Background Emerging studies indicate that some COVID-19 patients suffer from persistent symptoms including breathlessness and chronic fatigue; however the long-term immune response in these patients presently remains ill-defined. Methods Here we describe the phenotypic and functional characteristics of B and T cells in hospitalised COVID-19 patients during acute disease and at 3-6 months of convalescence. Findings We report that the alterations in B cell subsets observed in acute COVID-19 patients were largely recovered in convalescent patients. In contrast, T cells from convalescent patients displayed continued alterations with persistence of a cytotoxic programme evident in CD8 + T cells as well as elevated production of type-1 cytokines and IL-17. Interestingly, B cells from patients with acute COVID-19 displayed an IL-6/IL-10 cytokine imbalance in response to toll-like receptor activation, skewed towards a pro-inflammatory phenotype. Whereas the frequency of IL-6 + B cells was restored in convalescent patients irrespective of clinical outcome, recovery of IL-10 + B cells was associated with resolution of lung pathology. Conclusions Our data detail lymphocyte alterations in previously hospitalized COVID-19 patients up to 6 months following hospital discharge and identify 3 subgroups of convalescent patients based on distinct lymphocyte phenotypes, with one subgroup associated with poorer clinical outcome. We propose that alterations in B and T cell function following hospitalisation with COVID-19 could impact longer term immunity and contribute to some persistent symptoms observed in convalescent COVID-19 patients. Funding Provided by UKRI, Lister Institute of Preventative Medicine, The Wellcome Trust, The Kennedy Trust for Rheumatology Research and 3M Global Giving.

In patients with symptomatic Chiari I malformation and associated syringomyelia, syrinx resolution is more likely if the dura is hitched open rather than closed bysurgicel and tisseel overlay graft after durotomy.

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Cerebral air embolism following pulmonary barotrauma during flight in patients with giant pulmonary bullae is rare, with only five reported cases. We aim to highlight and better understand this unusual condition.A 47-year-old male airline passenger with a primary lung bulla experienced an inflight cerebral air embolism resulting in hypoxic brain injury. On landing, he was found unconscious and developed seizures. He was admitted to intensive care, requiring invasive ventilation. CT brain demonstrated diffuse oedema. Sub- sequent MR brain imaging demonstrated bilateral hypoxic injury, characteristic of air embolism. Chest CT revealed a giant pulmonary bulla.Air embolism occurs in patients with pulmonary bullae during flight due to pulmonary barotrauma. Pressure change during ascent causes expansion of bullae, resulting in tears in the pulmonary vasculature, with air leakage and embolisation to the arterial cerebral circulation. No British Thoracic Society air travel guide- lines extend to advice regarding risk of rupture of bulla given the rarity of this presentation.Neurological deficit in cerebral air embolism is variable, and some cases can be reversible. Our patient had modest improvement in clinical status and was discharged to a neurorehabilitation facility. Patients with known giant pulmonary bullae should be counselled on the risks associated with air travel.rachaelmatthews@doctors.org.uk

Introduction: Primary health care is essential healthcare made universally accessible to individuals and acceptable to them through their full participation and at an affordable cost. It can be effectively delivered at the Basic health unit (BHU). Assessment of its performance at regular basis is also crucial for the health care system. Objectives: To assess the services (EPI, antenatal care and basic healthcare) provided at selected BHUs of Peshawar with a view to determine service provision gaps in these BHUs. Materials & Methods: It was a questionnaire based descriptive survey conducted from September to November 2019, in which simple random sampling technique was used to select 15 BHUs of district Peshawar for assessment and evaluation purposes. Data were collected using a checklist and an indigenous structured questionnaire where responses were recorded in yes/no format. Data analyzed using SPSS V.22 for descriptive statistics. Results: All vaccines of the EPI program were being provided in BHUs except for Hepatitis B. Regarding BHU staff, in 80% BHUs male medical officers were absent, and in 40% BHUs female medical officers were absent. For the Maternal and Child Health Care (MCHC) services, Tetanus Toxoid vaccine and Folic Acid supplements were present in all BHUs but status of malnutrition was unsatisfactory. About 80% of BHUs had a satisfactory infrastructure; the safety and sanitation precautions in BHUs were not up to the mark regarding disposal of hazardous waste and needles. Conclusion: Majority of the healthcare facilities were present in sampled BHUs including immunization services, MCHC services, infrastructure, safety, and sanitation. While the female staff was adequate in number, the attendance of male staff was poor. Primary health care; basic health unit; Immunization; Prenatal care