So could you just start by saying your name and your position at the moment?
My name is Betty Rahman. I'm a senior academic cardiologist in the Department of Medicine and at the British Heart Foundation,
Centre for Research Centre of Research Excellence. Intermediate Transition Clinical Research Fellow.
Well, that's quite a mouthful. Yes. And you're based in the Oxford Centre for Magnetic Resonance Imaging?
Yes, that's right. So I'm working in Okayama, Radcliffe, Department of Medicine.
And first of all, just you don't have to tell me your entire life story, but if you just give me the headlines, how did you get to where you are now?
How did you first get interested in medicine and how did you come to specialise in cardiology and.
And what interested you now? Yeah, sure, of course. So I'm Indian and ethnic origin.
My parents and great my grandparents and great grandparents come from the southernmost tip of India, a place called Kanyakumari.
I was when I was young. My father, who's a doctor, had done a lot of inspirational work in the field of cardiology,
and that was part of my part of the inspiration to pursue medicine.
But I've also generally enjoyed biology and chemistry, which are both integral for medicine.
So that's the reason I picked up medicine.
I grew up in a place called Aman in the Middle East and moved to Australia to pursue medicine.
So at the age of 17 I was I was sent to Australia,
playschool Adelaide in Australia where I undertook my bachelor's in medicine and then specialised in cardiology there.
And in Australia was I became quite interested in cardiovascular research in
particular how people develop heart failure and the role of imaging in heart failure.
But I also was exposed to internal medicine where we had to learn about all parts of the body and just including mental health.
So I've had a very balanced exposure to medicine and during my clinical training in Australia I realised that I was really passionate about research.
So after completing my cardiology specialisation in Australia,
I applied to do a dphil here in the University of Oxford and got a fellowship to carry on the academic work.
And is that what you're still doing at the moment of you finish your dphil. So I finished my Dphil Right.
And so the subject was an inherited heart condition called hypertrophic cardiomyopathy.
It's most common genetic heart disease and also a leading cause of sudden death in young adults and athletes.
So during my dphil, I learned how to refine our ability to predict those who can develop progressive heart disease and who may die all of a sudden.
And during the dphil, I had a very productive period where I discovered an oxygen sensitive MRI approach,
which allowed me to then tell us more about the risk of someone dying with this condition.
So tell me a bit more about MRI for the benefit of people who might listen to this in the future.
How did you come to focus on that as a tool that could help answer the kinds of questions you were interested in?
Yes. So MRI is a fascinating technology and it utilises the magnetic property of the tissues to provide images,
which essentially a virtual autopsies or sections of the body.
It provides quite extensive detail about the tissue characteristic.
In particular, it is able to look into the tissue and tell you whether there's a scar in the organ,
whether there's any signs of inflammation or whether there are any problems with the small blood vessels that supply blood or oxygen to the tissue.
So it's like it's an amazing tool that is able to perform almost a virtual non-invasive autopsy in a living person.
So the technology was you know, it was clearly extremely of extremely interesting to to myself and a lot of specialists across the UK.
You'll find that this technology is now ubiquitous and it's being utilised in many disciplines and it's very safe for patients.
And it is safe and there's no really. Involved.
So yeah, so it's a great technology which provides quite a lot of detail that we wouldn't be able to access, say, 30 years ago.
Well, moving on to the the COVID pandemic. Can you remember where you were or how you first heard that there was something going on in China?
And how soon did you realise that that might be something that was going to affect your work?
Absolutely. So I had just returned from Oman, which is where my parents, beside having just had a wonderful wedding with my partner.
So which month? So this was in December. And I was looking forward to rising to starting my BHF Transition Intermediate Clinical Research Fellowship,
which was really aimed to study hypertrophic cardiomyopathy.
However, not long after I'd arrived back from Amman, arrived here in the UK.
This was around February.
We started hearing reports of COVID 19 in China, and I had a meeting with my mentor, who's the head of the department here, Professor Stefano Oyibo,
and we were just talking about how unbelievable the situation was and how we had hoped that the that it
wouldn't escalate because at the time there were reports only in China and a couple of other countries,
but it hadn't really affected the UK or any of the European countries or even the United States.
So we were really just speculating on, on, you know, how, how incredible this, this, this disease is and how there's so many unanswered questions.
And in a couple of meetings later, we we started talking about some reports that had come out of people who were admitted to hospital,
but who had signs of quite extensive multiorgan injury.
And Professor Stefano and I were saying, well, wouldn't be interesting if we if we studied and study these people who are acutely
unwell with with an MRI scan to see how it's affecting the various organs.
And and, of course, we we thought about it at the time,
but it was clear that we couldn't undertake an acute study because of the infection risk to people, the many unknowns.
And so we started thinking of how our knowledge and skills could be put to use in these difficult times.
And we we then considered perhaps a more long term study where we would look
at or assess people after they had they'd recovered from the acute infection.
And just to see whether there were any lingering effects of the infection on other organs,
but also on the general health of the individuals or how they felt not just from a physical level,
but also a mental health level, but also from a memory cognition perspective.
So you were thinking about all that before the concept of long COVID had even been recognised?
Yes, absolutely.
So yeah, that was quite unique because I think it I mean, it was just an idea that that I had when we were saying, you know, I said, well, you know,
it really affects I was telling Stephane it really affects people so severely that they need to go into ICU and,
you know, they need to be ventilated for such a prolonged period of time.
Surely it's going to affect their other organs, you know?
And this is before the first report came out and then before you know it, there were multiple reports, there was mortem studies and also, you know,
prospective studies of hospitalised patients where it was clear that the virus was
not just an ordinary influenza virus or just another virus that one could get over,
but that a significant proportion who were admitted to hospital was succumbing to the illness and not making it out of hospital.
So, so. So so that was one of the reasons why we thought, well, you know,
this is a severe illness and it is going to affect, you know, a lot of the faculties.
Like it's not just going to be the lungs. You know, we had a hunch back then that it would affect other organs as well.
So you were going to need patients to study. And soon enough it was quite obvious there were going to be patients in the UK.
So if we just skip on to March,
how did the arrival of the pandemic and the mitigation measures that were put in place immediately affect the work that you were doing?
So fortunately, Oxford has been a hub for research, not just in COVID but in other infectious diseases.
So we were we were relatively optimistic that we would have some we would have some support to carry on the the research that we were planning.
And indeed, that is what unfolded over the months to come.
And, you know, that was actually quite yeah,
that was an enormous support for us because we had the trust as well as the university, encouraging us to carry on our research.
And so that didn't affect us as much. But of course, all the other research that I had been funded to carry out had to be suspended.
And we shifted our focus to the pandemic and to trying and trying to understand how this infection will affect people.
And did you have to get new funding for that to where you wanted the BHF, let you move your funding across?
Yes.
So we did apply for funding to the BRC and I assure Oxford, BRC, who supported us with some pilot funding to gather some pilot data on 50 subjects.
And then we applied for national funding,
which also which was also successful to study a large number of patients of 500 subjects with advanced MRI data.
And we're collaborating quite closely with another national follow up study called FOS COVID, which which are designed to study 10,000 patients,
but not to look at the multi-organ MRI scans,
but to collect all the other sort of quality of life and symptom data from people as they recover from COVID 19.
And this cost stands for post hospitalisation. COVID said yes, yes.
And so. So the patients you focussed on have all been ones who've been ill enough to be in hospital, is that right?
Yes. So the original hypothesis was that if you were ill enough to get into hospital,
that the disease was severe enough to potentially affect other organs,
whether it was directly from the virus infecting the organs or the immune response to the virus that was causing it.
So although we've learned now following the initial data that there are studies now out there that are
detecting abnormalities even in people who are recovering in the community who didn't end up in hospital.
And that's that's an interesting observation. And we're trying to understand why that is.
I mean, are you thinking of collecting that kind of data yourselves?
Yes. So we've started now also studying people who didn't get admitted to hospital, but recovered, recovered at home,
as we know that a proportion of these people continue to have ongoing symptoms, which we now know is called long COVID.
And actually the number of people who didn't get admitted to hospital is far greater than those who were admitted to hospital.
So so we're trying to understand whether the reason why they continue to have symptoms is because
of multiple organ involvement or whether there's something else that we can try and decipher.
So that's what we talked about, the studies we should talk about the findings.
This is, first of all, starting with the hospital patients. You had a big publication out for December or January.
Yeah, that's right. Yes, yes, yes. So what what were your findings in the in the hospitalised patients.
Yeah, this is really quite interesting. So we looked at a small number of patients but we,
we were quite careful in making sure that the that we compared them to people who had
similar co-morbid conditions or similar co-morbidities like diabetes and hypertension,
because we were concerned that MRI can be quite sensitive and even conditions like diabetes and hypertension can cause changes on the MRI,
which may not be related to COVID 19.
So we decided to study 58 patients who were discharged from hospital and who were about 2 to 3 months from their infection.
And alongside we also enrolled people who were not affected by COVID 19,
so had a negative PCR test and had no symptoms of COVID 19, but could also be in hospital.
So unfortunately we couldn't we couldn't study hospitalised patients because of
the risk that we would be exposing them to by asking them to come in to hospital.
So they were done at the time. Hospitalised patients from other conditions who had not had COVID 19 were were asked to go.
Home and stay in self-isolation. So it was it was very difficult to get, get, get people who are hospitalised but didn't have COVID 19.
So yeah, so we compared people who were recovering from COVID 19 after being admitted to hospital and controls,
and we found that a proportion had changes on the MRI scan to suggest that there might be inflammation of the organs.
And and in addition to this, you know, a significant proportion, two and three people had reported symptoms of persistent breathlessness,
fatigue, brain fog, the range of symptoms that we now know is long COVID with two out of three.
Two out of three. Yeah. So it is indeed high. And in fact,
this is an underestimation because we we excluded people with many comorbidities because we couldn't find controls with many comorbidities.
So we had to be.
So things like if they've had chronic lung disease like COPD, we didn't include them or, you know, previous myocardial infarction or heart attacks.
It wasn't easy for us to quickly find controls and non-covid subjects with multiple comorbidities.
So we were quite careful in trying to make sure that the that the two groups that we,
we were studying were similar in characteristics to come to some conclusion about whether these changes were related to COVID or not,
although I appreciate that that still has its limitations,
but I'll talk about it in a bit in the sense that it would be the most ideal
design would be having an MRI before the infection and then after the infection.
So see, so, so we found that a proportion had abnormalities in an MRI and two out of three had ongoing symptoms.
You know, most people could not walk for a long time on a six minute walk test.
And there were significant discrepancies and differences in exercise tolerance
between people who were recovering from COVID 19 and a control subjects.
And we also undertook cardiopulmonary exercise tests to see what could be contributing to the limited exercise tolerance.
So we found a mixture of pattern, like some people had lung problems that were limiting them, some people had heart problems that were limiting them.
And then there were others with just muscle deconditioning and muscle impairment.
So we we got a lot of information from that small group, but, you know,
carefully selected group of patients and have been following them up as well as expanding our numbers across the by recruiting people across the UK.
And has that come to publication yet. But they didn't find enough, so no.
So we are so that the national study is quite complex because it requires a lot of so so there
are a lot of stakeholders and there has to be a lot of approvals to then release the data.
We do have some preliminary data now which confirms or which is in line with early study.
So it's reassuring to see that even with small numbers we saw the signals and the findings are reproducible in a larger dataset.
But this is these are exciting times because we have we have now accumulated a lot of data.
And in an era of artificial intelligence and machine learning,
I suspect we we are going to have some really important and interesting insights from from this data,
which we probably wouldn't have seen 20 years ago.
So. Yes. So you said you've continued to follow up your original 50 patients.
Absolutely. Are you able to say whether they got better?
Yeah. So a proportion of people do get better and recover.
But about this, there's still about 50%.
So one and two that still continue to feel the effects of of COVID and have persistent symptoms.
And again, after after six months.
But I can tell you that we also have data now and that so the six month data has been published, but we also have data now from the 12 months.
And again, this number doesn't change much at all.
So being admitted to hospital seems to be quite an important risk factor for long-covid or ongoing symptoms.
And this is certainly being found by other investigators who are studying the after-effects of COVID 19.
One question I had just came up because I've been speaking to somebody else who is doing big
data study is whether you've been able to look at people who've been hospitalised with flu,
for example, with another serious respiratory disease that kills people.
Yeah. So I'm sure you might have been you might be aware from the media coverage of this,
the number of people getting admitted with the flu has declined dramatically because of social isolation and masking.
So we're not seeing as many cases and recruitment of such patients is actually quite challenging.
But we have data from retrospective health registries that suggest that despite looking or making comparisons with people recovering from the flu,
there appears to be an increased risk of a number of the co-morbid a number of conditions,
including cardiovascular abnormalities, as well as clots and strokes and people recovering from COVID 19,
but do see some effects of long term effects of flu.
So there are of course, there are people recovering from the flu.
But again, not not the majority or not a significant proportion.
People who get admitted to hospital with the flu in the literature in relation to
this does not suggest a significant number continuing to experience symptoms.
I must say, however, that Long-covid resembles other some other post-viral syndromes like glandular fever.
So Epstein-Barr virus infections, herpes virus infection.
So there are some other viruses that have been known to result in ongoing symptoms beyond the acute infection.
Oh, I keep thinking of experiments to do.
Has anybody looked at whether previous infection with transient fever has any effect on susceptibility to COVID or how seriously ill COVID is?
I'm sure they have, but unfortunately I haven't read the paper.
So because I have to say that these questions have been asked by people, and certainly not just to not just glandular fever,
even as cytomegalovirus, people seem to think that the response body's response to this virus may determine whether you have ongoing symptoms.
So these are all important questions that are that are being asked.
And and and I'm happy to look it up, but I don't have the answers to it at the moment.
So just returning for a moment to the case of people who were not hospitalised and may even had quite a mild infection and acute infection,
but have gone on to have very long term symptoms.
What do you what is the general picture at the moment?
I know this hasn't been a particular focus of your work, but presumably it's something that interests you.
Yes, almost certainly. So I think there is something in common between the community patients who carry on or who have
lingering symptoms and those who were hospitalised and who still have symptoms by 12 months.
It's highly unusual for someone to have had a viral infection and continue to have symptoms by 12 months from the infection.
That's not something you'd hear like a year after you've had the infection, you still feeling the same way.
So there's a lot that can be learned from the community patients.
And and I would say that at the moment it isn't quite clear as yet what is driving this in the community patients.
We have some we have done some research in the hospitalised patients that suggests an inflammatory signal that might be contributing to ongoing.
I mean, can you explain that? Sure. So in about one in 1000 patients that were admitted to hospital by a median of five months
from the time they were admitted with the infection and there were tests done on the
blood samples were collected from these patients and we detected certain chemicals or
cytokines which were shown to predict whether they'd continue to have symptoms by 12 months.
And there were some cytokines or chemicals that were that independently predicted and these were also quite important for inflammation.
So these are things that are produced during inflammatory response.
Exactly. Yes. So so this is now the caveat is that this is in a hospitalised cohort and this was at five months, so not 12 months.
So we do need to do more research, study what happens by 12 months.
From my work, I know that there is a natural history, there are longitudinal changes in the the way the body responds to the disease.
So over time the body's immune system.
Becomes clever and smart and it's responds to the infection or the damage does evolve and some people improve and some people not might stay the same.
So I think it's really important to get that time factor right and to understand how the immune system changes and responds to things over time.
And that's something that we're we're currently doing. Mm hmm.
So just turning to you a bit more. So you're clearly a very experienced cardiologist.
But in terms of research, you've only just done your PhD.
And this is quite a big, important study. Did you did that feel like a big step up for you?
Yes. Well, I mean, I had done research in in Australia as well, and I had a really strong mentor who gave me a lot of confidence.
And then, of course, I've got some really passionate mentors here as well to Professor Hugh Watkins and Professor Stefano Lebow,
who always made me feel like there is no limit like that.
You know, if you want to answer a question, you know, just go for it.
Do the research as long as is well-designed and, you know, and the sky is basically the limit.
So they've really empowered me and I've felt very blessed to be in this position, I have to say,
because I don't know many Indian girls or women who have just finished their Ph.D. and have been allowed to lead a multi-center study.
So it's easy. I do feel very privileged. Yeah.
And in terms of your the the demands of the job, I mean, has it meant the hours have been intense?
Absolutely, yes. So there have been many sleepless nights and I've worked every weekend.
But I think I feel like this is an incredible opportunity.
And I I'm sure if I live for another 20, 30 years, the average life expectancy of my family, 60.
So but I'm sure that if if I live long enough, I look back thinking I'm glad I did that.
You know, I'm I'm really glad I grabbed that opportunity and I went to help, you know, I contributed to that, to that, to understanding the disease.
I also feel like Long-covid, unfortunately, is now being classified or is is being treated very much like chronic fatigue syndrome.
And I feel like because doctors don't have any quick answers, they're quick to lose interest and to walk away.
And I'm not going to do that. I'm going to I'm going to find some answers.
So, I mean, I think we've done that in the past with chronic fatigue syndrome.
And I just think that it would be like, you know, I think it's it would be criminal to not recognise that we don't we need to find answers for this.
And Chronic Fatigue syndrome and some of the things I've read,
there's a sense that that's being reassessed now that absolutely nice has changed its guidelines.
Absolutely. To the idea that it's all in the head of the patients.
Yeah.
The thing is, that's the irony of it is the only at least this is my point of view, you know, could differ, you know, when you talk to other people.
But I think part of this has to do with doctors falling sick.
So when you have a colleague who has endured the same amount of training, who has endured the same amount of work as you have over the years,
and they they attest to the fact that they are still experiencing ongoing symptoms, then it becomes more real.
It's more close to you. And and people are willing to acknowledge it.
And that includes even children or, you know, children of doctors who are experiencing it.
So I think because of the scale of Long-covid and because of the fact that it's
now crept into the medical system and it has affected many health professionals,
the medical system is now paying some attention, but I can hear people turning their back and saying, we don't have answers and we can't solve this.
But I believe that we can and I think we will. So.
And have you personally or your family been affected by the disease?
So I've been I've had COVID myself twice despite being vaccinated.
And I endured the symptoms for two weeks and I cried two weeks, two weeks, and I cried.
Imagine the people who are living with these symptoms for 12 months or more.
I mean, like I said, I just think it's you know, I think we have to do more.
We just have to try and understand why they feel this way and listen to them rather than say, look, it's in the head.
It might be in the head, but why is it in the head? What's causing all this.
So, I mean, it's going to be a very difficult and difficult problem to resolve.
But it's not within our limits. It's not beyond our limits.
And I think we can. Yeah, we can find the answers to it.
Mm hmm. So were you involved at all in this building?
The university brought in safety measures across its whole estate.
Were you involved in discussions about what those should be or and how satisfied were you with the way they were implemented?
So in terms of the protection of the health of the site.
Sure. I mean, I think it's difficult to to criticise the health system because I think everything happened at such a tremendous fast scale.
But it would have been nice to have more PPE, which was which for which there was a shortage of PPE at the start of the pandemic.
It would have been nice if we had the vaccines in time.
There are so many things that it could have been could have been done better.
But overall, I think we did the best we could with the resources we had and the pressures that were imposed by, you know, by the pandemic.
And. I've been doing all this without looking at my questions and.
Oh, yes. This is just a particular focus that I didn't ask you about, but I think for completeness, we should include it also.
Yes, I've written down Seymour. So is that the study that you would study in reading?
Yes. So sorry. The study you're leading is called Desert that.
So that stands for capturing the multiorgan effects of COVID 19.
And that's a national study. It is a national study. And it and it's it it works alongside for COVID.
So we are providing the MRI phenotyping for patients who are enrolled in COVID.
But we also have we are also enrolling patients independent of Roscoe.
And you've done a small study of something called Xenon MRI.
Yes. A little bit about that. Sure.
So I'm not the chief investigator of that, Substudy, but I can tell you about that study as I've helped with those efforts.
So so the signal from the lungs on MRI is muted when you compare it to the signal from the other organs,
because the lung is made up of air sacs that contain oxygen and oxygen in general has a poor magnetic signal.
So so the scientists or MRI physicists have cleverly devised a way to magnetise a gas xenon and provide it to patients
to inhale for a few seconds and to map out the magnetised gas as it enters the lung and diffuses into the blood vessels.
So we know from a decade of research done by Professor Fergus Gleeson's lab what normal pattern looks like of xenon gas,
ventilating the lungs and diffusing a cross into the blood.
And we know what the pattern looks like in other diseases like asthma and COPD.
And so Professor Gleason wanted to see whether this technology would detect subclinical changes, which,
by the by the term subclinical, refer to people who have normal CAT scans, normal CT scans, normal X-rays.
Can this technology tell us more than these normal than these investigations that are currently used as part of the NHS?
So he wanted to study people with ongoing symptoms,
but with normal CT scans and chest x rays with with this technology to see whether it was more informative and indeed it is.
So what we can see is that are abnormalities in gas transfer in the lung,
which would suggest that there may be problems with the alveolar capillary interface.
So it's the the the part where the gas crosses the lung.
So where the oxygen should be going from your lungs?
Into your blood? Into your blood. Exactly. And the carbon dioxide back the other way.
Yes. And so that researches what was really quite like novel, like innovative and fascinating because, you know,
we have a lot of people who get told, oh, you know, your scans are normal, we can't find anything.
But here you have something that is actually testing and that's looking into gas transfer in the lungs and that is detecting abnormalities.
So. So Professor Gleason Gleason was funded or was awarded a national funding to carry on the work which we've been supporting.
That's Page. Yeah. Yeah, that's.
So have your results so far changed practice in the in the medical, you know, in the areas in which you work?
Yes. So it has certainly brought to light the the persistence of symptoms in hospitalised patients and the significant burden.
It has also raised questions about whether a people who are discharged from hospital
should be having MRI scans to see if they have lingering changes in the body.
So it has certainly led to a change in practice in some institutions who are performing MRI.
But I think this is an area of active research and it will evolve as we gather more data.
Hmm. And it's.
Yes. I got a question. I think you more or less answered it, but I'll just pose it as a single question.
Do you think the fact that you were able to work on something that was so relevant to understanding this condition, supported your own well-being?
As you know, everybody in the country was dealing with lockdown and uncertainty.
I mean, for me, I think it's just the constant uncertainty about where we're going with this.
That was the most difficult to deal with. But you had a you had a job to do.
Was that helpful for you, do you think? Absolutely, yes.
So I think the fact that the research was focussed on an aspect that everyone was enduring and the whole world was affected by this,
everything became interested in looking at the news, which I wasn't very good at reading.
You know, I'd keep myself updated with the news. I mean, I think it injected a a renewed enthusiasm for research.
And, yeah, I consider myself extremely fortunate in that way.
And has the Upwork raised new questions that you were interested in exploring in the future?
Yeah. If the time comes when you're ever able to move on from performance or even even with COVID 19,
because I mean, presumably these after effects could be detectable for years to come.
Absolutely. So there are many questions that have surfaced from this work.
But I think one of the things that really stood out for me,
as I've as I've carried out carried out this study is the importance of listening to patients.
So we've always undertaken research to explore mechanisms, scientific mechanisms that could contribute to disease.
And that is important. But I feel like we have been deaf in a way to the patient voice, and I think COVID really brought that out.
So we truly so treated bodies as machines. Absolutely.
Yes. And I think I think it's become increasingly clear that, you know, if you know and this is not just for COVID, for any disease, for that matter.
I mean, I can tell you, being a cardiologist, that we've had patients with the cardiomyopathy that I'm studying who get told,
look, your scans look fine, everything, and that something has changed, but they're still feeling quite poorly.
But what are we doing to understand that, like what is a cause for these ongoing symptoms?
And I think long COVID might help answer some of those questions and and has certainly
emphasised the need to think about the patient as a whole rather than a disease or an organ.
And that's pretty much answered the my final question,
which is whether the experience has changed your attitude or your approach to your work and how you'd like to see things change in the future.
But you did pretty much cover that. It's is anything you want to add?
No, I mean, I think I think I really do hope that it becomes important to have or essential to have a patient public engagement in a group.
You know, when we submit research proposals, because I think their voice just needs to be heard and,
you know, and we'll all be one of them at some point in our lives.
So it's important to remember that. That's great.
Okay. So I'm still talking to Betsy Roman.
And the question that I forgot to ask was, having collected masses of data about what the ongoing symptoms of these hospitalised patients looked like,
have you been able to start to look at treatments and the effects of treatments?
Yes. So so I think Long-covid is not just one disease, but it's a cluster of different diseases in a way.
So there are some people who have ongoing inflammation and they stop you for a second because your heart is.
Can you move the microphone down a bit with it? It's okay. I think it wants to go on the other side.
Oh does it. Yeah. So that you had a shot against.
Yeah. Okay. Yeah. Okay.
So, so yes we are testing treatments.
We so long COVID is in my mind not just one disease but a cluster of many phenotypes, of which there are some dominant markers of disease.
So one in particular is presence of ongoing inflammation in people.
So we're currently designing a trial where we're testing a medication that reduces the immune response in people
or suppresses the immune response in people who have an exaggerated response and who have ongoing COVID symptoms.
The other cluster that is apparent is is essentially people who continue to have limited mobility
or exercise tolerance because of profound fatigue and who are unable to do their daily activity.
And what we've found is that. These people have problems with the metabolism in their muscles.
So we're testing a treatment, which is a composition of branching amino acids to see whether that will help the mitochondria or the
energy levels in the skeletal muscle and whether this will translate into an improvement in fatigue.
And the third treatment that is currently under review or that we are thinking about is medicine that reduces obesity and that helps reduce weight,
because there have been a lot of studies shown that it does that are showing us that the more obese someone is,
the more likely they are to develop ongoing and persistent symptoms of COVID 19.
Those studies are all still ongoing. Yes. So two of the studies are yet to receive approval,
but that's something in the pipeline and one has received approval and we have already started screening patients for it.
But it's too soon to say what the results. But yes, that's right.
Yeah, it's too soon. Okay, that's fine. Thank you very much.