROSIS OR ALL THESE SYMPTOMS THAT WE SEE IN OUR CLINIC IN RECOVERIES. >> SO THANK YOU DEFINING THAT INTERNAL EXPOSURE YOU HAVE DEPINING DISEASE AN HOST RESPONSE TO DISEASE. ONE OF THE REASONS IT'S HARD TO CHARACTERIZE. THANK YOU. OTHER WAYS WE MEMBER SURE, THINK ABOUT THAT. OKAY. SO THERE'S OUR -- OUR FIRST HALF AN HOUR BLOWN BY. WHY DON'T WE TAKE TWO MINUTES, DOES ANYONE WANT TO CALL OUT THE THINGS THAT WE TALKED ABOUT WHAT IS STICKING HERE? WHAT IS FEELING LIKE THIS IS REALLY THE CRUCIAL PIECE OR A CRUCIAL PIECE? >> THIS IS HOLLY FROM MICHIGAN. I WILL CHIME IN. THIS SORT OF PHENOTYPE THAT RENEE BROUGHT UP REALLY RESONATES WITH WHAT I HAVE SEEN TOO IN CLINIC. THERE'S A LOT OF PEOPLE STRUGGLING WITH DISDISEMEA. THE OBJECTIVE PULMONARY THINGS WE CHECK FIRST COME OUT OKAY. AN IMPORTANCE OF VALIDATING THOSE SYMPTOMS ARE REAL AND IMPORTANT AND TRYING TO FIND CARE PATHWAYS OR OTHER THINGS WE CAN DO TO HELP AND SUPPORT PATIENTS BECAUSE IT IS LIMITING PATIENT FUNCTIONING. SORRY ABOUT THE PIANO PRACTICE IN THE BACKGROUND IF YOU GUYS CAN HEAR THAT. >> I AGREE, PART MAYBE COMING UP WITH APPROPRIATE NOMENCLATURES TO LEGITIMIZE SYMPTOMS. >> TO THIS POINT, HOLLY, IN THE -- AND MARGARET, THE ARDS FOUNDATION WITH LYNN REUBEN, THE SURVIVOR, THEY ACTUALLY PROVIDE ALSO INPUT AND THEY HAVE BUT THEY HAVE A FOLLOWING OF PEOPLE THAT SURVIVORRED AND THEY SAY EXACTLY THOSE THINGS ABOUT STIGMA, FEELING INADEQUATE AND SO ON. YOU INTERACTED MARGARET, RIGHT? >> A LOT OF US -- I WAS GOING TO SAY I THINK MANY ON THIS PANEL HAVE KNOWN EILEEN VERY WELL FOR SURE. >> I WAS GOING TO ADD THINKING ABOUT THESE PHENOTYPES IF YOU WILL OF DISEMEA, POST COVID IN THIS LONG COVID LIKE THEN WHAT ARE THE RIGHT TREATMENT OPTIONS FOR PEOPLE WHO HAVE DIFFERENT PRESENTATIONS, PEOPLE WITH PARYNCHEMAL DISEASE, AIRWAY DISEASE, I THINK PRESCOTT AND BRAD MENTIONED SHOULD WE TREAT THEM WITH STEROIDS WITH INAILED CORTICAL STEROIDS, ANTI-FIE BROUGHTICS. WHAT ARE -- HOW DO WE RECOGNIZE AND DIAGNOSE PEOPLE IN THESE DIFFERENT TYPES OF SYNDROME AND IDENTIFY APPROPRIATE TREATMENTS. MAYBE NEED TO BE STARTED EARLY AS WAS BROUGHT UP. >> JUST TO PIGGY BACK ON THAT, BRONCHOSCOPY IS CHALLENGING IN PANDEMIC SO QUESTIONS ABOUT THAT PARTICULAR DIAGNOSTIC EVALUATION IN SETTING OF PANDEMIC AND WHEN AND WHERE AND WHY IS PARTICULARLY RELEVANT FOR THESE PATIENTS. >> EVEN PULMONARY FUNCTION TESTING, THOUGH WE WERE LIMITING USE OF THAT TEST SO EVEN IF SOMEBODY IS MORE THAN 90 DAYS OUT, MAYBE KIND OF HARD TO GET THAT. MEASURE. >> WE WERE CHATTING ABOUT THIS YESTERDAY AFTER THE WORKSHOP BUT FOR A LOT OF THESE PATIENTS WE WON'T HAVE PRE-MORBID DATA SO THAT'S WHERE THINGS HIKE THE C 4R PROJECT LINDSEY IS LEADING AND TRYING TO UTILIZE INFORMATION WE DO HAVE FROM THE COHORT PATIENTS WE DO HAVE, ON PRE-MORBID PFTDs AND TRYING TO GET SAME MEASUREMENTS AFTERWARDS WILL BE IMPORTANT. >> I THINK MAYBE THIS IS A PERFECT TIME TO PIVOT TO WHAT ARE SOME OF THE APPROACHES TO DEALING WITH THESE QUESTIONS. MAYBE MILAN AND LIZ CAN TEACH US ABOUT C 4R, PRESCOTT, I KNOW A NUMBER OF YOU ARE INVOLVED WITH THAT, A FEW MINUTES TO HELP CATCH THE GROUP UP ON WHAT THAT PROJECT IS ABOUT. >> LIZZIE ON -- WHO IS THE PI. >> I'M FROM COLUMBIA, I'M AN INTERNIST. AND COORDINATING A BIG TEAM EFFORT WITH MANY OF YOU TO PUT TOGETHER SO FAR 14 OF THE NIH FUNDED COHORT, 12 WHICH ARE NHLBI HALF ARE LUNG, HALF CARDIOVASCULAR AND TWO NINDS FROM THE BRAIN SIDE. AND WHAT WE WANT TO DO HERE IS HARMONIZE PRE-COVID DATA ACROSS OUR OVER 54,000 PARTICIPANTS WHO HAVE BEEN FOLLOWED DECADES FIGURING OUT WHICH OF THEM BECOME INFECTED, HOW INFECTED THEY ARE, AND FOLLOW THEM UP AFTER THAT BOTH WITHIN THE PLANS OF THESE COHORT STUDIES BECAUSE THE MAJORITY OF THESE STUDIES DO HAVE VISITS THAT ARE PLANNED FOR NOW, A LOT ARE DELAYED THROUGH 2024. AND TO THAT WE MAY HAVE EXCITING OPPORTUNITIES TO ADD IN EITHER TARGETED OR MORE GENERAL FASHION ADDITIONAL MEASURES USING A CASE COHORT APPROACH SO THINGS WE TALK ABOUT SO FAR ARE MORE BIOBANKING ORIENTED STUDIES, WHERE WE MIGHT NEED SAMPLES AND C 4R WE GET DRIED BLOT SPOT SAMPLES ACROSS THE BOARD WITH INTERESTING POTENTIAL APPLICATIONS BEYOND SEROLOGY. THEN THERE MAYBE HOME MONITORING THAT WE CAN DEPLOY WHICH IS IMPORTANT TO THINK ABOUT FROM A PULMONARY STANDPOINT, WHAT WOULD BE SOMETHING YOU COULD DO AT HOME THAT COULD BE VALUABLE IN TERMS OF TRACKING PEOPLE BECAUSE I KNOW MANY OF US ARE HAVING TROUBLE BRINGING PEOPLE INTO CLINIC. WHICH PEOPLE AND WHEN WOULD WE BRING THEM BACK INTO CLINIC AND WHAT WOULD WE MOST WANT TO DO IF WE TRY TO GET BASICALLY ANOTHER SET OF EVALUATIONS TO RELATE TO PRE-COVID EVALUATIONS THAT WE HAVE AND THE POST COVID EVALUATIONS THAT PLANNED. >> IF WE CAN HAVE BLOOD BANKING AND LICK BIOPSIES, IT WOULD BE WONDERFUL AND MAY PROVIDE -- LIQUID BIOPSIES. IT MAY PROVIDE INFORMATION. WE STARTED TO DO ME SOW SCRIPTING TRANSCRIPT OMICS. FOR LUNG CANCER BUT WE PUBLISHED IN PATIENTS THAT DEVELOP FIBROSIS, THEIR SIGNATURES IN THE NASO TRANSCRIPT THAT ARE ALSO RELATED. THIS IS RELATIVELY NON-INVASIVE AND MAYBE CAN BE -- WE ARE STARTING THAT TO DO IN THE PATIENTS WHILE THEY ARE WITH RESPIRATORY FAILURE AND THEN FOLLOW THEM AFTER THAT IN CLINIC. RELATIVELY -- IT NEEDS EXPERTISE BUT RELATIVELY EASY AND NON-INVASIVE. >> IN THE C 4R PULMONARY COHORT WHICH ARE SPUR ROMIC COPG THERE'S NASAL SWABS BUT NOT MANY, THERE ARE HUNDREDS THOUSANDS ALMOST PRIOR SPEW THEM INDUCTIONS. AND AND THERE ARE OTHER SAMPLING PROCEDURES THAT COULD BE DONE BUT I WOULDN'T FORGET THAT. AND THOSE SPUTEM INDUCTIONS COULD USED THE ASSESS INNATE AND ADAPTIVE IMMUNE RESPONSES, ANTIBODY RESPONSES MUCOUS ANTIBODIES, MICROBIOME AND MANY OTHER LUNG SPECIFIC PATHOLOGIES THAT COULD RELATE TO POST COVID SYNDROME. >> PRESCOTT, THE NASO SCRAPINGS ARE A LITTLE MORE INVASIVE THAN THE SWABS AND THEY DO -- IT'S FOR CELL TRANSCRIPTOMICS AND MICROBIOME SO IT CAN BE ANOTHER TECHNIQUE. >> THIS IS GEORGE. HOW MUCH SORT OF PERIINFECTION DATA ARE YOU COLLECTING? IS THERE GOING TO BE ANYTHING ABOUT ACUTE EVENT? >> THE SHORT ANSWER IS NO UNLESS YOU COUNT EVENTS AS CERTAINMENT ACTIVITIES. >> OKAY. AND I THINK THAT IS AN EXCITING POTENTIAL OPPORTUNITY AND IF WE WANT TO DO IT WE HAVE TO MOVE QUICKLY. ASSUMING A VACCINE ACTUALLY HELPS US WE NEED TO QUICKLY. SO WE ARE IN THIS MOMENT I THINK THAT KIND OF DATA COLLECTION IS SOMETHING WE CAN AND SHOULD BE THINKING ABOUT C 4R IS DEPLOYING SELF-COLLECTION OF DRIED BLOOD SPOTS BUT IS NOT GOING -- IS NOT GOING INTO THE HOSPITALS AT THE MOMENT TO GET ADDITIONAL MATERIALS. WE HAVE TALKED A LOT ABOUT WHAT RECORDS WE CAN AS CERTAIN. IMAGING WE CAN PULL. WHAT IMAGING CAN WE PULL AND HARMONIZE WITH THE PRE-COVID IMAGING. SO THAT'S A PROJECT WE WANT TO DO AND WE FEEL LIKE WE CAN DO. BUT THE OTHER THINGS LIKE TRANSCRIPT TOMES, ET CETERA, WE ARE NOT DOING IN THE HOSPITAL. >> VIROMICS IS DOING EXACERBATION, WE ARE MAILING TO PARTICIPANTS WHO HAVE EXACERBATIONS KITS THAT INCLUDE THE NASAL SWAB SPONTANEOUS SPUTEM IN A NON-TOUCH PROTOCOL AND WE ARE HOPING TO CAPTURE THE COVID-19, PILOTING THAT WE COULD DECIDE WHETHER THAT'S MORE GENERALIZABLE ACROSS COHORT. >> THANK YOU. THAT'S GOING TO BE A TREMENDOUS RESOURCE. HOW ABOUT EVEN BIGGER COHORT? DOES ANYTHING EXIST LOOKING FOR, FOR EXAMPLE LET'S SAY THAT ONE PERCENT, THAT'S CERTAINLY NOT TRUE BUT ONE PERCENT OF PEOPLE WITH COVID DEVELOP SOME PULMONARY FIBROPICTURE THAT'S CLINICALLY IMPORTANT FIVE YEARS. HOW ARE WE GOING TO KNOW THAT? >> I AM AWARE THAT THE AMERICAN COLLEGE OF RADIOLOGY IS ATTEMPTING TO PUT TOGETHER SOME TYPE OF DATABASE WITH AT LEAST CURRENT IMAGING THEY CAN COBBLE CTs DONE IN THE ER. I DON'T KNOW IF THEY ARE DOING POST IMAGING FOLLOW-UP COLLECTION AS WELL. I COULD CERTAINLY FIND OUT BUT I AM AWARE OF THAT EFFORT. >> THERE IS SOME OTHER O COHORT, GEORGE AND ROB YOU GUY VERSUS THE LUNG HEALTH STUDY YOU MADE COMMENT PROSPECTIVE MORE TYPE YARD OWE LIKE, RIGHT, GEORGE? YOU ARE MUTED. -- CARDIO LIKE. RIGHT GEORGE? >> PERFECT. HOW ABOUT NOW? GOOD. SO THERE ARE SOME NEW COHORT COMING ONLINE, THERE'S THE LUNG HEALTH COHORT, 4,000, 25 TO 35-YEAR-OLD MILLENNIALS ACROSS CENTERS OF THE ACRC. IN FACT, WE ARE SUPPOSED TO IN THEORY BE GETTING PEOPLE IN THE DOOR AS EARLY AS THIS MONTH JUST GOT IRB APPROVAL THIS MORNING IN FACT. BUT AND THEN THE MIRROR TWO THAT, THE OTHER NEW COHORT IS RURAL. SO (INAUDIBLE) IS LEADING THAT, THE NEXT GENERATION OF THE FRAMINGHAM HART STUDY. SO THAT ALSO -- THEY HAVE VERY INTERESTING THING, MOBILE EXAM UNIT GOING THROUGH UNDERSERVED AREAS IN ESSENTIALLY THE SOUTHEAST. AND THEY WILL BE RECRUITING 4,600 PEOPLE AND SO WE HAVE BEEN WORKING WITH THEM TO HARMONIZE IT, THINKING HARMONIZE THE DATA COLLECTION, THE QUESTIONERS PFTs AND IMAGING DATA. SO THAT'S COULD BE VERY OPPORTUNE OR NOT DEPENDING UPON HOW PANDEMIC EFFECTS COLLECTION AND THINGS LIKE THAT. >> THERE IS A COHORT CALLED I SPY. VERY INTERESTING STARTED FOR BREAST CA BUT I THINK YOU GUYS AT UCSF ARE INVOLVED RIGHT, WITH THAT? THIS IS A VERY INTERESTING BECAUSE IT CAN RAPIDLY DRUGS AND HOW PEOPLE RESPOND. I DON'T KNOW IF SOMEBODY ELSE CAN COMMENT ON THAT MORE. WE HAVE ANOTHER COHORT CALLED SCRIPT WHICH IS A U 19 FROM NAD THAT LOOKS MORE SUCCESSFUL RECOVERY CLINICAL RECOVERY IN THE MORNING AND LOOKS AT LAVAGE AND THIS IS THE PAPER I MENTION BEFORE MORE TRANSCRIPT OMICS AND FOLLOW-UP IN PATIENTS BEFORE IT WAS VIRAL INFECTION AND INFECTION NOW INCLUDES COVID. WE TALK ABOUT HOW THE COVID EXPERIENCE IS PRETTY DIFFERENT ACROSS DIFFERENT ROUTES IN THE UNITED STATES. DO WE KNOW OTHER COHORT, ITS PURPOSE IS TO BE MULTI-ETHNIC BUT HOW ARE WE GOING TO MAKE SURE COHORT WE ARE LOOKING AT HAVE ENOUGH SPANISH, AFRICAN AMERICANS WHAT DO WE KNOW OF OUT THERE NOW TO TOUCH ON THAT? >> PEOPLE ARE LUCKILY HAVE HISPANIC -- 8,000 LATINX. WE HAVE STRONG STUDY OF AMERICAN INDIAN. WE HAVE JACKSON HART STUDY OF AFRICAN AMERICANS, STUDY OF SOUTH ASIAN WHICH IS NOT COMPLETELY REPRESENTATIVE OF THE U.S. POPULATION BUT THERE IS BROAD REPRESENTATION COMPARED TO SOME OTHER RESOURCES. THAT'S ON TOP OFFER LICK ALSO MULTI-ETHNIC TO BEGIN WITH, SO IT'S SCRATCHING THE SURFACE. WE HAVE THOSE OPPORTUNITIES THERE WHICH I THINK IS A GOOD START. AND WE WILL BE HAPPY TO ADD ADDITIONAL RESOURCES WHERE WE ARE UNDER-REPRESENTED IS EAST ASIAN THAT IS REALLY A VERY MINIMALLY REPRESENTED GROUP. THE SOUTH ASIAN POPULATION IS RELATIVELY SMALL COMPARED TO SAMPLE SIZE WE HAVE IN OTHER GROUPS. THAT'S AN AREA WE ARE RELATIVELY UNDERPOWERED. >> THIS IS BRAD ROBINS. THE MAX WISE COHORT STUDY 13 SITE LONGITUDINAL STUDY ON PERSONS WIFING WITH HIV AND HIV UNAFFECTED COMPARE TORRS SO THEY HAVE SIGNIFICANT REPRESENTATION IN THE SOUTH EASTERN UNITED STATES WITH DISADVANTAGE IS IT PARTICIPANTS. MAX WISE HAS PRE-COVID PFT DATA PIR ROM INDUSTRY LCO ON MAJORITY OF COHORT, THINKING HOW TO ANCHOR ON PRE-EXISTING LUNG DISEASE POST COVID LUNG DISEASE IS A USEFUL COHORT. FOR PERSONS LIVING WITH HIV BUT ALSO THE HIV UNAFFECTED COMPARE TON GROUPS. >> WE HAVE BEEN WORKING WITH MAX WISE VERY HAPPILY. SO WE ARE NOT FUNDED BY THE SAME STREAM BUT WE HAVE BEEN ANY OTHER SINCE APRIL OR SO. SO THERE'S OPPORTUNITIES THERE. >> EXCITING TO HEAR HOW MUCH COORDINATION BETWEEN THE GROUPS. COMPARE TORR WITHIN THE VA, A NATIONAL HEALTH SYSTEM WE HAVE 6 TO 8 MILLION VETERAN ENROW LEES SO THERE ARE EFFORTS TO USE NATIONAL DATA TO LOOK AT COVID OUTCOMES. WE HAVE PREEXISTING DATA THAT CAN BE OBTAINED FROM THE ELECTRONIC HEALTH RECORD INCLUDING BASELINE STATUS BUT AGAIN SOME OF THIS IS LIMITED BY WHAT HAS BEEN CLINICALLY OBTAINED AND ALSO IF A CLINICAL WORK UP OCCURS TO BE ABLE TO DETERMINE IF SOMEBODY HAS A NEW PULMONARY DIAGNOSIS, NEW CARDIOVASCULAR DIAGNOSIS, BUT THERE IS A RFA OUT TO DEVELOP THESE COVID RESOURCE CENTERS WITHIN VA. SOME OF THAT MAY PROVIDE THE OPPORTUNITY FOR MORE STANDARDIZED DATA COLLECTION AND ALSO PARTICIPANT DATA COLLECTION ON SELF-REPORTED OUTCOMES. AND VA HAS A LARGE RURAL POPULATION AS WELL AND SOME UNDER-REPRESENTED MINORITIES WITHIN THAT GROUP TOO. SO IF YOU ARE USING AN EXISTING CLINICAL DATABASE, YOU CAN REACH SOME POPULATIONS THAT AREN'T ENROLLED IN SOME OF THESE STUDIES AS WELL. >> THIS IS AN ISSUE THAT WE HAVE BEEN DISCUSSING QUITE A LOT WITH C 4R. THE EMR STUDIES ARE EXTREMELY EXCITING AND IMPORTANT AND LARGE AND HAVE ALL THESE BENEFITS. THE COHORT WORLD CANNOT LINK TO THE DEIDENTIFIED COVID EMRs SO WE HAVE HUGE FANTASTIC EMR STUDIES AN HUGE FANTASTIC DIFFERENT WAYS COHORT STUDIES BUT THEY CAN'T CROSS TALK AT THE MOMENT DUE TO PRIVACY ISSUES. ONE IS PRETTY IDENTIFIED AND OTHER IS COMPLETELY DEIDENTIFIED. SO EXCITING AREA FOR GROWTH BUT AT THE MOMENT WE ARE IN THE BRAINSTORMING OBSTACLE PHASE OF THE CONVERSATION. >> SO WE ARE SPENDING A MOMENT ON THAT, IT FEELS LIKE WITHIN PUBLIC HEALTH SURVEILLANCE AND SOME OF THE DIFFERENT APPROACHES THAT WE HAVE BEEN TAKING WITHIN THE PANDEMIC TO DEALING WITH HIPAA TYPE ISSUES, MIGHT THERE BE OPPORTUNITIES TO CONNECT AND LEVERAGE DATA SETS IN WAYS WE HAVEN'T BEFORE. ANYONE HAVE ANY EXPERIENCE OR THOUGHTS ON THAT? >> THIS IS HALLLY. WE HAVE A MULTI-STATE REGISTRY -- SORRY MULTI-HOSPITAL REGISTRY IN MICHIGAN THAT COLLECTS DATA ON ACUTE HOSPITALIZATION AND THEN WE HAVE 60 DAY TELEPHONE FOLLOW-UP WITH PATIENTS AND WE ALSO HAVE LIKE AND ALL PAYER CLAIMS DATA SET FOR MICHIGAN SO WE ARE DOING A LINKAGE WHICH WE DON'T HAVE NAMES BUT WE HAVE THE YEAR OF BIRTH, MONTH OF BIRTH, DATE OF ADMISSION AND DISCHARGE AND THAT'S ENOUGH FOR US TO LINK. SO WE WILL BE USING THAT TO ESSENTIALLY GET LONGITUDINAL CLAIMS DATA. TO FIGURE OUT AT LEAST LIKE HOSPITAL READMISSIONS AN LONGER TERM HEALTHCARE UTILIZATION POST COVID IN THIS VERY DIVERSE SET OF 38 HOSPITALS. >> THAT WAS ONE WAY WE WERE ABLE TO DO IT WHEREAS WE DON'T HAVE THE ACTUAL DATE OF BIRTH AND PATIENT NAME BUT WE HAD ENOUGH INFORMATION TO MAKE A LINKAGE, IT WAS PRETTY HIGH-QUALITY. >> GREAT SEEING OUTPUT FROM THAT ALREADY. CONGRATULATIONS ON THAT WORK. >> THANKS. >> SO I SEE THIS POINT HAS COME UP AROUND AN INVENTORY OF DATA SOURCES AND AGAIN MAYBE SOME MAPPING OF HOW WE CAN CONNECT DETAILED ACUTE DATA OR LONGITUDINAL HEALTH SYSTEMS DATA WITH THIS MORE CAREFULLY PHENOTYPED DATA AND SOME OF THESE COHORT CERTAINLY SEEMS IMPORTANT. I WONDER DO WE WANT TO TAKE A MOMENT AND SLASH UP OUR SECOND SET OF QUESTIONS TO MAKE SURE WE COVER THE AREAS WHERE WE WANTED TO GO? I THINK WE ARE BEAUTIFULLY. I THINK WE'LL JUST HAVE A NICE CONVERSATION ON WHAT COHORT AND COLLABORATIONS EXIST. THIS IS ALSO THE TIME FOR BIG THINKING, THERE'S A LOT OF MONEY WHICH IS RARE FOR MOST OF US WHO HAVE BEEN DOING THIS FOR DECADES TO THINK BIG AND SAY IF WE WERE TO DEVELOP THE COHORT THAT WE NEED TO THROUGHLY ANSWER SOME OF THESE QUESTIONS WHAT WOULD THAT LOOK LIKE? I FEEL LIKE I'M USED TO USING RETROSPECTIVE DATA, DATA SETS AND COBBLING THINGS TOGETHER BUT THERE'S WAYS TO DESIGN HOW TO DO THIS RIGHT IN THE WAY WE PUSH FORWARD YET. MAYBE ONE MOMENT ON THAT. ANY THOUGHTS ON THE MILLION PERSON STUDY WOULD LOOK LIKE TO ANSWER SOME OF OUR QUESTIONS? >> UNLESS THAT IS RIDICULOUS. >> I THINK THERE'S MORE THAN ONE STUDY. RIGHT NOW THERE'S TOO MANY PARTICIPANTS IF WE WERE STARTING DE NOVO. NUMBER OF CASES IS GETTING VERY WORRYINGLY HIGH OBVIOUSLY. AND IS NOT STOPPING. I THINK THAT THE PROBLEM KEEPS GROWING. AND FROM C 4R STANDPOINT THERE ARE THINGS THAT I THINK WE -- SOME VERY EXPENSIVE THINGS WE MIGHT WANT TO DO IN SOME OF OUR CASES BUT WE KNOW SO MUCH AND MORE ABOUT THESE PEOPLE PRE-DISEASE THAN REALLY WE SHOULD. BECAUSE PEOPLE HAD CARDIAC MRI FOR NO REASON, NOT A USUAL HEALTH RESOURCE. IT IS A SPECIAL INVESTMENT MADE BY NIH. I WOULD LIKE TO TAKE ADVANTAGE AND SEE IN THOSE PEOPLE WHAT HAPPENED TO THE CARDIAC MI BECAUSE WHEN THEY HAD NO COVID AND NO SYMPTOMS WE KNEW WHAT HAPPENED WITH COVID OR POST COVID OR NOT POST COVID. THERE ARE QUESTIONS THERE BUT ONLY THE TIP OF THE ICEBERG IN TERMS OF ALL THE WAYS WE MIGHT SPEND MONEY BECAUSE THERE'S SO MANY OPEN QUESTIONS. I WILL STOP THERE. >> THAT IS REALLY IMPORTANT V. WE OPTIMALLY LEVERAGED C 4R IS A LIKED TOUCH REALLY FOR THESE INCREDIBLY DETAILED COHORT. HOW YOU MAKE C 5R, I DON'T KNOW WHAT C STANDS FOR BUT ARE THERE -- AS AN ICU PERSON THINKING ABOUT HOW OPTIMAL ARE DATA AROUND EXPOSURES AND MAYBE POTENTIALLY MODIFIABLE FACTORS THAT MAY CHANGE LONGER TERM OUTCOMES, ARE WE CAPTURING THOSE OPTIMALLY, HOW DO WE CONNECT BETTER. THOSE ARE SOME OF THE THINGS I THINK ABOUT. >> I THINK WE HAVE SO MANY OPPORTUNITIES TO STUDY POST COVID IN THESE EXISTING STUDIES, I WILL MENTION ONE MORE SO THAT OUR FOCUS SHOULD BE ON MAKING SURE WE HAVE THE FULLY COMPREHENSIVE APPROACH AND STANDARDIZE ONE ACROSS STUDIES, WILL GET MOST BANG FOR OUR BUCK. THE ONE I'M THINKING HADN'T BEEN MENTIONED IS NAAID SEVERE IMPACT STUDY WITH SEVERE ORIZE HOSPITALIZED IN COVID-19 AND NOW FOLLOW-UP FACE ENROLLING UP TO A THOUSAND PEOPLE THAT NEEDS TO HAVE THE SAME STANDARDIZE FOLLOW-UP STUDIES AS SAY THE COHORT FOR PRE-COVID PATHOLOGY IS KNOWN. >> I CAN TELL YOU, MAYBE THEY MENTION ON THE IMPACT CALL BUT PATRICE, ONE OF THE PROGRAM OFFICERS FROM NIAID RUNNING THAT STUDY JUST REACHED OUT, I THINK THEY ARE INTERESTED IN TRYING TO HAVE IN PERSON FOLLOW-UP COMPONENT TRYING TO GET FUNDING FOR THAT RIGHT NOW. SO I THINK A LOT OF DISCUSSION WE WERE HAVING HERE COULD IMMEDIATELY BE TRANSLATED INTO THAT IMPACT COHORT. THAT'S UNUSUAL IN THAT IT HAS MORE DETAIL MAMEE KNOW PHENOTYPING AND THAN A LOT OF COHORT WE TALKED ABOUT, I DON'T THINK WE HAVE MUCH IN THE WAY OF VIRUS. >> THAT'S THE THING, THAT'S REALLY EXCITING ABOUT IT. IS THAT WE HAVE AN OPPORTUNITY IN THE LUNG BREAK OUT TO STUDY THE IMMUNE SYSTEM OF THE LUNG WHICH IS REALLY GOING TO BE MAJOR PLAYER HERE, NOT AVAILABLE TO THE CARDIOLOGIST OR NEPHROLOGIST. AND IMPACT WE HAVE DONE IT ACUTELY AND HAVE AN OPPORTUNITY TO DO IT IN FOLLOW-UP SO HOW DO YOU DO THAT. WHAT DO YOU STUDY EXACTLY. >> ONE OTHER THOUGHT. THERE'S MONEY BUT THINKING PRAGMATICALLY LEVERAGING THE NEED FOR HEALTH SYSTEMS TO START POST COVID CLINICS AND POST ICU CLINICS, WAYS TO HAVE THEM DO THINGS SYSTEMATICALLY ENOUGH TO GENERATE LARGE DATA SETS OF OUTCOMES IN THESE PATIENTS OVERTIME MIGHT BE ANOTHER AAPPROPRIATE OUTCOME DATA FOR THESE PATIENTS AS WELL, MOST POST ICU SIZE AND MILDER NON-HOSPICE PATIENT POPULATION SIDE. >> IS THERE A STANDARD DATA COLLECTION ACROSS POST COVID CLINICS. I WOULD LOVE TO SEE THAT A STEP FARTHER TOO WHICH IS HOW ARE WE COLLECTING INFORMATION ABOUT THE VALUE AND THE EFFICACY OF DIFFERENT POST COVID APPROACHES. WE CAN GO THAT SHIP WHILE IT'S SAILING TOO, THAT MAY END UP BEING THE MOST IMPORTANT I THINK. >> WILL ANY OF THESE EXISTING DATABASES OR COHORT GIVE US INFORMATION ABOUT THE TRUE NUMERATORS? WHAT PERCENT OF PEOPLE ACTUALLY DEVELOP POST COVID SYMPTOMS? DO WE NEED TO PIVOT TO -- I LOVE THE IDEA OF SEEING WHAT THEY WERE BEFORE AND AFTER. THAT IS WHOLLY UNIQUE. I LOVE THAT IDEA BUT HOW MANY WHAT PERCENT OF PEOPLE IN THE ICU DEVELOP SYMPTOMS? WHAT PERCENT OF PEOPLE AND OBVIOUSLY UNFORTUNATELY WE HAVE MASSIVE NUMBER OF PEOPLE. >> I THEY WILL. IMPACT STUDY ENROLL HOSPITALIZED PATIENTS AT LARGE. IT INCLUDES FRAMINGHAM AND LARGE POP LAY BASED STUDIES. I THINK THE EPIDEMIOLOGIC DESIGNS ARE PRETTY GOOD FOR THAT. LIZ ARE YOU NODDING YOUR HEAD? >> I AM, I WAS EXCITED TO HEAR WHO IS STANDARDIZING POST COVID CASE REPORT FORM. BECAUSE WE CAN REVIEW THAT, MOST FORMS ARE LONG BUT IT WILL BE GREAT IF WE CAN AGREE ACROSS STUDIES TO USE SIMILAR INSTRUMENTS SO WE CAN SORT OF -- AT THE END OF THE DAY WITH TECHNOLOGY OUR DENOMINATOR CAN APPROACH THE U.S. POPULATION. C 19 HAS DONE A GOOD JOB REACHING OUT. THERE ARE OTHER INNOVATIVE WAYS. SO WE CAN GET OUR DENOMINATORS INCREASINGLY AND IF WE USE THE SAME INSTRUMENTS WE WILL BE ABLE TO ADD THE RESOURCES TOGETHER. AND GET OUR ANSWERS. >> ONE OF THE THINGS I WORRY ABOUT IS THAT WE HAVE A NUMBER OF DETAILED COHORTS THAT FLEXED UP EARLY THAT COLLECTED A LOT OF DATA AND THEN THE PANDEMIC SHIFTS, VIRAL STRAINS ARE DIFFERENT, THE PATIENTS IN THE HOSPITALS ARE DIFFERENT AN CERTAINLY HOSPITAL TREATMENTS ARE DIFFERENT, EVERYONE OF YOUR HAVE RESPIRATORY FAILURES ON STEROIDS NOW, DO WE FEEL LIKE WE ARE WELL-POSITIONED TO UNDERSTAND HOW THIS THE IS CHANGING AND HOW THAT MIGHT IMPACT POST COVID AS WELL. >> AGREE WITH YOU TERRY. THE THING I THINK WE HAVE TO REMEMBER IS THAT ALMOST ALL EVALUATIONS THAT WE DEPEND ON ARE NOT BEING DONE ROUTINELY. IMAGING PFTs, NOBODY WANTS TO DO WHILE PEOPLE ARE INFECTED. NOBODY REALLY EVEN WANTS TO DO THEM FOR A WHILE AFTER PEOPLE ARE INFECTED SO UNBLESS WE SPECIFICALLY SET UP FOR CALL PUT FUNDING INTO DOING THOSE PROCEDURES IN A SYSTEMATIC WAY AND SAFELY, I'M THINKENING PARTICULAR WHAT YOU SAID, PARTICULARLY OUTPATIENTS THAT WERE NEVER HOSPITALIZED, WE HAVE ALMOST NOTHING ON THOSE PATIENTS. I HAVE AS THE PANDEMIC GOES ON I HAVE PATIENTS WITH CHRONIC LUNG DISEASE THAT NOW HAVE COVID AND I HAVE HAD NO INFORMATION ON THEM YET. SO I THINK THAT'S AN AREA WE NEED TO THINK ABOUT PUT MONEY INTO MORE DATA COLLECTION. >> THAT'S RIGHT. ONE OF THE AREAS THE SELECTION WORRIES ME THE MOST. I FEEL IT'S EASY TO CAPTURE A HOSPITALIZED POPULATION THAT LESS BIASED STILL BIASED OF COURSE, BUT WITH OUTPATIENT IT FEELS ONES COMING BACK TO US AN SYMPTOMS BUT NOT UNDERSTANDING THE WHOLE PICTURE. >> I WOULD LIKE TO BUILD ON THAT. SO I THINK A MAJOR GAP THAT WE HAVE IS WE DON'T UNDERSTAND HOW THE INNATE OR ADAPTIVE IMMUNE RESPONSE FACTORS IN VERY EARLY. SO WE HAVE SOME BRONCHOSCOPY OR NON-BRONCO SCOPIC BAL STUDIES DONE, ONCE THE PATIENT IS IN THE ICU BUT THEY HAVE TYPICALLY BEEN SICK FOR WEEKS BEFOREHAND. NOBODY WANTS TO BRO INOC THESE PATIENTS RIGHT AFTER THEIR POSITIVE TEST OR WHEN THEY BECOME SYMPTOMATIC. BUT I THINK THOSE ARE THE DATA WE NEED. I DON'T KNOW THAT WE CAN ADEQUATELY UNDERSTAND THE IMMUNE RESPONSE. BY SAMPLING BLOOD OR SAMPLING SAYAL EPITHELIUM. WE CAN GET INSIGHTS BUT WE REALLY NEED TO UNDERSTAND WHAT IS GOING ON IN THE LUNG, PORTAL OF ENTRY FOR THIS INFECTION AND WE HAVEN'T ASSESSED IT ADEQUATELY. >> I AGREE. THAT'S WHY WE HAVE THAT -- 84 PATIENTS WITH COVID HAVE DETAIL TRANSCRIPT OMICS. I THINK IF WE CAN ACTUALLY LEVERAGE ALL THE COHORT THAT EXIST BUT IF WE CAN ESTIMATE THAT THEY WILL BE 15 OR 20% POPULATION INFECTED, EVEN AFTER VACCINATION, THAT WILL BE A HUGE NUMBER, I THINK I DON'T KNOW THAT THE EXISTING STRUCTURES OR COHORTS WILL BE ABLE TO CAPTURE EVERYTHING AND I THINK THAT THAT'S WHY THIS KIND OF WORKSHOPS ARE IMPORTANT TO DELINEATE WHAT ARE IMPORTANT ASPECTS HA CAN BE STUDIED OR MAYBE SOME NEW STRUCTURE AND ASPECTS NEED TO BE STUDIED. >> TO YOUR POINT, YOUR COHORT IS FABULOUS BUT THE PROBLEM -- A PROBLEM IS THAT BY THE TIME YOU HAVE STUDIED THEM THE HORSE IS OUT OF THE BARN, THEY HAVE SYMPTOMS FOR WEEKS, WE NEED TO KNOW WHAT HAPPENED UP FRONT. IN ADDITION TO THE BEAUTIFUL WORK YOU ARE DOING. >> OF COURSE, I FULLY AGREE, HOW WOULD YOU DO IT THOUGH, BILL? >> SOMEONE WOULD NEED TO OR GROUP WOULD NEED TO BE ABLE TO SAFELY DO BRONCHOSCOPIES IN PATIENTS THAT ARE INFECTED. >> WE DO IT WITH DISPOSABLE BRONCO SCOPES OF COURSE. >> WE HAVE ALL BEEN AFRAID TO DO IT AND WE DON'T HAVE THE PPE OR RESOURCES TO DO IT IN GENERAL. BUT I THINK IF ONE WAS GOING TO DESIGN A STUDY AND FOLLOW A COHORT IT WOULD IDENTIFY THESE PATIENTS INCREDIBLY EARLY IN THEIR ILLNESS COURSE. MANY WOULDN'T GO ON TO BE HOSPITALIZED BUT DETERMINING WHAT FACTORS REGULATED THAT AND LED TO HOSPITALIZATION VERSUS NOT WOULD BE INCREDIBLY POWERFUL. WE DON'T KNOW WHY SOME PEOPLE RECOVER AND SOME DON'T. >> I FEEL LIKE AS SOMEBODY STUDYING POST ICU WE HAVE BEEN SAYING FOR A DECADE IF ONLY WE HAD THE PERSON -- THE PATIENT AT RISK BEFORE THEY PRESENTED TO THE HOSPITAL BUT YOU DON'T KNOW BEFORE YOU GET HIT BY A TRUCK BUT IT FEELS LIKE THERE IS TRUCK WE KNOW. THERE'S TEN DAYS AND SYMPTOM T BEFORE SOMEBODY PRESENTS WITH RESPIRATORY FAILURE. >> ABSOLUTELY. >> IMPORTANT IDEA. >> THIS IS BRAD. WANT TO MAKE A COMMENT THAT'S OFF TOPIC BUT AREA OF O INTEREST FOR ME AND THAT I THINK THE PANDEMIC IS REALLY HIGHLIGHTING DISPARITY OF LACK OF INTEROPERABILITY OF DATA ELEMENTS SO ESPECIALLY IN PULMONARY FIELD WHERE MOST OF US CAN PROBABLY PULL ALL THE WHITE BLOOD CELL COUNTS ACROSS DIFFERENT HEALTHCARE SYSTEMS AND ITS UNIFIED BUT DOING THAT WITH FEV 1 OR CT REPORTS REMAINS A NON-STARTER. I THINK THAT IF THERE IS AN NIH INITIATIVE TO LEVERAGE THE CHALLENGES OF COVID TO REALLY ENHANCE THE INTEROPERABILITY OF OUR ELECTRONIC HEALTHCARE SYSTEMS, THAT WOULD HELP MARKEDLY IMPROVE OUR OVERALL POPULATION HEALTH ASSESSMENTS THAT'S WHAT YOU TALKED YESTERDAY TERRY DURING THE TALK THINKING POPULATION HEALTH IF YOU CAN MAP OUT FEV 1 OF ENTIRE STATE AND LOOK FOR HOT SPOTS, THOSE SORTS OF THINGS, AND THE INTEROPERABILITY DISPARITY IS ONE THAT WE CAN POTENTIALLY USE ADVANCE. >> SO ONE OF THE BULLETS WE HAVE IN THE SECOND SET OF QUESTIONS IS HOW DO WE ENSURE THAT CURRENTLY UNRECOGNIZED PULMONARY SELL QUELL LAY ARE CAPTURED AND I WOULD MUSH THAT MORE TO -- SEQUEL LAY, HOW DO WE MAKE SURE POTENTIALLY TREATABLE PULMONARY SEQUEL LA ARE CAPTURED POST COVID. THERE'S GOING TO BE THIS WORLD OF DISOMY YEAH, A BUNCH OF PEOPLE THAT STILL HAVE WHITE STUFF ON THEIR CHEST IMAGING AND THEN SMALL GROUP WITHIN THOSE THAT HAVE TREATABLE PULMONARY ABNORMALITIES. >> MAYBE TAN GENERALLIAL BUT TO THIS POINT IS THAT PATIENT THAT COME WITH COVID THEY COME WITH CO-INFECTION ALSO LIKE IN OTHER VIRAL INFECTION AND WE SEE APPROXIMATELY CLOSE TO 20% OF PATIENTS WITH COVID THAT COME ALSO WITH BACTERIAL INFECTION AND THAT OF COURSE CONFOUND AND AMPLIFIES THE PROBLEM. I DON'T KNOW WHAT WAS THE EXPERIENCE OF THE GROUP WITH CO-INFECTIONS. >> CO-INFECTIONS, OTHER -- >> I WOULD SAY IN TORONTO WE HAVE HAD A LOT OF FOLKS AND THE CO-INFECTION RATE WAS INCREDIBLY HIGH. INCREDIBLY HIGH WITH STAFF IN CLUB SEE YELL LA AND GRAM NEGATIVES, IT WAS EXTREMELY HIGH. >> HOW DID THAT IMPACT MORTALITY OR OUTCOMES? >> I THINK WE ARE STILL LOOKING AT ALL THOSE DATA FOR SURE. I WILL TELL YOU THERE'S A HUGE AMOUNT OF BRONCOOTIC DISEASE IN THESE PATIENTS AS WELL. THERE'S BEEN A LOT OF DISCUSSION ABOUT RANGE OF PULMONARY SEQUELLAE AND TO TERRY'S POINT A LOT OF THIS IS RESIDUAL OF BEING LONG STAKE ICU PATIENT AND NOT NECESSARILY SPECIFIC TO COVID BUT IT WAS STUNNING HOW MANY HAD POSITIVE WACK TIERIAL -- BACTERIAL CULTURE. I DON'T KNOW IF THAT'S TORONTO THING BUT WE'LL SEE HOW IT PLAYS OUT IN THE CANADIAN COHORT STUDY. I CAN'T COMMENT ON THAT, SORRY. >> THE MICHIGAN STATE DATA IT WAS ABOUT FOUR TO FIVE PERCENT HAD CONFIRMED BACTERIAL CO-INFECTION AMONG ALL COMERS TO THE HOSPITAL SO PRETTY LOW BUT ANYONE LOOK AT PEOPLE IN THE ICU AND PEOPLE WHO ARE DYING OF COVID IT'S MUCH HIGHER SO I DO THINK TO MARGARET'S POINT THIS IS SOMEWHAT A REFLECTION OF THE PEOPLE WHO END UP WITH THESE MORE PROLONGED HOSPITALIZATION, THERE'S MORE HOSPITAL ACQUIRED INFECTION THAN BACTERIAL CO-INFECTION ON PRESENTATION TO THE HOSPITAL. >> I WOULD POINT TO MAX'S WORK USING NASAL BRUSHES TO DETERMINE VIRAL CO-INFECTION. IT LOOKS LIKE A HIGH LATE OF VIRAL CO-INFECTION. I DON'T KNOW IF THAT SETS THE STAGE FOR WORSENING DISEASE FROM FROM THOSE PRIOR INFECTIONS LAST FOR A WHILE. BUT WE SHOULDN'T FORGET THE ROLE OF CO-INFECTION IN OUTPATIENTS. I THINK THAT MIGHT BE CRITICAL. >> I THINK THERE ARE A NUMBER OF VIRUS SPECIFIC ISSUES, MAYBE WE HAVEN'T TALKED ENOUGH ABOUT LOOKING AT OTHER VIRAL INFECTIONS AT REACTIVATION OF COVID OR REINFECTION AND THEN OF COURSE LUCKILY THE VACCINATION ISSUE SHOULD BE AT PLAY SOON. ANY THOUGHTS ON HOW WE NEED TO SHAPE EARLY THE WAY DATA IS COLLECTED POTENTIALLY, ANY THOUGHTS AROUND THAT? >> THIS IS GEORGE. ONE OF THE THINGS YOUR QUESTION AND THEN MILAN SAID EARLIER, WHAT BRAD IS WORKING ON WITH STANDARDIZATION RESONATED THAT IF YOU THINK SMOKING IS HISTORY IS POORLY DOCUMENTED IN EHR, THESE SYMPTOMS ARE ALL THE PLACE. WHAT IS THE NOMENCLATURE STANDARDIZE INTAKE SO WE ARE SPEAKING THE SAME LANGUAGE DEFINE THE PHENOTYPE. THAT WOULD BE A HUGE SERVICE TO THE COMMUNITY. BECAUSE THEN WE AS SOON AS WE CAN AGREE WE ARE TALKING ABOUT THIS VERSUS THAT, THERE'S A WHOLE LANGUAGE OF DISEMEA ALONE THAT WE NEED TO -- I WOULDN'T SAY TAKE A DEEP DIVE INTO BUT WE HAVE TO HAVE A STANDARDIZED APPROACH OF AS CERTAINMENT. >> THANK YOU. >> MAY I ADD SOMETHING? >> PLEASE. >> THIS IS -- I MAY BE THE ONLY VIROLOGIST IN THIS SUBGROUP. SO I WILL RYE TO MAKE A PITCH TO UNDERSTAND SOME OF WHAT IS HAPPENING AT THE VIRAL LOGIC LEVEL. WE CERTAINLY HEAR ABOUT PEOPLE THAT HAVE PERSISTENT PCR POSITIVITY. WE CANNOT CULTURE VIRUS PAST ABOUT DAY 8 FROM ET CETERA PRAYTORY SAMPLES. BUT IT'S UNUSUAL TO SEE VIRAL SHEDDING FOR WEEKS AND SIGNIFICANCE OF THAT IS REALLY PRETTY UNCLEAR. I THINK THAT IN WHATEVER YOU SET UP IN TERMS OF FOLLOW-UP I THINK IT WOULD BE GOOD TO KEEP AN EYE ON THAT. AND HAVE A SUBSTANDARDIZATION ON SAMPLES COLLECTED. AND APPROACHES USED TO TRY TO UNDERSTAND WHAT IS GOING ON WITH THE VIROLOGY. >> GREAT POINT. DO YOU HAVE ANY RECOMMENDATIONS WHAT THAT STANDARDIZATION MIGHT LOOK LIKE? >> IT IS TRICKY BECAUSE THE VIRUS ITSELF IS VERY STABLE AND WE CAN FREEZE IT, THAW IT, THERE'S PLENTY THERE. BUT FROM THE CLINICAL MATERIAL, IT SEEMS AS IF TO LOOK FOR CULTURABLE VIRUS YOU HAVE TO LOOK AT IT FRESH. THAT'S TRICKY. SO I THINK THAT IF EVEN IN A SUBSET OR IN INSTITUTIONS THAT HAVE VIRAL LOGIC CAPABILITY THAT IS BEYOND JUST PCR YES, NO, TRYING TO GET AN IDEA OF VIRAL LOAD, TRYING TO LOOK AT WHETHER -- SO MOST PCR ASSAYS LOOK FOR GENOMIC RNA. SUB GENOMIC RNA IS A REFLECTION OF REPLICATION. SO YOUR NORMAL PCR TEST DOESN'T TELL YOU IF VIRUS IS REPLICATING. THE ONLY WAY TO TELL VIRUS REPLICATING IS DO SUB GENOMIC RNA WHICH REQUIRES A DIFFERENT SET OF PRIMERS OR LOOK FOR CULTURABLE VIRUS AND QUANTIFY. SO THOSE KINDS OF THINGS WOULD BE REAL INTEREST IN ASSOCIATION WITH THE IMMUNOLOGIC ASSAYS. FOR INSTANCE IF YOU ARE DOING NASAL BRUSHINGS OR BALs, WHATEVER THE SAMPLE COLLECTION IS, TO SYSTEMATICALLY MAKE SURE THAT THEY ARE BEING EVALUATED FOR THESE THINGS AS WELL. >> THANK YOU. >> IMPACT WILL BE A NICE RESOURCE MAYBE WE NEED IMPACT SECOND COHORT POTENTIALLY FOR THAT. GO AHEAD. >> WE ANSWERED THE QUESTION YET WHETHER THERE'S REACTIVATION OF VIRUS OVER TIME? OR RATES OF INFECTION AN NOTION OF REACTIVATION AS WELL HAS COME UP. DO WE HAVE THAT ANSWER YET? SHOULD THAT BE A QUESTION WE SHOULD CON AND ANSWER SOON. >> THAT IS SOMETHING THAT SHOULD BE ASKED. BECAUSE AT THIS POINT IT'S ANECDOTAL SO IT'S NOT A SYSTEMATIC LOOK AT SO REINFECTION IS RARE BUT ON THE OTHER HAND WE WILL ONLY KNOW BY LOOKING SYSTEMATICALLY. AT THIS POINT IT'S ALL ANECDOTAL. >> THAT COMES -- BECOMES VERY PRACTICAL WHEN TRYING TO DO DISEMEA FOLLOW-UPS AT THREE AND SIX MONTHS, DO THOSE HAVE TO BE OUTSIDE IN TENTS? >> COUPLE OF COMMENTS MADE OVER THE LAST MOMENTS ABOUT SORT OF MARGARET MADE SOME COMMENT ON -- MAYBE IT'S A RON TOE THING. THE GEOGRAPHIC VARIATION. IF WE GO BACK TO SOCIAL DETERMINANTS AND HEALTH DISPARITIES, THERE'S DEFINITELY A BULLET THERE, BUT IT GOES MUCH MORE BEYOND CO-MORBIDITIES AND RACIAL DIFFERENCES. I DON'T REALLY SEE ECONOMIC DISPARITIES THERE OR GEOGRAPHIC. SO IF WE THINK TO ME DISPARITIES FALLS INTO TWO BUCKETS. THE RISK OF DISEASE OR THE RISK OF LONG TERM OUTCOME COMPLICATIONS, SO WILL IS THE RISK AND INDIVIDUAL SUSCEPTIBILITY AND THEN ON THE OTHER HAND THERE IS THE OUTCOME, AN DIFFERENCES IN OUTCOME THAT WILL LEAD TO FURTHER DISPARITIES AMONG OUR U.S. POPULATION. IF YOU THINK ABOUT RISK PIECE FOR A SECOND, THESE COHORT OFTEN HAVE INFORMATION ON INDIVIDUAL SELF-REPORTED RACE, THERE'S INCOME, THERE'S EDUCATION BUT THERE'S SO MANY OTHER FACTORS WAY BEYOND THAT THAT CONTRIBUTE TO RISK. IS IT FINANCIAL AND SECURITY? IS IT WHERE YOU LIVE? I KNOW A LOT OF ELECTRONIC HEALTH RECORDS WILL HAVE ADDRESSES THAT SHOULD HOPEFULLY BE GEOCODED SO THAT WE COULD LOOK NOT JUST AT SITE DIFFERENCES BUT WITHIN SITES IF YOU ARE RURAL, IF YOU ARE URBAN, IF YOU LIVE IN A POOR AREA, OR RACIALLY SEGREGATED AREA. HOUSING QUALITIES LIKE ALL THESE HEALTHCARE ACCESS, ALL THESE FACTORS THE BETTER JOB WE CAN DO UP FRONT AT COLLECTING THE INFORMATION I THINK IS A REALLY BIG CONTRIBUTOR AND WE HAVE TO ANSWER THE QUESTION OF RACIAL DISPARITIES AND COVID AND IT IS JUST NOT -- IT IS NOT FULLY EXPLAINED BY NUMBERS OF PEOPLE THAT GET DISEASE. IT REALLY GOES BEYOND THAT. AND THEN AT THE END OF THE DAY, THESE LONG TERM COMPLICATIONS ARE GOING TO FURTHER AFFECT CERTAIN COMMUNITIES RATHER THAN OTHERS. AND WE REALLY NEED TO UNDERSTAND THAT. WHAT ARE THE WORK IMPACTS, HOW PEOPLE ARE ABLE TO GO BACK TO WORK, IS DISEMEA KEEPING FOLKS FROM GOING BACK TO WORK. THIS IS GOING TO FURTHER LEAD TO FURTHER ECONOMIC DISPARITIES AND SORT OF THE LONGER TERM OUTCOMES THAT I REALLY PAY A LOT OF ATTENTION AT CAPTURING AND CAPTURING MORE FULLY THAN JUST RACE CO-MORBIDITIES, INDIVIDUAL INCOME. >> I WANT TO CHIME IN AND SAY THAT'S SUPER IMPORTANT, AS WE WERE TALKING STANDARDIZING ASSESSMENT OF DISEMEA AND RESPIRATORY SYMPTOM, THINKING WHAT IS A STANDARDIZED WAY OF CAPTURING SOME OF THESE SOCIAL DETERMINANTS OF HEALTH SO THEY COULD BE HARMONIZED ACROSS STUDIES. >> I THINK THAT'S A REALLY IMPORTANT QUESTION. I THINK ALSO AT SOME POINT RELATIVELY SOON WE CAN THINK A LITTLE BIT ABOUT WHAT SOME EARLY INTERVENTIONS MIGHT BE EVEN IN OUR SETTING OF PAUCITY OF DATA TO TRY TO DECREASE THE IMPACT POST COVID. I MUST SAY WHEN I START THINKING ABOUT THE PRTs AND CTs AND ALL THINGS WE ARE DOING TO PATIENTS WONDERING IF WE GAVE THEM COUPLE OF THOUSAND BUCKS WE JUST SPENT, THE IMPACT THAT WOULD HAVE ON OUTCOMES PROBABLY BE HUGE. >> THOSE ARE GREAT THOUGHTS SOCIOECONOMIC STATUS. I WONDER IMPACT OF TRAUMA AS WELL AS STRESS AND BUYOLOGY AND HOW THAT IMPACTS DISEMEA, THOSE ARE DIFFICULT THINGS TO STUDY BUT SHOULD BE FOCUSED ON AS WE AS PART OF THE THE MEASURE. >> THAT IS A BIT ASPIRATIONAL BUT FEELS LIKE A DELIVERABLE THAT DURING AND POST COVID THAT IF WE REALLY THINK ABOUT A WAY THE CHARGE STUDIES WITH STUDY SECTIONS WE NOW TALK ABOUT THE SEX DIFFERENCES AND BIOLOGIC BASES THAT MAYBE THIS IS THE TIME THAT GETS SUBJECTIVE TO ALL THE RESEARCH WE ARE DOING. SO MAYBE ONE OF THE QUESTIONS THAT WE SENT AROUND IS THIS ONE, THAT MAYBE STARTS BRINGING SOME OF THESE IDEAS TOGETHER AND THEN MAYBE WE CAN TRY TO REALLY BULLET WHAT WE THINK SOME OF OUR KEY NEXT STEPS ARE. BUT THIS ONE IS HOW DO WE ENSURE OPTIMAL INTEGRATION WITH THE ENTIRE RESEARCH SPECTRUM BASIC TO TRANSLATIONAL TO CLINICAL TO IMPLEMENTATION FROM THE BEGINNING. LET'S SPEND A LITTLE TIME THINKING ABOUT TALKING ABOUT THAT. WE TOUCHED ON IT BUT MOVE ONE STEP FURTHER. >> I'M IMPRESSED AT HOW THE HEART AND LUNG COHORTS HAVE BEEN INTEGRATED IN A WAY THAT NEVER HAPPENED BEFORE SO THERE'S CLEARLY ENOUGH MOTIVATION TO DO SOMETHING ORGANIZATIONAL. WE SHOULD SUGGEST SOMETHING TO THE NIH. IT IS A HUGE AMOUNT OF WORK, YOU HAVE LIZZIE WHO SPENDS 90% OF HER TIME ORGANIZING. RIGHT? >> I THINK MY TIME IS NOW OUT OF DIFFERENT DENOMINATOR. >> HAS A HUMAN DIMENSION THAT'S REALLY A BIG COMMITMENT. BUT IT NEEDS TO COME FROM THE NIH. AND I THINK IT NEEDS TO HAVE A SMALL GROUP OF PEOPLE, A STEERING COMMITTEE OR AN EXECUTIVE COMMITTEE AT THE TOP THAT WILL BE THINKING SPENDING A LOT OF TIME THINKING ABOUT IT. >> THERE'S BEEN INCREDIBLE TEAM EFFORT AND COMMITMENT AND INCREDIBLE ENTHUSIASM FOR THIS INTEROPERABILITY BECAUSE WE ALL RECOGNIZE THAT IT'S CRITICAL TO ADDRESS. ASKING FOR NIH TO ASSIST IN SETTING THE REPOSITORIES TO USE AND A WAYINGS TO COMMUNICATE AROUND THESE THINGS WOULD BE HELPFUL. SOMETHING WE WERE ENCOURAGED TO USE TRYING TO DEVELOP COMMON INSTRUMENTS. AND FENEX IS FANTASTIC AND PUBLIC BUT IT IS -- IT CONTAINS A LOT OF DIFFERENT OPTIONS NOW. SO THERE ISN'T ONE CONSENSUS OPTION ON THERE. HOW DO WE COME TO CONSENSUS, HOW IMPORTANT IS CONSENSUS AND WHO COMES TOGETHER TO DECIDE WHAT IS THE CONSENSUS OPTION, THAT IS AN OPEN QUESTION BUT WOULD BE SOMETHING TO GET MORE CLARITY ON. THE NEXT STEP FROM THERE WHICH IS DIFFICULT TO ANSWER IS ISSUES AROUND DATA SHARING AND SORT OF SHARING. >> WONDER IF ONE POSSIBLE APPROACH TO INTEGRATION IS WE START TO THINK EARLY ABOUT SOME INTERVENTIONAL STUDIES IN THIS POPULATION. THEN BECOME SORT OF THE PLATFORM OR PORTAL FOR COLLECTION OF MORE ALL THESE OTHER DETAILED DATA ELEMENTS AND NOT EVERYBODY HAS TO PARTICIPATE IN EVERYTHING BUT THAT CERTAINLY AT LEAST COULD BE ENTRY POINT. WE ARE NOT FOCUSED ON THIS MUCH YET AND WE HAVE 20 MINUTES LEFT. LET'S TALK A LITTLE BIT ABOUT WHAT DO WE THINK ARE SOME OF THE LINE CANDIDATES FOR INTERVENTION AND IMPROVING POST COVID OUTCOMES PARTICULARLY ACROSS PULMONARY AXIS OR ACUTE RESPIRATORY FAILURE PATIENTS. BUT EVERYONE. WHAT SORTS OF THOUGHTS DO PEOPLE HAVE. >> PUT THIS IN THE CHAT EARLIER BUT ONE OF THE THINGS I NOTED THAT HAPPENED DURING THE PANDEMIC IS IT GOT HARDER TO DO BEST PRACTICES THAT WE KNOW FROM DECADES HAVE BEEN HELPFUL SO I'M THINKING OF THE ABCDEF BUNDLE BUT SOME OF OUR ATTENTION NEEDS TO BE FOCUSED HOW TO MAINTAIN DELIVERY OF THESE BEST PRACTICES DESPITE PANDEMIC SITUATION. DESPITE INFECTION CONTROL NEWLY ACTIVATED ICUs, POLLING NEW STAFF, EVERYTHING WAS MUCH HARDER THAN IT WAS AND IT WAS NEVER EASY SO I THINK THAT -- WE KNOW THOSE THINGS WORK HOW DO WE MAKE SURE WE WERE GOING TO DELIVER THEM WELL DURING THE PANDEMIC. >> HALLLY'S COMMENTS MAKING SOMETHING CLEAR TO ME WHICH IS WE HAVE THE POST INTENSIVE CARE SYNDROME WHICH WE HAVE VERY HERE IN COVID AND WHICH WE KNOW A LOT ABOUT WHAT TO DO. THEN WE HAVE THE NON-POST INTENSIVE CARE SYNDROME POST COVID SYMPTOMS WHICH WE KNOW VERY LITTLE ABOUT HAIR CAUSE, THE DISOMY YEAH, COUGH, CHEST PAIN, THOSE WHICH ARE VERY COMMON AND BIG PUBLIC HEALTH BURDEN. FOR THE FIRST CATEGORY WE KNOW WHAT TO DO IN A LOT OF INSTANCES AND WE SHOULD START TO TEST AN IMPLEMENT THEM BUT FOR THE SECOND BUCKET PULMONARY PRESENTATION WE NEED TO DO BASIC RESEARCH FIRST TO UNDERSTAND WHAT THE CAUSE IS. >> I LOVE THE POINT THOUGH I WOULD DISAGREE, WE DON'T HAVE A SINGLE EVIDENCE BASED PRACTICE AT LEAST THAT I KNOW OF THAT CHANGES OUTCOMES IN THE POST ICU SPACE. >> OKAY. AT LEAST WE KNOW WHAT WE THINK IS CAUSING THE SYMPTOMS. OR NO? NOT THAT? >> DO WE KNOW? >> I THINK WE KNOW THE PHENOTYPE, WE DON'T KNOW A LOT ABOUT THE MECHANISMS. >> I THINK THAT TO GET TO HALLY'S POINT WE HAVE GOTTEN AWAY FROM THINGS WE KNOW WILL FUNDAMENTAL, WE NEAT TO GET BACK TO THOUGH BUT WE ALSO -- STILL HARM PATIENTS BY OUR CURRENT ICU PRACTICES AND TO GET TO A POINT TERRY MADE EARLIER, THIS IS AN OPPORTUNITY TO REALLY GO BACK AND LOOK AT WHAT WE DO FOR ARDS. BIG QUESTIONS. NUMBER ONE IS NON-INVASIVE VENTILATION, HELPFUL OR NOT. OR CAUSING PATIENT INDUCED LUNG INJURY. EARLY IN THE PANDEMIC WE ARE INTUBATING EVERYBODY HE WILL EARLY AND OUTCOMES WERE OKAY, NOW WE HAVE PATIENTS ON BILEVEL FOR WEEKS AND GO ON AND GET TERRIBLE FIBROSIS. SO WHAT IS THE ROLE OF NON-INVASIVE? WE STILL DON'T KNOW WHETHER THESE PATIENTS GET VASCULITIS. SEEMS LIKE THAT'S LIKELY. AND THAT CONTRIBUTES TO ENDOTHELIAL DAMAGE AND DISORDERED COAGULATION AND LOTS BUT THAT'S STILL A HYPOTHESIS THAT NEEDS TO BE TESTED SO WE DON'T KNOW HOW TO ANTI-COAGULATE THESE PEOPLE AND THEN FINALLY, WE DON'T UNDERSTAND THE HOST RESPONSE. SO WHILE WE ARE NOW GIVING STEROIDS TO EVERYONE I SUSPECT THAT IN A GENERAL POPULATION SENSE THAT'S BENEFICIAL BUT WE ARE PROBABLY CAUSING HARM TO A SMALLER GROUP OF PATIENTS. WE ARE CERTAINLY SEEING THAT IN TERMS OF VENTILATOR ASSOCIATED CONDITIONS AND PNEUMONIA. I THINK WE ARE CAUSING HARM TO SOME PATIENTS AND WE NEED TO GET BACK TO THE BASICS TO START TO UNDERSTAND THAT. >> SO MAYBE THE LARGER BUCKET THERE IS TO MAKE SURE THAT WE HAVE SOME COHORT THAT INCLUDE ENOUGH CRITICALLY ILL PATIENTS THAT WE CAN MAP ASSOCIATIONS OR HOPEFULLY DO INTERVENTIONAL STUDIES AS WELL, MAYBE TO IMPROVE IMPLEMENTATION OF BEST PRACTICES AND THEN SEE IF YOU SEE CHANGES IN WHAT POST COVID LOOKS LIKE. I THINK PRECISION MEDICINE APPROACHES TO USE OF STEROIDS, THOSE ALL COME IN REALLY NICELY. ONE CHALLENGE, TWO MAJOR CHALLENGES THERE, PROBABLY MORE TOO, ONE IS THAT YOU NEED A LOT OF PEOPLE TO BE ABLE TO WORK THROUGH ALL DIFFERENT TREATMENTS TO TRY THE ACCOUNT FOR MEDICATION BIASES, ARE YOU SURGING SO EVERYBODY DYING SO YOU HAVE OTHER PROBLEMS, SO I DO THINK THAT LIKE THERE'S NOT GOING TO BE ONE SINGLE SYSTEM COHORT THAT'S GOING TO DEAL WITH THAT. NHLBI TELENETWORK PUTTING TOGETHER 1500 PATIENT COHORT. THAT IS WAY TOO SMALL TO TRY TO UNDERSTAND A LOT OF THESE KINDS OF QUESTIONS. I THINK WAYLY IMPORTANT POINTS THERE. HOW ABOUT THAT SECOND GROUP? THE PATIENTS WITH THE PERSISTENT DISEMEA CHEST PAIN COUGH ITSELF, THAT AREN'T -- WE CAN'T BLAME ON PIX BECAUSE THEY NEVER SAW ICU. WE STILL DON'T KNOW IN THAT GROUP, THERE'S SO MUCH WE DON'T KNOW BUT THERE ARE THINGS PEOPLE ARE TRYING AND WE DON'T KNOW IF THEY ARE HELPFUL, STEROIDS, THE DATA IS ALL OVER PLACE. OR OTHER STANDARD THERAPIES THAT WE WOULD THROW PEOPLE BRONCO DILATORS DURING OR POST PHASE, WE DON'T KNOW IF THEY ARE HELPFUL. EARLY REHAB. I GUESS IT IS PROBABLY MORE FOR THE SICKER GROUP. I THINK IT WAS RENEE BROUGHT UP EARLIER WE DON'T HAVE ANY TREATMENT FOR THIS CHRONIC COUGH RIGHT NOW. THERE ARE DRUGS ACTUALLY THAT I THINK GAB BE PEN TIN THAT IS NEARLY APPROVED FOR CHRONIC COUGH, SOMETHING LIKE THAT HELPFUL OR NERUNTIN. SO THERE'S LOW HANGING FRUIT THAT COULD BE LEFT OUT. AS A STARTING PLACE, CLEARLY MORE NEEDS TO BE DONE. >> I WOULD LIKE TO RE-EMPHASIZE WHAT BILL JANSON SAID TOO, WHILE WE STUDY THOSE PATIENTS AND WE HAVE DIFFERENT TREATMENT LIKE, NON-INVASIVE VENTILATION, HIGH FLOW VENTILATION, MORE MECHANISTIC UNDERSTANDING OF THE HOST RESPONSE, MAYBE DEVELOPMENT OF PULMONARY HYPERTENSION WITH HYPERCOAGULATION ABILITY WITHOUT ANTIBODIES SO AS WE DO THE COHORTS AND THE EPIDEMIOLOGICAL STUDIES ARE GOING, WE ALSO NEED TO EMPHASIZE THE MECHANISTIC UNDERSTANDING BECAUSE THAT WILL ALLOW US TO HARM LESS PEOPLE AND TREAT THEM BETTER. >> THIS IS BRAD, I WANT TO ECHO WHAT MILAN SAID, I THINK THINK IN THAT GROUP OF PATIENTS WITH CHRONIC SYMPTOMS DESPITE NEVER SEEING THE ICU, I THINK WE REALLY SHOULD TRY TO STAND UP CLINICAL TRIALS RATHER THAN JUST EMPIRIC TREATMENT. WE ARE SEEING PATIENTS COMING TO OUR REFERRAL CENTER WITH SIX WEEKS OF PREDNISONE AS OUTPATIENT WITH NO IMPROVEMENT IN SYMPTOMS. THERE'S UNFORTUNATELY WHILE MECHANISMS ARE OBVIOUSLY INCREDIBLY IMPORTANT THE COMMUNITY AT LARGE CAN'T WAIT FOR THAT TO BE TEASED OUT. SO STANDING UP CLINICAL TRIALS OF POTENTIAL THERAPEUTICS EARLIER RATHER THAN LATER SHOULD BE HIGH PRIORITY TO GUIDE CLINICAL PRACTICE AN AVOID HARM AT POPULATION LEVEL. >> BRAD, I CAN'T ECHO THAT ENOUGH. >> SORRY. JUST PROVIDE THE OPPORTUNITY FOR LEVERAGING OBSERVATIONAL NATURAL HISTORY STUDIES ON TOP ALONG WITH INTERVENTION TRIAL. >> I WOULD RECOMMEND -- I THINK A STRUCTURE THAT WOULD WORK NICELY IS SOMETHING HA IS PRAGMATIC THAT'S RELATIVELY LIGHT TOUCH FOR MAJORITY OF PEOPLE, OFFERS OPPORTUNITY FOR MORE EXQUISITE PHENOTYPING AND A PLATFORM SO ONCE YOU GET INTO IT WE HAVE THE SAME ASSESSMENT OF SOCIAL DETERMINANTS OF HEALTH, WHAT THEIR COVID EXPOSURE WAS. THAT IS ALL THE SAME FROM ONE INTERVENTION TO NEXT AND ONE DOMAIN TO THE NEXT. I'M PICTURING REMAP FOR THOSE WHO MAYBE ARE FAMILIAR WITH REMAP CAT PROTOCOLS BASICALLY YOU HAVE LOCK AND LOAD OF DIFFERENT INTERVENTIONS DEPENDING WHAT YOUR PATIENT LOOKS LIKE. WHAT THE NEEDS ARE WHAT INCLUSION CRITERIA ARE. ARE THERE -- IS THERE ANYTHING LIKE THAT IN PNEUMONIA SPACE? ONLY KNOW INPATIENT SPACE. >> OPD SPACE MAYBE? >> NOT REALLY OUTPATIENT SETTING FOR PNEUMONIA. BUT NOT POST PNEUMONIA. >> THAT WOULD BE A HUGE CONTRIBUTION. >> THE ONLY COPD SPACE, THE CLOSEST PERHAPS IS THE RELIANT STUDY, A PRAGMATIC CLINICAL TRIAL OF ZITHRO FOR PATIENTS HOSPITALIZED WITH FREQUENT EXACERBATION BUT I THINK YOUR POINT ABOUT A PLATFORM DESIGN IS WHAT YOU NEED BUT RELIANT STUDY MODELS THE PRAGMATIC APPROACH WHICH CAN BE LOW TOUCH BUT POTENTIALLY INFORMATIVE QUICKLY THOUGH RECRUITMENT IS CHALLENGING TO COVID. U >> GIVEN WE CAN HAVE FAIRLY QUICK -- THE PROBLEM WITH THESE TRIALS WITH CHRONIC LUNG DISEASES ARE READ OUTS BUT IF WE WENT ON SYMPTOMS, THAT MAKE US BE ABLE TO MAKE DECISIONS WHETHER THERAPIES WERE -- OR NOT. >> ABSOLUTELY. >> THERE IS A NOT A PRAGMATIC BUT A PLATFORM ADAPTIVE PLATFORM NIH STUDY IN ASTHMA, PRECISE PLATFORM WHICH IS TRYING TO GET STARTED IN THE MIDST OF THE COVID EPIDEMIC. SO ADAPTIVE DESIGN WE CAN LOOK AT. >> WHAT DO YOU THINK THE IMPORTANCE OF TRYING TO BE GLOBAL? IS THAT IMPORTANT AT THIS POINT PUTTING TOGETHER A PROTOCOL WE ALSO DO WITH OUR FRIENDS IN CANADA, AUSTRALIA OR -- IS THAT SCOPE NOT NECESSARY AT THIS POINT? >> MAYBE THE CANADIANS SHOULD BE -- I WOULD SAY THAT I THINK IT'S INCREDIBLY IMPORTANT. I THINK GOING BACK TO THE ORIGINAL COMMENTS ABOUT STANDARDIZED FOLLOW-UP POINTS AND SOME MINIMAL DATA SET AND STANDARDIZATION OVER TIME IS CRUCIAL AND REALLY WILL ALLOW US TO SHARE DATA. WE DO HAVE DIFFERENT POPULATIONS OF PEOPLE AND DIFFERENT ETHNICITIES AND IT MATTERS A LOT, I THINK TO SOME OF THE EARLIER DISCUSSION ABOUT WE DIDN'T TALK GENETICS HERE, BUT GENETICS, ETHNICITY, SOCIAL DETERMINANTS OF HEALTH THEY VARY SO MUCH ACROSS% WORLD AND OR LOW TO MIDDLE INCOME COUNTRIES, IT IS IMPORTANT TO UNDERSTAND HOW ALL THESE THINGS INTERACT. SO I WOULD VOTE ENTHUSIASTICALLY YES, IT IS REALLY IMPORTANT FOR ALL OF US TO TRY TO DO SOME OF THE SAME THINGS SO WE HAVE COMPARATORS BUILT IN AND CAN LOOK INTERNATIONALLY. >> WE ARE DOWN TO THE LAST TEN MINUTES. YES. >> IN TERMS OF CROSS COLLABORATION DO WE NEED TO PROMOTE NHLBI NIAID COLLABORATIONS? >> I FEEL LIKE THEY ARE NOT NECESSARILY ALWAYS TALK TO EACH OTHER AND REALLY GOOD WITH THE IMMUNE PHENOTYPING. AND REALLY GOOD WITH THE COHORT. WE CAN GET A LOT OUT OF COMBINING THE TWO. >> I'M HOPEFUL SINCE WE ARE SITTING IN NIAID OR ORGANIZED WORKSHOP WITH OUR POs FROM NHLBI THIS IS STEP ONE. I COMPLETELY AGREE. OKAY. SO LET'S SEE. T HOW MANY SLIDES HAVE WE -- WE PUT TOGETHER A LOT. ANY IDEAS ON HOW TO QUICKLY REVIEW WHERE WE HAVE BEEN AND GET A COUPLE OF FINAL POINTS TOGETHER. I HAVE A HUNDRED PIECES OF PAPER. LET ME START. SO I THINK SOME OF THE KEY THINGS THAT I HEARD ARE IMPORTANCE OF DEFINITIONS AND HARMONIZATION. THESE DEFINITIONS ARE TRUE FOR WHAT THE COVID EXPERIENCE WAS THAT WE ARE DEFINING YOUR INITIAL ILLNESS AND THAT THAT'S PROBABLY NOT GOING TO BE A SINGLE POINT IN TIME DEFINITION GIVEN COMPLEXITIES OF COVID. THAT WE WANT TO HAVE A HARMONIZED AAPPROPRIATE TO OUR ASSESSMENTS OF SOCIAL DETERMINANTS OF HEALTH TO CO-MORBID DISEASE, THAT THAT -- THOSE ARE PIECES THAT I WILL NEED TO BE IN COMMON. THAT IMPORTANTLY OF COURSE WE ARE NOW PUSHING FORWARD TAXONOMY OF OUR OUTCOMES WITHIN LUNG COVID WE DO THESE IN THE SAME WAYS WE ARE TRANSFERABLE ACROSS DIFFERENT RESEARCH GROUPS IN PLACES. COUPLE OF DOMAINS WITHIN THERE THAT WE FOCUSED ON, FIRST AN FOREMOST WAS SYMPTOMS THAT A LUNG COVID SYMPTOM CLUSTER AROUND ONE AROUND DISKNEEIA AND COUGH I THINK WERE THE TWO WE TALKED MOST ABOUT AND USING THOSE DEFINITIONS THEN TO POTENTIALLY IMPANEL A NEW COHORT TO CREATE A PLATFORM FOR INTERVENTIONAL STUDIES AN CREATE A PORTAL FOR MORE DETAILED MECHANISTIC STUDIES. THOSE WILL SOME OF THE EARLY THINGS I HAVE HEARD. WHAT WILL SOME OF THE OTHER BIG THINGS STICKING OUT FOR YOU? SLEEP SYMPTOMS IN OUR PURVIEW, I THINK OTHER THAN THE COVID SOMNIA IN THE LAY PRESS WHICH HAPPENS TO PEOPLE WITH COVID AND WITHOUT, I ACTUALLY NOT HEARD MUCH DISCUSSION SO MAYBE WE CAN USE THAT AS WHAT ARE OTHER AREAS OF KEY SYMPTOMTOLOGY THAT MAPS TO OUR EXPERTISE THAT HAVEN'T BEEN EXPLORED YET. >> ONE OF THE THINGS WE ALSO HEARD WAS NEED FOR MORE DETAILED INFORMATION ON THE PATIENTS THAT AREN'T GETTING HOSPITALIZED. ALSO FOR GETTING MORE DATA IN A SYSTEMATIC WAY DURING INFECTION THAT WE ARE NOT CURRENTLY COLLECTING BECAUSE OF DIFFICULTIES OF DOING SO. >> SPECIFIC TO POST COVID LONG HAUL SYMPTOMS. A LOT OF PATIENTS FIT WITHIN THE CHRONIC FATIGUE SYNDROME, ENCEPHALOMYELITIS POST EXERTIONAL MALAISE, OFTEN SEEN AS EXPERTS WITHIN OUR CENTERS SO WE HAVE TO THINK IF THAT'S SOMETHING TO INVESTIGATE FOR CLEARLY. NOT EXCITED BUT -- >> I MIGHT INSTEAD OF HAVING A BULLET ON THE NON-HOSPITALIZED POPULATION I MIGHT INSTEAD SAY MAKE SURE WE INCLUDE A SPECTRUM OF INITIAL WHICH WILL HEAVILY INCLUDE A NON-HOSPITALIZED POPULATION CLEARLY. >> TERRY, THIS IS WRITTEN. I WOULD LIKE TO -- LYNN. I WOULD LIKE TO ADD TO IDENTIFIED GAPS, THE IMPORTANCE OF LOOKING AT REHABILITATION, PULL MANYNARY OR PHYSICAL REHABILITATION LONG TERM AND OUTCOME OF THAT ON PATIENT RECOVERY. >> THANK YOU, LYNN. AGREE. >> WITHIN OUR GAPS PEOPLE IT IS CLEAR WHAT THE NEXT RECOMMENDED KEY NEXT STEPS CERTAINLY THE NEXT STEP FOR GAPS AROUND STANDARDIZATION IS REALLY CREATINGEN -- AND AGREEING UPON THESE DEFINITIONS MEASUREMENTS, POOR OUTCOMES, ET CETERA. WHY DON'T -- LET'S TALK ABOUT -- SO WHAT ARE A COUPLE OF LOW HANGING FRUIT AND THEN MAYBE LESS ONE HIGHER UP ON THE FREE FRUIT OF -- REFRUIT. WHAT CAN WE DO NOW AND WHAT WE NEED TO WORK TOWARDS IS OUR BIG PICTURE. >> SO IN TERMS DATA COLLECTION, THERE'S ONE THAT NHLBI FUND THROUGH OUR GROUP THROUGH SURVIVORS (INAUDIBLE) THE HOSPITAL. THERE'S A COVID SPECIFIC CONCEPT THAT'S BEEN CREATED RECENTLY PUBLISHED FOR OUTCOMES AS WELL AS WHAT SHOULD BE COLLECTED ON THE INPATIENT ASPECT OF STUDIES SO MAKING SURE THAT WE ARE SORT OF AWARE OF THOSE EXISTING THINGS AND KNOTTILY INVENTING THE WHEEL. -- REINVENTING THE WHEEL. >> REALLY IMPORTANT POINT. WE WON'T NEED TO REINVENT THE WHEEL. I SUSPECT WE WILL NEED TO TYPE (INAUDIBLE) I DON'T KNOW MUCH ABOUT WHEELS. IT'S INTERESTING TO ME HOW MANY THINGS WE PUSH FORTH IN MARTHA WEREN'T YET INFORMD BY THE 14 MILLION AMERICANS WITH COVID SINCE. BUT I ABSOLUTELY AGREE THAT WE ARE NOT STARTING FROM SCRATCH HERE. WHAT ELSE DO WE SEE, BIG GAPS, INCIDENCE AN PREVALENCE. YEAH. SO BASIC EPIDEMIOLOGY OF LONG HAUL COVID. COMPLETELY AGREE. WE TALKED ABOUT RESEARCH NEXT STEPS WHAT ARE WAYS THAT WE CAN AUGMENT SOME OF OUR EXISTING OUR EXISTING COHORTS, AND MAYBE WE SEE THAT ALREADY. HOW DO WE CREATE A PLATFORM FOR EARLY TREATMENT. OF LUNG COVID THAT ALSO IS AN INFRASTRUCTURE FOR UNDERSTANDING BIOLOGY POTENTIALLY FOR KNOWLEDGE TRANSLATION LIMITATION SCIENCE AS WELL. POST COVID CLINIC INFRASTRUCTURE COLLABORATION AGREE. THAT'S DEFINITELY ONE WAY TO FILL THAT GAP AND MAYBE TO CREATE THE STRUCTURE THEN OF IF WE WERE TO DO A TRIAL, A POST COVID TRIALS NETWORK. CERTAINLY THOSE CLINICS ARE FANTASTIC STARTING POINT. >> ONE THING THAT PLATFORMS STUDIES NEED AND WE HAVEN'T TALKED ABOUT IS BIOMARKERS. SO THAT IF YOU ARE GOING TO DO ADAPTIVE TRIAL YOU WANT TO HAVE SOME BIOMARKERS EVEN STRATIFICATION OR IDENTIFYING EARLY RESPONSES. SO WE NEED TO UNDERSTAND WHETHER CRP IL 6 AND SOMEBODY INDEED KNOWN BIOMARKERS ARE IMPORTANT RELATIVE TO THE RESPIRATORY SYMPTOMS. >> ABSOLUTELY. >> OKAY. >> SO OPPORTUNITY TO ADDRESS A GAP, THANK YOU. >> THIS IS BRAD. THIS IS A HIGHER LEVEL PERHAPS PULMONARY SPECIFIC COMMENT BUT I FEEL SO MANY INDIVIDUALS THAT ARE INFECTED, HAVE NEVER -- THEY ARE YOUNGER NEVER HAD TO ENGAGE IN CLINICAL RESEARCH OR HAD THE OPPORTUNITY, THEY PROBABLY HAVE ENGAGED IN HEALTHCARE BEFORE THIS. FOR JUST BECAUSE OF THEIR AGE. I FEEL AS THOUGH THE NIH SHOULD MAKE AN INITIATIVE TO EDUCATE THE POPULATION ABOUT HOW TO ENGAGE IN CLINICAL RESEARCH FOR COVID RECOVERY. >> I LOVE IT. EDUCATION BOTH IN COVID AND LUNG COVID AND ENGAGEMENT IN RESEARCH. BRILLIANT. WE -- JOSH WE PROBABLY WANT TO MAKE SURE WE HAVE MAKE SURE THAT SOME OF THE BIOLOGIC MECHANISMS ARE PLACED IN HERE BECAUSE THEY WILL BE INFORMATIVE. I THINK THAT LOOKS LIKE A REALLY GOOD START. >> TERRY, IT'S GREAT. THIS IS CARLY WILLIAMS FROM NIAID AND IT'S TIME TO LOG BACK IN TO THE ORIGINAL ZOOM LINK. I THINK I WANT PEOPLE TO LOG BACK IN AND THEN WE ARE GOING THE TAKE BREAK. >> PERFECT. ALL RIGHT. YOU GUYS ARE AMAZING. THANK YOU VERY MUCH. GOT THROUGH A LOT AND THERE'S A LOT OF WORK LEFT TO DO. >> GREAT JOB. >> GREAT JOB. >> THANK YOU.