Epidemiological and clinical perspectives of long COVID syndrome

Modeling the potential public health and economic impact of COVID-19 vaccination strategies using an adapted vaccine in Peru

BACKGROUND

This study evaluated the impact of various vaccination strategies using an adapted vaccine in Peru.

RESEARCH DESIGN AND METHODS

Using a previously published combined Markov-decision-tree model adapted for Peru, this study estimated the outcomes of different vaccination strategies targeting various age and risk groups. The model used age-specific epidemiology, clinical, cost, and quality-of-life inputs derived from the published literature and national surveillance data. Sensitivity analyses were conducted to assess uncertainty.

RESULTS

The vaccination strategy targeting older adults aged ≥60 years and the high-risk population between 12 and 59 years old with a 24% vaccine uptake was estimated to prevent 78,483 symptomatic cases, 2,962 hospitalizations, 103 deaths, and 2,913 lost QALYs compared with no vaccination, translating to an incremental decrease of $12,856,654 in total direct costs and an incremental decrease of $35,090,748 in total societal costs. These gains were further increased by expanding vaccination to additional age groups and increasing vaccine uptake.

CONCLUSIONS

Vaccination in the population aged ≥60 years and the high-risk population between 12 and 59 years old in Peru was projected to yield substantial health and economic benefits. The impact could be substantially increased by expanding eligibility to younger age groups and increasing vaccine uptake.

Post-acute sequelae of COVID-19 in residents in long-term care homes: Examining symptoms and recovery over time

BACKGROUND

Post-COVID-19 condition (PCC) has been studied extensively since the inception of the COVID-19 pandemic. In the population of long-term care (LTC) home residents, however, information about PCC and recovery after the acute phase of COVID-19 is lacking. This study contributes evidence about symptoms over time in 459 residents in nine Canadian LTC homes.

METHODS

In a comprehensive retrospective chart review, we recorded medical symptoms in a 4-week period before contracting COVID-19 ("PRE-COVID") and during 24 weeks after contracting infection (a 4-week "ACUTE-COVID" period and five subsequent 4-week periods "POST1-5"). We investigated the number and type of symptoms over time, examined different "recovery trajectories", and compared the characteristics of residents across different trajectories.

RESULTS

In the sample overall, the number of different symptoms increased from PRE-COVID to ACUTE-COVID (mean difference of 3 symptoms, p<.001), returning to the PRE-COVID level within the first two months post-infection. An individual-level examination revealed that after ACUTE-COVID about a quarter of residents did not return to their symptom baseline. There was no statistically significant difference in demographic characteristics or PRE-COVID comorbidities across different recovery trajectories. Comparing the group of residents that did not return to their symptom baseline and the group that did, the risk for not returning to baseline increased with the number of symptoms in ACUTE-COVID (adjusted for age, sex, and PRE-COVID comorbidities, exp[B]=1.15, 95% CI [1.05;1.25], p=.002). Additionally, there was a greater increase in the number of symptoms from PRE-COVID to ACUTE-COVID in the former group (significant interaction effect, p<.001). We present symptom types in each time-period.

CONCLUSIONS

Group-level results indicated that the number of symptoms after contracting COVID-19 fell to the pre-COVID level within the first two months post-infection. An examination of individual-level symptom trajectories contributed a more granular picture of recovery after infection and characteristics of residents across different trajectories.

Use of Long COVID Clinics in the Veterans Health Administration: Implications for the path forward

Long COVID is a serious chronic illness that can present in many forms and impact daily functioning and quality of life. Without curative treatments, management of long COVID requires coordination and ongoing access to multidisciplinary care. Starting in 2020, the Veterans Health Administration (VHA), established a national network of Long COVID Clinics (LCCs). In this retrospective cohort study of 494 547 veterans with documented SARS-CoV-2 infection in the VHA from March 2020 to April 2022 (n = 494 547), we examined trends in ICD-10 U09.9 diagnosis code use for long COVID and LCC use in the VHA up to May 2024. Overall, 5.9% (n = 29 195) of patients in our cohort had a documented U09.9 code and 2% had at least 1 LCC visit. Among veterans with a U09.9 code, 17.4% (n = 5089) used LCCs. LCC use rates were low across all patient subgroups. LCCs were more available to veterans residing in the South census region (28% vs <7% use rate) than veterans in other regions. Developing evidence about LCC effectiveness and ensuring equitable access to LCCs within and beyond the VHA will be critical in meeting the evolving needs of people with long COVID.

Persistent IP-10/CXCL10 dysregulation following mild omicron breakthrough infection: Immune network signatures across COVID-19 waves and implications for mRNA vaccine outcomes

This study explores immune responses in mild Omicron-era COVID-19 breakthrough cases, focusing on cytokine dysregulation, antibody dynamics, and Long COVID. Samples from 114 mild COVID-19 patients across multiple waves were analyzed at three timepoints (T1: 2-4 weeks, T2: 3-4 months, T3: 6-8 months post-infection). Persistent IP-10 elevation up to 8 months suggests prolonged low-grade immune activation. Hybrid immunity from Omicron breakthrough infections provided broad cross-variant antibody recognition but showed declining neutralization over time. Among vaccination regimens, mRNA-inclusive combinations were associated with lower Long COVID scores. CoV-229E antibody levels correlated with Long COVID scores. These findings underscore the need for extended monitoring of mild COVID-19 cases and highlight the potential of mRNA vaccines in reducing post-COVID-19 complications. Insights into immune alterations and vaccine effects can inform the development of future vaccination strategies and approaches for managing post-COVID-19 conditions.

COVID-19 and the impact of physical activity on persistent symptoms

Introduction

Physical activity is protective against chronic disease but whether activity is associated with persistent symptoms in non-hospitalized coronavirus disease 2019 (COVID-19) survivors is unknown. The purpose of the study was to determine the impact of the COVID-19 pandemic on physical activity levels and the influence of physical activity on acute COVID-19 and long COVID symptoms in non-hospitalized COVID-19 survivors.

Methods

In total, 64 non-hospitalized COVID-19 survivors (45 female participants, 40 ± 18 years) were assessed for activity levels, body composition, and symptoms of COVID-19 8.5 ± 4.7 months post-infection and categorized into two groups: (1) persistent symptoms and (2) no symptoms at the time of testing. Furthermore, 43 of the 64 participants (28 female participants, 46 ± 18 years) completed a follow-up questionnaire online 51.0 ± 39.7 months (4.25 years) post-infection. A subset of 22 COVID-19 survivors (16 female participants, 35 ± 16 years) were matched for age, sex, and body mass index with healthy controls. Physical activity was quantified using (1) self-reported questionnaire (International Physical Activity Questionnaire; IPAQ-SF) at three time periods; prior to COVID-19 infection, at the time of laboratory testing (8.5 ± 4.7 months after infection), and during an online follow-up (51.0 ± 39.7 months, i.e., 4.25 years after infection); and (2) 7 days of wearing an ActiGraph accelerometer following laboratory testing.

Results

Physical activity (IPAQ-SF) declined in COVID-19 survivors from pre-COVID-19 infection to 8.5 ± 4.7 months after infection [3,656 vs. 2,656 metabolic equivalent of task (MET) min/week, 27% decrease, p < 0.001, n = 64] and rebounded to levels similar to pre-COVID-19 infection at 4.25 years after infection (p = 0.068, n = 43). Activity levels quantified with accelerometry did not differ between COVID-19 survivors and controls. However, COVID-19 survivors who reported persistent symptoms 8.5 months after infection (n = 29) engaged in less moderate-vigorous physical activity and steps/day than those without persistent symptoms (n = 27) (37 vs. 49 MET min/day, p = 0.014 and 7,915 vs. 9,540 steps/day, p = 0.014).

Discussion

Both COVID-19 survivors and matched controls reported reductions in physical activity indicating that lower levels of activity were likely due to the pandemic rather than COVID-19 infection alone. However, those who were most affected by COVID-19 infection with persistent symptoms had the greatest reductions in physical activity, even at ∼8 months and ∼4 years post-infection.

Role of nutrient supplements in children with post-COVID condition: a retrospective preliminary observation and narrative review

BACKGROUND

Post-COVID Condition (PCC), emerging as a significant long-term consequence of SARS-CoV-2 infection, affects not only adults but also the pediatric population. Despite ongoing research, the precise pathophysiology of PCC remains elusive. However, several putative mechanisms have been identified, leading to the exploration of various therapeutic strategies. Notably, in the adult population, there has been substantial interest in the potential efficacy of nutritional supplements. Regrettably, information regarding the use of such supplements in the pediatric population is currently lacking.

METHODS

The present study was conducted to assess the impact of nutritional supplements on alleviating long COVID symptoms in children. To achieve this, we conducted a retrospective analysis of nutrient supplements administered by parents to children with Post-COVID Condition (PCC) between February 2020 and October 2022. Statistical analyses were employed to determine associations between categorical variables.

RESULTS

A total of 1243 children were enrolled following documented SARS-CoV-2 infection, with 940 (76.2%) diagnosed as recovered and 294 (23.8%) diagnosed with Long COVID. Among Long COVID patients experiencing disabling symptoms, treatment with oral lactoferrin and/or a Multi-Element Product (MEP) with antioxidant and anti-inflammatory properties was initiated. The correlation analysis between the use of supplements and persistence of long COVID at the next follow-up showed that the use of MEP alone (OR 5.7, 95% CI 3.8-8.5), or the combination of MEP and lactoferrin (OR 5.06, 95% CI 3.3-7.6) three months after the initial infection and for the following three months, were associated with a lower risk having long covid at six months following initial infection, when compared with the use of lactoferrin alone (OR 7.6 95% CI 5.1-11.4).

CONCLUSIONS

This proof-of-concept study revealed that MEP and lactoferrin, when administered three months after initial infection in patients with a new diagnosis of long covid, may have a positive impact on improving Long COVID symptoms in children during follow-up evaluations. This positive trend toward reducing Post-COVID Condition (PCC) exhibited by MEP and lactoferrin suggested a potential benefit worthy of exploration in future randomized controlled trials.

Pediatric Long COVID Subphenotypes: An EHR-based study from the RECOVER program

Pediatric Long COVID has been associated with a wide variety of symptoms, conditions, and organ systems, but distinct clinical presentations, or subphenotypes, are still being elucidated. In this exploratory analysis, we identified a cohort of pediatric (age <21) patients with evidence of Long COVID and no pre-existing complex chronic conditions using electronic health record data from 38 institutions and used an unsupervised machine learning-based approach to identify subphenotypes. Our method, an extension of the Phe2Vec algorithm, uses tens of thousands of clinical concepts from multiple domains to represent patients' clinical histories to then identify groups of patients with similar presentations. The results indicate that cardiorespiratory presentations are most common (present in 54% of patients) followed by subphenotypes marked (in decreasing order of frequency) by musculoskeletal pain, neuropsychiatric conditions, gastrointestinal symptoms, headache, and fatigue.

SIRT1: A likely key for future therapeutic strategies for pain management

Sirtuin 1 (SIRT1), a NAD+ -dependent histone deacetylase, plays a crucial role in mitigating oxidative stress, regulating inflammation, and maintaining mitochondrial function. Reduced SIRT1 activity has been linked to elevated pro-inflammatory cytokines, mitochondrial dysfunction, and chronic pain, all of which are observed in long COVID pathology. Emerging evidence identifies mitochondrial dysfunction and oxidative stress as central contributors to these symptoms. Increases reactive oxygen species (ROS) such as superoxide, nitric oxide, and peroxynitrite, leading to oxidative damage, chronic inflammation, and central/peripheral sensitization. Nutraceuticals, particularly the polyphenolic fraction of bergamot (BPF), have demonstrated potent antioxidant, anti-inflammatory, and antiviral properties. This study highlights BPF's ability to modulate SIRT1 activity in a rat model of inflammation and hyperalgesia. It provides novel evidence of SIRT1 nitration within the nucleus as a key event in inflammatory pain pathogenesis. BPF administration preserved SIRT1 activity, reduced oxidative stress markers such as malondialdehyde (MDA) and 8-hydroxydeoxyguanosine (8-OHdG), and minimized post-translational modifications of nuclear proteins, including nitration, acetylation, and carbonylation. Additionally, it alleviated hyperalgesia and allodynia. These findings underscore the therapeutic potential of polyphenols like BPF in reducing oxidative stress and inflammation-driven pain. By activating SIRT1, BPF may provide relief for pain conditions. Further research on SIRT1-targeted therapies is essential to combat inflammation and oxidative stress, preventing chronic conditions and enhancing treatment options.

Identification of an immunological signature of long COVID syndrome

Introduction

Acute COVID-19 infection causes significant alterations in the innate and adaptive immune systems. While most individuals recover naturally, some develop long COVID (LC) syndrome, marked by persistent or new symptoms weeks to months after SARS-CoV-2 infection. Despite its prevalence, there are no clinical tests to distinguish LC patients from those fully recovered. Understanding the immunological basis of LC is essential for improving diagnostic and treatment approaches.

Methods

We performed deep immunophenotyping and functional assays to examine the immunological profiles of LC patients, individuals with active COVID-19, recovered patients, and healthy donors. This analysis assessed both innate and adaptive immune features, identifying potential biomarkers for LC syndrome. A Binomial Generalized Linear Model (BGLM) was used to pinpoint immune features characterizing LC.

Results

COVID-19 patients exhibited depletion of innate immune cell subsets, including plasmacytoid and conventional dendritic cells, classical, non-classical, and intermediate monocytes, and monocyte-derived inflammatory dendritic cells. Elevated basal inflammation was observed in COVID-19 patients compared to LC patients, whose immune profiles were closer to those of healthy donors and recovered individuals. However, LC patients displayed persistent immune alterations, including reduced T cell subsets (CD4, CD8, Tregs) and switched memory B cells, similar to COVID-19 patients. Through BGLM, a unique adaptive immune signature for LC was identified, featuring memory CD8 and gd T cells with low proliferative capacity and diminished expression of activation and homing receptors.

Discussion

The findings highlight a unique immunological signature associated with LC syndrome, characterized by persistent adaptive immune dysregulation. While LC patients displayed recovery in innate immune profiles comparable to healthy and Recovered individuals, deficits in T cell and memory B cell populations were evident, differentiating LC from full recovery. These findings provide insights into LC pathogenesis and may support the development of diagnostic tools and targeted therapies.

COVID-19 beyond the lungs: Unraveling its vascular impact and cardiovascular complications-mechanisms and therapeutic implications

COVID-19, caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), is primarily a respiratory illness but significantly affects the cardiovascular system as well. After entering the body through the respiratory tract, the virus directly and indirectly disrupts the vascular system. Vascular endothelial cells (ECs), which express ACE2 and TMPRSS2, are targets for viral invasion. However, the predominant cause of widespread vascular damage is the "cytokine storm" induced by the immune response. This leads to EC activation, inflammation, neutrophil activation, and neutrophil-platelet aggregation, causing endothelial injury. Additionally, increased expression of plasminogen activator inhibitor-1 disrupts the balance between prothrombotic and fibrinolytic processes, while activation of the renin-angiotensin-aldosterone system adds oxidative stress to the vascular endothelium. In the heart, SARS-CoV-2 invades ECs, leading to apoptosis and pyroptosis, exacerbated by inflammation and elevated catecholamines. These factors contribute to arrhythmias, strokes, and myocardial infarction in severe cases of COVID-19. This narrative review aims to explore the mechanisms by which SARS-CoV-2 affects the cardiovascular system and to highlight the resulting complications. It also identifies research gaps and discusses potential therapeutic strategies to mitigate the cardiovascular impacts of COVID-19.

Vagal nerve stimulation for the management of long COVID symptoms

This review investigates the therapeutic potential of vagal nerve stimulation (VNS) in managing long COVID, a condition marked by persistent symptoms following acute SARS-CoV-2 infection. Long COVID manifests as ongoing fatigue, cognitive impairment, and autonomic dysfunction, hypothesized to arise from sustained inflammatory and neurological dysregulation. The vagus nerve, central to modulating systemic inflammation and autonomic homeostasis, represents a promising therapeutic target for symptom alleviation through VNS. A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science to identify studies evaluating VNS in the context of long COVID. Preliminary evidence from small-scale pilot studies suggests VNS may attenuate systemic inflammation through activation of the cholinergic anti-inflammatory pathway (CAP), thus restoring autonomic balance and ameliorating symptoms such as fatigue, cognitive dysfunction, and anxiety. In targeting the inflammatory cascade that underlies both acute COVID-19 pathophysiology and its prolonged sequelae, VNS holds potential as an innovative intervention for persistent post-viral symptoms. While these initial findings indicate promise, current data remain limited in scope and robustness, underscoring the need for larger, controlled trials to validate the efficacy and mechanisms of VNS in long COVID management. Establishing a clearer understanding of VNS's impact on inflammation and autonomic regulation in this context is crucial to inform clinical guidelines and therapeutic strategies for long COVID, potentially offering a targeted approach for mitigating this disabling condition.

Perceptions of Long COVID Patients Regarding Health Assistance: Insights from a Qualitative Study in Spain

OBJECTIVE

This study investigates the perceptions of Long COVID patients in Spain regarding the healthcare they receive to identify demands and areas for improvement.

METHODS

Using a qualitative descriptive phenomenological approach, the study included 27 participants selected through non-probabilistic convenience sampling. Data were collected via online semi-structured interviews and analyzed using thematic analysis.

RESULTS

The findings reveal three key themes: (i) health status and challenges in healthcare during the initial COVID-19 infection; (ii) perceptions about healthcare as Long COVID patients; and (iii) demand for and aspects of improving quality of healthcare. The participants, predominantly women (66.67%) with a median age of 51 years, experienced symptoms that they generally perceived as severe, although only 14.81% required hospitalization. The participants reported initial self-management of symptoms at home, which was influenced by familial responsibilities and hospital overcrowding, and the persistence of a wide range of Long COVID symptoms that significantly impacted their daily lives. Satisfaction with healthcare services varied, with frustrations over systemic inefficiencies and long waiting times.

CONCLUSIONS

The study highlights the need for timely access to medical care, comprehensive and empathetic healthcare services, and specialized Long COVID units. The results emphasize the importance of patient-centered approaches and multidisciplinary care to address the complex nature of Long COVID effectively. These findings provide crucial insights for improving healthcare protocols and systems to better support Long COVID patients. This study was prospectively registered with the Ethics Committee for Research on Medicines of the Albacete Integrated Health Care Management System (registry) on 22 February 2022 with registration number 2022/001.

Effects of sulphur thermal water inhalations in long-COVID syndrome: Spa-centred, double-blinded, randomised case-control pilot study

BACKGROUND

The long-COVID syndrome is characterised by a plethora of symptoms. Given its social and economic impact, many studies have stressed the urgency of proposing innovative strategies other than hospital settings. In this double-blinded, randomised, case-control trial, we investigate the effects of sulphur thermal water inhalations, rich in H2S, compared to distilled water inhalations on symptoms, inflammatory markers and nasal microbiome in long-COVID patients.

METHODS

About 30 outpatients aged 18-75 with positive diagnosis for long-COVID were randomised in two groups undergoing 12 consecutive days of inhalations. The active group (STW) received sulphur thermal water inhalations whereas the placebo group received inhalations of sterile distilled non-pyrogenic water (SDW). Each participant was tested prior treatment at day 1 (T0), after the inhalations at day 14 (T1) and at 3 months follow-up (T2). At each time point, blood tests, nasal swabs for microbiome sampling, pulmonary functionality tests (PFTs) and pro-inflammatory marker measure were performed.

RESULTS

The scores obtained in the administered tests (6MWT, Borg score and SGRQ) at T0 showed a significant variation in the STW group, at T1 and T2. Serum cytokine levels and other inflammatory biomarkers reported a statistically significant decrease. Some specific parameters of PFTs showed ameliorations in the STW group only. Changes in the STW nasopharyngeal microbiota composition were noticed, especially from T0 to T2.

CONCLUSIONS

Inhalations of sulphur thermal water exerted objective and subjective improvements on participants affected by long-COVID. Significant reduction of inflammatory markers, dyspnoea scores and quantitative and qualitative changes in the nasopharyngeal microbiome were also assessed.

Investigating the FLiRT variants of COVID-19: Is it an emerging concern?

The ongoing COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to multiple waves of infections globally. As the virus continues to evolve, new variants have emerged, some with concerning changes in transmissibility and virulence. Among these variants, the "FLiRT Variants" have recently gained attention due to their potential to alter the dynamics of transmission and disease severity. According to the Infectious Disease Society of America, the nickname 'FLiRT' is based on the technical names for their mutations. The FLiRT variants, particularly KP.2, seem to exhibit heightened transmissibility in comparison to earlier Omicron sub-variants. Additionally, they demonstrate a capacity to evade immunity conferred by prior infection and vaccines, although the full extent of this evasion is still being investigated. In this article, we review the characteristics of the FLiRT variants, including their genetic mutations, epidemiological features, potential impact on public health measures, and implications for vaccine efficacy. We also discuss strategies for surveillance, prevention, and mitigation efforts to control the spread of this variant and mitigate its impact on global health.

SARS-CoV-2 S1 subunit produces a protracted priming of the neuroinflammatory, physiological, and behavioral responses to a remote immune challenge: A role for corticosteroids

Long COVID is a major public health consequence of COVID-19 and is characterized by multiple neurological and neuropsychatric symptoms. SARS-CoV-2 antigens (e.g., spike S1 subunit) are found in the circulation of Long COVID patients, have been detected in post-mortem brain of COVID patients, and exhibit neuroinflammatory properties. Considering recent observations of chronic neuroinflammation in Long COVID patients, the present study explores the idea that antigens derived from SARS-CoV-2 might produce a long-term priming or sensitization of neuroinflammatory processes, thereby potentiating the magnitude and/or duration of the neuroinflammatory response to future inflammatory insults. Rats were administered S1 or vehicle intra-cisterna magna and 7d later challenged with vehicle or LPS. The neuroinflammatory, physiological, and behavioral responses to LPS were measured at various time points post-LPS. We found that prior S1 treatment potentiated many of these responses to LPS suggesting that S1 produces a protracted priming of these processes. Further, S1 produced a protracted reduction in basal brain corticosteroids. Considering the anti-inflammatory properties of corticosteroids, these findings suggest that S1 might disinhibit innate immune processes in brain by reducing anti-inflammatory drive, thereby priming neuroinflammatory processes. Given that hypocortisolism is observed in Long COVID, we propose that similar S1-induced innate immune priming processes might play role in the pathophysiology of Long COVID.

Post-COVID-19 condition symptoms among emergency department patients tested for SARS-CoV-2 infection

Symptoms of the Post-COVID-19 Condition are often non-specific making it a challenge to distinguish them from symptoms due to other medical conditions. In this study, we compare the proportion of emergency department patients who developed symptoms consistent with the World Health Organization's Post-COVID-19 Condition clinical case definition between those who tested positive for Severe Acute Respiratory Syndrome Coronavirus-2 infection and time-matched patients who tested negative. Our results show that over one-third of emergency department patients with a proven acute infection meet Post-COVID-19 Condition criteria 3 months post-index visit. However, one in five test-negative patients who claim never having been infected also report symptoms consistent with Post-COVID-19 Condition highlighting the lack of specificity of the clinical case definition. Testing for SARS-CoV-2 during the acute phase of a suspected infection should continue until specific biomarkers of Post-COVID-19 Condition become available for diagnosis and treatment.

Pediatric Long COVID Subphenotypes: An EHR-based study from the RECOVER program

Pediatric Long COVID has been associated with a wide variety of symptoms, conditions, and organ systems, but distinct clinical presentations, or subphenotypes, are still being elucidated. In this exploratory analysis, we identified a cohort of pediatric (age <21) patients with evidence of Long COVID and no pre-existing complex chronic conditions using electronic health record data from 38 institutions and used an unsupervised machine learning-based approach to identify subphenotypes. Our method, an extension of the Phe2Vec algorithm, uses tens of thousands of clinical concepts from multiple domains to represent patients' clinical histories to then identify groups of patients with similar presentations. The results indicate that cardiorespiratory presentations are most common (present in 54% of patients) followed by subphenotypes marked (in decreasing order of frequency) by musculoskeletal pain, neuropsychiatric conditions, gastrointestinal symptoms, headache, and fatigue.

Association of physical symptoms with accelerometer-measured movement behaviors and functional capacity in individuals with Long COVID

Long COVID has been linked to a decline in physical activity and functional capacity. However, it remains unclear which physical symptoms are associated with specific aspects of movement behaviors and functional capacity. We aimed to investigate the associations of fatigue, dyspnea, post-exertional malaise, myalgia, and the co-occurrence of symptoms with movement behaviors and functional capacity in individuals with Long COVID. A cross-sectional multicenter study was conducted. Questionnaires were used to assess fatigue, dyspnea, post-exertional malaise, and myalgia. Accelerometry was employed to assess sedentary time, steps per day, light physical activity, and moderate-to-vigorous physical activity. The six-minute walk test, 30-s chair stand test, and timed up and go were used to assess functional capacity. One hundred and two community-dwelling individuals who had been living with Long COVID for 15 ± 10 months participated in the study. Fatigue, post-exertional malaise, and the co-occurrence of physical symptoms showed a negative association with step count, while post-exertional malaise was also negatively associated with moderate-to-vigorous physical activity. Dyspnea showed a negative association with the functional score, including all tests. Our findings suggest that fatigue, post-exertional malaise, and the co-occurrence of physical symptoms are negatively associated with physical activity, while dyspnea is negatively associated with functional capacity in individuals with Long COVID.

Long COVID Syndrome: A Narrative Review on Burden of Age and Vaccination

Background/Objective: The COVID-19 pandemic has led to the emergence of post-acute COVID-19 syndrome, also known as long COVID, which presents a significant challenge due to its varied symptoms and unpredictable course, particularly in older adults. Similar to COVID-19 infections, factors such as age, pre-existing health conditions, and vaccination status may influence the occurrence and severity of long COVID. The objective is to analyze the role of aging in the context of long COVID and to investigate prevalence rates and vaccination efficacy to improve prevention strategies and treatment in this age group. Methods: Four researchers independently conducted a literature search of the PubMed database to trace studies published between July 2020 and July 2024. Results: Aging influences both the likelihood of developing long COVID and the recovery process, due to age-related physiological changes, immune system alterations, and the presence of comorbidities. Vaccination plays a key role in reducing the risk of long COVID by attenuating the inflammatory responses associated with its symptoms. Conclusions: Despite the protection vaccines offer against severe infection, hospitalization, and post-infection sequelae, vaccine hesitancy remains a major obstacle, worsening the impact of long COVID. Promising treatments for this condition include antivirals although further research is needed.

Clinical Spectrum of Long COVID: Effects on Female Reproductive Health

The COVID-19 pandemic caused by SARS-CoV-2 has presented numerous health challenges, including long-term COVID, which affects female reproductive health. This review consolidates the current research on the impact of SARS-CoV-2 on the menstrual cycle, ovarian function, fertility, and overall gynecological health. This study emphasizes the role of angiotensin-converting enzyme receptors in viral entry and the subsequent tissue-specific pathological effects. It also explores the potential influence of long COVID on hormonal balance and immune responses, contributing to menstrual irregularities and impaired ovarian function. The findings indicate a higher prevalence of long-term COVID-19 among women, highlighting the substantial implications for reproductive health and the need for sex-sensitive longitudinal studies. Enhanced surveillance and targeted research are essential to develop effective interventions that prioritize women's reproductive well-being following SARS-CoV-2 infection. This review advocates for a sex-informed approach to ongoing COVID-19 research and healthcare strategies, aiming to provide up-to-date and pertinent data for healthcare providers and the general public, ultimately improving outcomes for females affected by long COVID.

Intervention modalities for brain fog caused by long-COVID: systematic review of the literature

Individuals suffering from long-COVID can present with "brain fog", which is characterized by a range of cognitive impairments, such as confusion, short-term memory loss, and difficulty concentrating. To date, several potential interventions for brain fog have been considered. Notably, no systematic review has comprehensively discussed the impact of each intervention type on brain fog symptoms. We included studies on adult (aged > 18 years) individuals with proven long- COVID brain-fog symptoms from PubMed, MEDLINE, Central, Scopus, and Embase. A search limit was set for articles published between 01/2020 and 31/12/2023. We excluded studies lacking an objective assessment of brain fog symptoms and patients with preexisting neurological diseases that affected cognition before COVID-19 infection. This review provided relevant information from 17 studies. The rehabilitation studies utilized diverse approaches, leading to a range of outcomes in terms of the effectiveness of the interventions. Six studies described noninvasive brain stimulation, and all showed improvement in cognitive ability. Three studies described hyperbaric oxygen therapy, all of which showed improvements in cognitive assessment tests and brain perfusion. Two studies showed that the use of Palmitoylethanolamide and Luteolin (PEA-LUT) improved cognitive impairment. Noninvasive brain stimulation and hyperbaric oxygen therapy showed promising results in the treatment of brain fog symptoms caused by long-COVID, with improved perfusion and cortical excitability. Furthermore, both rehabilitation strategies and PEA-LUT administration have been associated with improvements in symptoms of brain fog. Future studies should explore combinations of interventions and include longer follow-up periods to assess the long-term effects of these treatments.

Exploring the Pathophysiology of Long COVID: The Central Role of Low-Grade Inflammation and Multisystem Involvement

Long COVID (LC), also referred to as Post COVID-19 Condition, Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), and other terms, represents a complex multisystem disease persisting after the acute phase of COVID-19. Characterized by a myriad of symptoms across different organ systems, LC presents significant diagnostic and management challenges. Central to the disorder is the role of low-grade inflammation, a non-classical inflammatory response that contributes to the chronicity and diversity of symptoms observed. This review explores the pathophysiological underpinnings of LC, emphasizing the importance of low-grade inflammation as a core component. By delineating the pathogenetic relationships and clinical manifestations of LC, this article highlights the necessity for an integrated approach that employs both personalized medicine and standardized protocols aimed at mitigating long-term consequences. The insights gained not only enhance our understanding of LC but also inform the development of therapeutic strategies that could be applicable to other chronic conditions with similar pathophysiological features.

Postinfectious conditions challenge disease-specificity of SNOT-22

PURPOSE

The Sino-Nasal-Outcome-Test 22 (SNOT-22) questionnaire assesses treatment outcome and health-related quality of life (HRQOL) in patients with chronic rhinosinusitis (CRS). However, given the overlap between CRS and olfaction in terms of nasal function and the definition of CRS, a fundamental question arises: can patients with olfactory dysfunction (OD) stemming from other causes attain SNOT-22 scores similar to those seen in CRS, even in the absence of CRS? Our study aimed to explore whether OD arising from various postinfectious mechanisms challenges the disease-specificity of SNOT-22 for CRS. If so, could focus on scores within specific symptom domains of SNOT-22 prove valuable in distinguishing between different etiologies.

METHODS

The study adopted an observational, retrospective cohort design based on prospectively registered patients and related variables using the REDCap platform. 460 patients experiencing OD due to either (1) simple or (2) complex post-COVID-19, (3) postinfectious non-COVID-19, and (4) CRS, were included in the analysis.

RESULTS

The study revealed that the total SNOT-22 score lacks disease-specificity for CRS. This is evident, because complex postinfectious mechanisms resulting from COVID-19 can produce similar symptoms in patients. Notably, elevated total scores were primarily driven by high subdomain scores within the "sleep and cognition" domain.

CONCLUSIONS

The application of SNOT-22 as a screening tool needs to be approached with caution, as the total score alone does not provide disease-specific insights. A more thorough exploration of the four symptom domains and the identification of distinctive scoring patterns within the clinical context may prove pivotal in effectively differentiating between various underlying causes.

Long-Term Effects of COVID-19: The Stories of 2 Physicians Who Became Patients

Approximately 10% of patients who survive COVID-19 will proceed to have lasting, often debilitating effects, known as "long COVID." These symptoms can take various forms, most commonly including postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, heart palpitations, diminished sexual desire or capacity, loss of smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Here, 2 physician-patients present their own experiences with long COVID and share their perspectives on the experience. One key insight is that patients who are not familiar with long COVID may not attribute ongoing symptoms to their illness. Diagnosis requires an astute, compassionate physician who understands long COVID and can appropriately situate the symptoms within the evolving understanding of the condition, leading the patient toward recovery.

Impaired Hand Grip Strength Correlates with Greater Disability and Symptom Severity in Post-COVID Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Background: Post-COVID syndrome (PCS) encompasses a diverse array of symptoms persisting beyond 3 months after acute SARS-CoV-2 infection, with mental as well as physical fatigue being the most frequent manifestations. Methods: In 144 female patients with PCS, hand grip strength (HGS) parameters were assessed as an objective measure of muscle fatigue, with 78 meeting the Canadian Consensus Criteria for postinfectious myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). The severity of disability and key symptoms was evaluated using self-reported questionnaires. Results: Patients with ME/CFS exhibited heightened overall symptom severity, including lower physical function (p < 0.001), a greater degree of disability (p < 0.001), more severe fatigue (p < 0.001), postexertional malaise (p < 0.001), and autonomic dysfunction (p = 0.004) compared to other patients with PCS. While HGS was impaired similarly in all patients with PCS and exhibited a significant correlation with physical function across the entire patient group, HGS of patients with ME/CFS uniquely demonstrated associations with key symptoms. Conclusions: Thus, impaired HGS serves as an objective marker of physical function in patients with PCS. Only in patients meeting ME/CFS criteria is impaired HGS also associated with the severity of hallmark symptoms. This suggests a common mechanism for muscle fatigue and other symptoms in the ME/CFS subtype, distinct from that in other types of PCS.

A Comparative Analysis of Liver Injury Markers in Post-COVID Syndrome among Elderly Patients: A Prospective Study

BACKGROUND

In the wake of the global COVID-19 pandemic, understanding its prolonged impact on vulnerable populations has become a critical area of investigation. This study aimed to elucidate the distinctive post-acute sequelae of SARS-CoV-2 infection (PASC) and liver injury in Romania's elderly population, hypothesizing unique demographic, clinical, and healthcare factors influencing the manifestation.

METHODS

A longitudinal design was employed, enrolling COVID-19 patients from the Victor Babes Hospital for Infectious Diseases and Pulmonology in Timisoara, Romania. Participants were stratified into three groups based on age and Long COVID status. The study focused on a variety of demographic, clinical, and biological parameters, including liver function tests, to assess the trajectory and severity of liver injury over six months post discharge.

RESULTS

Involving 238 participants, the study revealed a significant increase in the duration of hospitalization for those over 65 (15.8 ± 8.2 days) compared to younger groups (p < 0.001). Notably, elderly Long COVID patients exhibited a marked elevation in liver enzymes post discharge, with median ΔALT and ΔAST of 24.1 U/L and 30.2 U/L, respectively, suggesting ongoing liver injury (p < 0.001). Significant metabolic disruptions were observed, with the ΔFasting glucose showing a substantial median decrease of 21.1 mmol/L in the elderly group (p < 0.001). A pronounced reduction in ΔGGT (16.7 U/L) and ΔLDH (48.7 U/L) was noted, indicating a recovery in liver function and reduced tissue damage (p < 0.001). Coagulation profiles and liver fibrosis risk scores, particularly ΔFIB-4 and ΔAPRI, also significantly improved post discharge, indicating a reduced risk of ongoing liver complications.

CONCLUSION

This study confirms the hypothesis of more severe PASC and liver injury among the elderly Romanian population. Significant improvements post discharge suggest a degree of recovery, yet the persistent alterations in liver enzymes, glucose metabolism, and fibrosis risk scores call for continued monitoring and tailored management strategies.

Postmortem Minimally Invasive Autopsy in Critically Ill COVID-19 Patients at the Bedside: A Proof-of-Concept Study at the ICU

BACKGROUND

Economic restrictions and workforce cuts have continually challenged conventional autopsies. Recently, the COVID-19 pandemic has added tissue quality and safety requirements to the investigation of this disease, thereby launching efforts to upgrade autopsy strategies.

METHODS

In this proof-of-concept study, we performed bedside ultrasound-guided minimally invasive autopsy (US-MIA) in the ICU of critically ill COVID-19 patients using a structured protocol to obtain non-autolyzed tissue. Biopsies were assessed for their quality (vitality) and length of biopsy (mm) and for diagnosis. The efficiency of the procedure was monitored in five cases by recording the time of each step and safety issues by swabbing personal protective equipment and devices for viral contamination.

FINDINGS

Ultrasound examination and tissue procurement required a mean time period of 13 min and 54 min, respectively. A total of 318 multiorgan biopsies were obtained from five patients. Quality and vitality standards were fulfilled, which not only allowed for specific histopathological diagnosis but also the reliable detection of SARS-CoV-2 virions in unexpected organs using electronic microscopy and RNA-expressing techniques.

INTERPRETATION

Bedside multidisciplinary US-MIA allows for the fast and efficient acquisition of autolytic-free tissue and offers unappreciated potential to overcome the limitations of research in postmortem studies.

Persisting Gastrointestinal Symptoms in Children with SARS-CoV-2: Temporal Evolution over 18 Months and Possible Role of Lactoferrin

BACKGROUND AND AIM

Persisting gastrointestinal symptoms are reported to be relatively common in children with long COVID; however, their detailed characterization and long-term outcomes have not yet been described.

METHODS

We performed a retrospective study aiming to investigate the temporal evolution of gastrointestinal symptoms in children with SARS-CoV-2, from acute infection to 18-months follow-up. To further investigate possible therapeutic strategies, we evaluated the role of lactoferrin in improving gastrointestinal symptoms in these children, compared with those not treated.

RESULTS

A total of 1224 patients (47.7% females) were included. Of these participants, 246 (19.8%) were vaccinated and 143 (11.5%) presented with comorbidities. A total of 175 patients (14.1%) presented gastrointestinal symptoms during acute infection, 54 (4.4%) at three months, 23 (1.9%) at six months, 6 (3.3%) at twelve months, and 2 (2.3%) at eighteen months follow-up. At six months follow-up, children who were treated with 3 months oral lactoferrin had less persisting symptoms compared to those who did not receive lactoferrin, although this difference was not statistically significant (three patients (25%) in the lactoferrin group vs. fourteen patients (33.3%) not treated, p = 0.73), probably due to the low number of patients with persisting GI symptoms.

CONCLUSIONS

GI symptoms are relatively common during acute SARS-CoV-2 infection in children, and a non-negligible proportion of these children reported persisting symptoms for up to 12-18 months after the acute infection. In addition, we found a trend even if statistically nonsignificant toward faster improvement of persisting gastrointestinal symptoms in children with long COVID treated with lactoferrin. Despite the limitations relating to the present study's design, given the significant burden of gastrointestinal symptoms in children with long COVID, our findings provide the basis to perform a prospective, placebo-controlled study.

Obesity and its Relationship with Covid-19: A Review of the Main Pharmaceutical Aspects

Important physiological changes are observed in patients with obesity, such as intestinal permeability, gastric emptying, cardiac output, and hepatic and renal function. These differences can determine variations in the pharmacokinetics of different drugs and can generate different concentrations at the site of action, which can lead to sub therapeutic or toxic concentrations. Understanding the physiological and immunological processes that lead to the clinical manifestations of COVID-19 is essential to correlate obesity as a risk factor for increasing the prevalence, severity, and lethality of the disease. Several drugs have been suggested to control COVID- 19 like Lopinavir, Ritonavir, Ribavirin, Sofosbuvir, Remdesivir, Oseltamivir, Oseltamivir phosphate, Oseltamivir carboxylate, Hydroxychloroquine, Chloroquine, Azithromycin, Teicoplanin, Tocilizumab, Anakinra, Methylprednisolone, Prednisolone, Ciclesonide and Ivermectin. Similarly, these differences between healthy people and obese people can be correlated to mechanical factors, such as insufficient doses of the vaccine for high body mass, impairing the absorption and distribution of the vaccine that will be lower than desired or can be linked to the inflammatory state in obese patients, which can influence the humoral immune response. Additionally, different aspects make the obese population more prone to persistent symptoms of the disease (long COVID), which makes understanding these mechanisms fundamental to addressing the implications of the disease. Thus, this review provides an overview of the relationship between COVID-19 and obesity, considering aspects related to pharmacokinetics, immunosuppression, immunization, and possible implications of long COVID in these individuals.

Risk factors for post-COVID cognitive dysfunctions: the impact of psychosocial vulnerability

BACKGROUND

Cognitive dysfunction is a well-established manifestation of the post-COVID syndrome. Psychological vulnerability to stressors can modify disease trajectories, causing long-term risk for negative outcomes. Nonetheless, how premorbid risk factors and response to stressor affect neuropsychological changes is still incompletely understood. In this study, we explored the impact of psychosocial variables on cognitive functioning in a post-COVID sample.

METHODS

All subjects were submitted to a comprehensive neuropsychological battery and an assessment of perceived loneliness, post-traumatic stress, and changes in anxiety and depression levels. A social vulnerability index was also calculated. The set of psycho-social variables was reduced to two Principal Component Analysis (PCA) components: distress and isolation.

RESULTS

Forty-five percent of individuals showed cognitive impairments, with predominant memory and executive deficits. Post-traumatic stress disorder was clinically relevant in 44% of the sample. Social vulnerability scores of the sample were comparable to those of general population. The individual performance in learning and response initiation/suppression was directly related to distress component, encasing anxiety, stress, and depression measures.

CONCLUSION

These findings suggest that psychosocial assessment of post-COVID patients can detect fragile individuals at risk of cognitive impairments. Dedicated psychological support services may play a useful role in the prevention of post-COVID cognitive dysfunction.

A Narrative Review of Commercial Platforms Offering Tracking of Heart Rate Variability in Corporate Employees to Detect and Manage Stress

The COVID-19 pandemic has resulted in employees being at risk of significant stress. There is increased interest by employers to offer employees stress monitoring via third party commercial sensor-based devices. These devices assess physiological parameters such as heart rate variability and are marketed as an indirect measure of the cardiac autonomic nervous system. Stress is correlated with an increase in sympathetic nervous activity that may be associated with an acute or chronic stress response. Interestingly, recent studies have shown that individuals affected with COVID will have some residual autonomic dysfunction that will likely render it difficult to track both stress and stress reduction using heart rate variability. The aims of the present study are to explore web and blog information using five operational commercial technology solution platforms that offer heart rate variability for stress detection. Across five platforms we found a number that combined HRV with other biometrics to assess stress. The type of stress being measured was not defined. Importantly, no company considered cardiac autonomic dysfunction because of post-COVID infection and only one other company mentioned other factors affecting the cardiac autonomic nervous system and how this may impact HRV accuracy. All companies suggested they could only assess associations with stress and were careful not to claim HRV could diagnosis stress. We recommend that managers think carefully about whether HRV is accurate enough for their employees to manage their stress during COVID.