Associations of Post-Acute COVID syndrome with physiological and clinical measures 10 months after hospitalization in patients of the first wave

A biopsychosocial analysis of risk factors for persistent physical, cognitive, and psychological symptoms among previously hospitalized post-COVID-19 patients

A significant number of COVID-19 survivors continue to experience persistent physical, cognitive, and psychological symptoms up to one year after discharge. This study aimed to examine the frequency, severity, and progression of and risk factors for these symptoms. This single-centre retrospective cohort study included 126 COVID-19 patients admitted to the VieCuri Medical Centre between 2020 and 2022. Follow-up assessments were conducted at 3 and 12 months postdischarge, including pulmonary function tests, CT scans, bioimpedance analysis, and questionnaires on physical, cognitive, and psychological symptoms. At both follow-up assessments, 31-32% of patients reported moderate to severe physical symptoms, 26-27% reported multiple cognitive symptoms, and 14-18% experienced depressive or posttraumatic stress symptoms (PTSSs). Only anxiety symptoms significantly decreased between the 3-month follow-up and the 12-month follow-up (from 22 to 12%; p = .014). The persistence of symptoms at 12 months was significantly associated with premorbid conditions (chronic respiratory disease, multiple comorbidities), illness severity (infection during the third wave), physical factors (COVID-19-related pulmonary abnormalities, lower total lung capacity, and dyspnoea), and cognitive and psychological factors (cognitive symptoms, anxiety, depression, and PTSS) (p < .05). These findings suggest that a significant proportion of COVID-19 survivors continue to experience persistent symptoms due to biopsychosocial factors, thus emphasizing the need for a biopsychosocial approach in early screening and treatment.

Donepezil for Fatigue and Psychological Symptoms in Post-COVID-19 Condition: A Randomized Clinical Trial

Importance

Fatigue is the most commonly reported symptom of post-COVID-19 condition (also known as long COVID) and impairs various functions. One of the underlying mechanisms may be intracerebral inflammation due to decreases in acetylcholine levels.

Objective

To examine the effects of donepezil hydrochloride, an acetylcholinesterase inhibitor, on post-COVID-19 fatigue and psychological symptoms.

Design, Setting, and Participants

A multicenter, double-blind randomized clinical trial was performed in Japan. Between December 14, 2022, and March 31, 2024, adult patients within 52 weeks of the onset of COVID-19 and with a global binary fatigue score of 4 or greater on the Chalder Fatigue Scale were randomized into a donepezil or a placebo group.

Exposure

The intervention was conducted during a 3-week period, with donepezil hydrochloride being administered at a dosage of 3 mg/d for the first week and then 5 mg/d for 2 weeks.

Main Outcomes and Measures

The primary outcome was a change in the Chalder Fatigue Scale score and the absolute score 3 weeks after the initiation of treatment. Other outcomes at 3 and 8 weeks, such as psychological symptoms and quality of life, were evaluated as secondary outcomes.

Results

A total of 120 eligible patients were enrolled and 10 withdrew or were lost to follow-up; therefore, 110 patients (55 in each group) were included in the efficacy analysis (64 [58%] female; mean [SD] age, 43 [12] years). No significant differences were observed in baseline characteristics between the 2 groups. The baseline-adjusted estimating treatment effect of donepezil, measured as the mean difference on Chalder Fatigue Scale scores at 3 weeks, was 0.34 (95% CI, -2.23 to 2.91), showing no significant effect of the intervention (P = .79). Scores for the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, EuroQol 5-Dimension 5-Level Version, Patient Health Questionnaire, and Daily Health Status at 3 and 8 weeks were similar. No serious adverse events occurred in either group.

Conclusions and Relevance

In this randomized clinical trial of donepezil to treat post-COVID-19 condition, the efficacy for fatigue and psychological symptoms was not confirmed in a general population. The development of effective therapeutics for post-COVID-19 symptoms is needed, and more clinical trials should be conducted in the future.

Trial Registration

Japan Registry of Clinical Trials Identifier: jRCT 2031220510.

Global prevalence of post-COVID-19 condition: a systematic review and meta-analysis of prospective evidence

INTRODUCTION

We investigated the prevalence of new or persistent manifestations experienced by COVID-19 survivors at 3 or more months after their initial infection, collectively known as post-COVID-19 condition (PCC).

METHODS

We searched four electronic databases and major grey literature resources for prospective studies, systematic reviews, authoritative reports and population surveys. A random-effects meta-analysis pooled the prevalence data of 22 symptoms and outcomes. The GRADE approach was used to assess the certainty of evidence. PROSPERO CRD42021231476.

RESULTS

Of 20 731 identified references, 194 met our inclusion criteria. These studies followed 483 531 individuals with confirmed COVID-19 diagnosis over periods of up to 2 years. Most focused on adults, nearly two-thirds were conducted in Europe and 63% were of high or moderate quality. The supplementary search identified 17 systematic reviews, five authoritative reports and four population surveys that reported on PCC prevalence. Our analysis revealed that more than half of COVID-19 survivors experienced one or more symptoms more than a year after their initial infection. The most common symptoms were fatiguedyspneamemory, sleep or concentration disturbances; depressionand pain. Limitation in returning to work was the most common outcome. Prevalence tended to be higher among females, individuals hospitalized during their initial infection and those who experienced severe COVID-19 illness.

CONCLUSION

PCC presents a significant health burden, affecting some groups more than others. This information will help inform health care system policies and services for people living with PCC and those caring for them.

Prevalence of depression, anxiety, stress, and suicide tendency among individual with long-COVID and determinants: A systematic review and meta-analysis

BACKGROUND

While mental health alterations during active COVID-19 infection have been documented, the prevalence of long-term mental health consequences remains unclear. This study aimed to determine the prevalence of mental health symptoms-depression, anxiety, stress, and suicidal tendencies-and to identify their trends and associated risk factors in individuals with long-COVID.

METHODS

We conducted a systematic literature search of databases including PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, Web of Science, and PsycINFO up to August 2024, targeting observational studies published in English. Study quality was assessed using structured standard tools. The primary outcome was the pooled prevalence of depression, anxiety, stress, and suicidal tendencies in individuals with long-COVID. Secondary outcomes included trends in these mental health problems over time and identification of associated determinants.

RESULTS

A total of 94 eligible studies were included in the analysis. The pooled prevalence estimates, regardless of follow up times duration, were as follows: depression, 25% (95%CI:22-28%; PI:1-59%); anxiety (adjusted via trim and fill method), 23%(95%CI:21-25%;PI:2-35%); composite outcomes of depression and/or anxiety, 25% (95%CI:23-27%;PI:2-51%); stress, 26%(95%CI:13-39%;PI:1-69%); and suicidality, 19%(95%CI:15-22%;PI:13-25%). The results of meta-regression analyses revealed a statistically significant trend showing a gradual decrease in the prevalence of the composite outcome of anxiety and/or depression over time (RD = -0.004,P = 0.022). Meta-regression results indicated that being female and younger age were significantly associated with a higher prevalence of mental health symptoms. Study design and study setting did not contribute to heterogeneity.

CONCLUSION

One-fourth of individual with long-COVID experience mental health symptoms, including depression, anxiety, and stress, which remain prevalent even two years post-infection despite a slight decreasing trend. Factors such as female gender and younger age were linked to higher rates of anxiety and depression. These findings indicate the need for ongoing mental health screening and early interventions to mitigate long-term psychological distress in long-COVID patients.

Functional Recovery of Adults Following Acute COVID-19: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the objective, functional recovery of patients more than 3 months after acute coronavirus disease 2019 (COVID-19) infection.

METHODS

Comprehensive database searches of EMBASE, PubMed/MEDLINE, Cochrane COVID-19 Study Register, CINAHL, and Google Scholar in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were carried out until October 19, 2022. Data were extracted and agreed in duplicate. Data were narratively synthesized, and a series of meta-analyses were performed using the random-effects inverse variance method.

RESULTS

One-hundred six papers covering 20,063 patients, who were either hospitalized or not hospitalized with acute COVID-19 and were followed-up between 3 and 24 months, were included. Percentage predicted 6-minute walk distance at 3 months to <5 months was 84.3% (95% CI = 79.2-89.3; n = 21; I2 = 98.3%) and 92.5% (95% CI = 89.8-95.3; n = 9; I2 = 94.5%) at ≥11 months. Cardiopulmonary exercise testing revealed the percentage predicted peak oxygen consumption rate ($peak\dot{\mathsf{V}}{\mathsf{o}}_{\mathsf{2}}$) at 3 months to <5 months was 77.3% (95% CI = 71.0-83.7; n = 6; I2 = 92.3%) and 95.4% (95% CI = 87.1-103.6; n = 2; I2 = 77.3%) at ≥11 months. Mean handgrip strength was greatest at ≥11 months at 31.16 kg (95% CI = 19.89-42.43; n = 2; I2 = 98.3%) of all time points. All analyses showed marked heterogeneity.

CONCLUSION

Patients have reduced physical function more than 3 months after COVID-19 infection. Better physical function in multiple physical domains is found after a longer recovery time.

IMPACT

Physical function as measured by the 6-minute walk test, hand grip strength, and cardiopulmonary exercise testing is reduced at 3 months after COVID-19 infection and can remain over 11 months of follow-up. This protracted recovery following acute COVID-19 infection supports the need to assess physical function at any clinical follow-up, and further research into rehabilitation programs and intervention for patients who have not recovered.

Post-COVID breathlessness: a mathematical model of respiratory processing in the brain

Breathlessness is among the most common post-COVID symptoms. In a considerable number of patients, severe breathlessness cannot be explained by peripheral organ impairment. Recent concepts have described how such persistent breathlessness could arise from dysfunctional processing of respiratory information in the brain. In this paper, we present a first quantitative and testable mathematical model of how processing of respiratory-related signals could lead to breathlessness perception. The model is based on recent theories that the brain holds an adaptive and dynamic internal representation of a respiratory state that is based on previous experiences and comprises gas exchange between environment, lung and tissue cells. Perceived breathlessness reflects the brain's estimate of this respiratory state signaling a potentially hazardous disequilibrium in gas exchange. The internal respiratory state evolves from the respiratory state of the last breath, is updated by a sensory measurement of CO2 concentration, and is dependent on the current activity context. To evaluate our model and thus test the assumed mechanism, we used data from an ongoing rebreathing experiment investigating breathlessness in patients with post-COVID without peripheral organ dysfunction (N = 5) and healthy control participants without complaints after COVID-19 (N = 5). Although the observed breathlessness patterns varied extensively between individual participants in the rebreathing experiment, our model shows good performance in replicating these individual, heterogeneous time courses. The model assumes the same underlying processes in the central nervous system in all individuals, i.e., also between patients and healthy control participants, and we hypothesize that differences in breathlessness are explained by different weighting and thus influence of these processes on the final percept. Our model could thus be applied in future studies to provide insight into where in the processing cascade of respiratory signals a deficit is located that leads to (post-COVID) breathlessness. A potential clinical application could be, e.g., the monitoring of effects of pulmonary rehabilitation on respiratory processing in the brain to improve the therapeutic strategies.

Long COVID-19 and Coexistence of Fatigue and Depression: A Cross-sectional Study from Saudi Arabia

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) is associated with various manifestations even after infection resolution. This study aimed to assess the prevalence of post-COVID-19 fatigue and its predictors.

METHODS

We conducted a nationwide cross-sectional study among Polymerase Chain Reaction test confirmed COVID-19 cases in Saudi Arabia from July 2021 to February 2022. We collected data through telephonic interviews covering socio-demographics, comorbidities, body mass index, smoking, illness severity, and COVID-19 vaccination status. We assessed fatigue using Fatigue Severity Scale while depression was assessed using Patient Health Questionnaire-2. Logistic regression was employed to analyze the relationship between post-COVID-19 fatigue and depression.

RESULTS

The analysis included 361 participants with a mean age of 37 ± 10.5 years, among whom 43% were female. Approximately 10% had comorbidities, and 21% were current smokers. Nearly two-thirds (68%) of the participants reported mild illness. The prevalence of perceived fatigue was 22.7%, while fatigue measured by the Fatigue Severity Scale was 14.4%. The multivariable logistic regression model revealed that COVID-19 severity and depression were significant predictors of post-COVID-19 fatigue; adjusted odds ratio 1.87 (95% CI: 1.10 to 3.18) and 14.3 (95% CI: 4.55 to 45.0), respectively.

CONCLUSION

Our findings suggest a higher prevalence of perceived fatigue compared to that measured by the Fatigue Severity Scale, underscoring the importance of using a valid assessment tool for fatigue among COVID-19 patients to ensure proper management. The significant association between post-COVID-19 fatigue and depression highlights the need for psychological assessment of COVID-19 patients to enhance their post-infection quality of life.

Factors associated with phenotypes of dyspnea in post-COVID-19 condition: a cross-sectional study

Post-COVID-19 condition (PCC) is defined as the persistence of symptoms, like fatigue and dyspnea, at least 3 months post-COVID infection. As dyspnea is a common symptom, we attempted to further clinically phenotype those with PCC-associated dyspnea. 1642 adults (average age of 49.6y with 63% female-predominance and BMI of 31.2 kg/m2) with physician confirmed diagnosis of PCC from June 2020-April 2023 in Alberta, Canada were included. Those with dyspnea were more likely to be female (56.5%, p = 0.005) and have higher BMI (31.3 kg/m2 vs. 29.5 kg/m2; p = 0.0008), history of asthma (21.1% vs. 12.3%; p < 0.001), more persistent PCC symptoms (p = 0.0001), more functional limitations, as well as lower quality of life (p < 0.0001). Multivariable-adjusted logistic regression analysis demonstrated dyspnea was independently associated with fatigue (OR = 4.20; CI = 2.71,6.59) and inversely associated with hospitalization for COVID-19 (OR = 0.53; CI = 0.32,0.91), age (OR = 0.98 per one year of age; CI = 0.96,0.99) and 6-min-walk-distance per 10 m difference (OR = 0.98, CI = 0.96,1.0). Fatigue was a predictor of dyspnea, and was associated with milder infection, higher BMI, and reduced 6-min-walk-distance despite normal pulmonary function. Reduced TLC or DLCO was associated with more severe infection and reduced 6-min-walk-distance. Thus, we speculate there are at least two dyspnea-associated phenotypes: phenotype with pronounced fatigue (normal PFT) and phenotype with pronounced pulmonary abnormalities (abnormal PFT). Improved understanding of the dyspnea-associated phenotypes may allow for better targeted rehabilitation.

Assessing Electronic Health Literacy in Individuals With the Post-COVID-19 Condition Using the German Revised eHealth Literacy Scale: Validation Study

BACKGROUND

The eHealth Literacy Scale (eHEALS) is a widely used instrument for measuring eHealth literacy (eHL). However, little is known so far about whether the instrument is valid for the assessment of eHL in persons who are affected by the post-COVID-19 condition. This is particularly important as people with the post-COVID-19 condition are frequently affected by false information from the internet.

OBJECTIVE

The objective of our study was to evaluate the validity and reliability of the German Revised eHealth Literacy Scale (GR-eHEALS) in individuals with the post-COVID-19 condition.

METHODS

A cross-sectional study was conducted from January to May 2022. The self-assessment survey consisted of the GR-eHEALS, health status- and internet use-related variables, sociodemographic data, and (post)-COVID-19-related medical data. Confirmatory factor analysis (CFA), correlational analyses, and tests of measurement invariance were deployed.

RESULTS

In total, 330 participants were included in the statistical analyses. CFA revealed that the 2-factor model reached an excellent model fit (comparative fit index=1.00, Tucker-Lewis index=0.99, root mean square error of approximation=0.036, standardized root mean square residual=0.038). Convergent validity was confirmed by significant positive correlations between eHL and knowledge of internet-based health promotion programs, experience in using these programs, and the duration of private internet use. In addition, a significantly negative relationship of eHL with internet anxiety supported convergent validity. Further, significant relationships of eHL with mental health status and internal health locus of control confirmed the criterion validity of the instrument. However, relationships of eHL with physical health status and quality of life could not be confirmed. The 2-factor model was fully measurement invariant regarding gender. Regarding age and educational level, partial measurement invariance was confirmed. The subscales as well as the overall GR-eHEALS reached good-to-excellent reliability (Cronbach α≥.86).

CONCLUSIONS

The GR-eHEALS is a reliable and largely valid instrument for assessing eHL in individuals with the post-COVID-19 condition. Measurement invariance regarding gender was fully confirmed and allows the interpretation of group differences. Regarding age and educational level, group differences should be interpreted with caution. Given the high likelihood that individuals with the post-COVID-19 condition will be confronted with misinformation on the Internet, eHL is a core competency that is highly relevant in this context, in both research and clinical practice. Therefore, future research should also explore alternative instruments to capture eHL to overcome shortcomings in the validity of the GR-eHEALS.

Evaluation of post-acute-COVID-19, and long-COVID symptoms with a questionnaire: Within one year, a longitudinal study

OBJECTIVE

Long-term consequences of COVID-19 vary widely, representing a growing global health challenge. The aim of this report was to define the presence of symptoms in post-acute-COVID-19 syndrome (PCS) patients and to assess the frequency, associated factors, and the spectrum of persistent symptoms.

METHODS

In this longitudinal study, 487 adults with a previously diagnosed "Severe Acute Respiratory Syndrome Coronavirus 2" (SARS-CoV-2) who admitted to COVID-19 follow-up outpatient clinic between December 1, 2020 and November 31, 2021 were interviewed face-to-face three times. Data was collected on patient demographics, comorbidities, and symptoms. A questionnaire of 160 questions was asked and organized into the following: identification and consent, socio-demographic/epidemiological characteristics, previous medical history, diagnosis and clinical presentation of acute COVID-19, as well as systematic symptoms. Data were evaluated using univariate comparisons and multiple logistic regression.

RESULTS

The most prevalent symptoms among all PCS patients during their initial visit were dyspnea, weakness, forgetfulness, fatigue, and arthralgia respectively. The most common symptoms in patients with 6 months or more time from discharge to follow-up at the first and second visits, appear to be persistent. While incidence rates decreased by the third visit, the five most common symptoms remained the same. The possibility of weakness and arthralgia was found to be higher in non-hospitalized patients. Females were associated with the most common persistent symptoms and the strongest association was with arthralgia.

CONCLUSION

A large number of COVID-19 survivors had continuing symptoms at the first year of post-COVID-19-infection. Neither the presence of comorbidities of the patient nor smoking status were associated with the severity of PCS symptoms. A better understanding of the mechanisms, predisposing factors and evaluation require a multidisciplinary team approach.

Updated Clinical Practice Guidelines for the Diagnosis and Management of Long COVID

"Long COVID" is a term used to describe a condition when the symptoms and signs associated with coronavirus disease 2019 (COVID-19) persist for more than three months among patients infected with COVID-19; this condition has been reported globally and poses a serious public health issue. Long COVID can manifest in various forms, highlighting the need for appropriate evaluation and management by experts from various fields. However, due to the lack of clear clinical definitions, knowledge of pathophysiology, diagnostic methods, and treatment protocols, it is necessary to develop the best standard clinical guidelines based on the scientific evidence reported to date. We developed this clinical guideline for diagnosing and treating long COVID by analyzing the latest research data collected from the start of the COVID-19 pandemic until June 2023, along with the consensus of expert opinions. This guideline provides recommendations for diagnosis and treatment that can be applied in clinical practice, based on a total of 32 key questions related to patients with long COVID. The evaluation of patients with long COVID should be comprehensive, including medical history, physical examination, blood tests, imaging studies, and functional tests. To reduce the risk of developing long COVID, vaccination and antiviral treatment during the acute phase are recommended. This guideline will be revised when there is a reasonable need for updates based on the availability of new knowledge on the diagnosis and treatment of long COVID.

The global prevalence of depression, anxiety, and sleep disorder among patients coping with Post COVID-19 syndrome (long COVID): a systematic review and meta-analysis

BACKGROUND

Post COVID-19 syndrome, also known as "Long COVID," is a complex and multifaceted condition that affects individuals who have recovered from SARS-CoV-2 infection. This systematic review and meta-analysis aim to comprehensively assess the global prevalence of depression, anxiety, and sleep disorder in individuals coping with Post COVID-19 syndrome.

METHODS

A rigorous search of electronic databases was conducted to identify original studies until 24 January 2023. The inclusion criteria comprised studies employing previously validated assessment tools for depression, anxiety, and sleep disorders, reporting prevalence rates, and encompassing patients of all age groups and geographical regions for subgroup analysis Random effects model was utilized for the meta-analysis. Meta-regression analysis was done.

RESULTS

The pooled prevalence of depression and anxiety among patients coping with Post COVID-19 syndrome was estimated to be 23% (95% CI: 20%-26%; I2 = 99.9%) based on data from 143 studies with 7,782,124 participants and 132 studies with 9,320,687 participants, respectively. The pooled prevalence of sleep disorder among these patients, derived from 27 studies with 15,362 participants, was estimated to be 45% (95% CI: 37%-53%; I2 = 98.7%). Subgroup analyses based on geographical regions and assessment scales revealed significant variations in prevalence rates. Meta-regression analysis showed significant correlations between the prevalence and total sample size of studies, the age of participants, and the percentage of male participants. Publication bias was assessed using Doi plot visualization and the Peters test, revealing a potential source of publication bias for depression (p = 0.0085) and sleep disorder (p = 0.02). However, no evidence of publication bias was found for anxiety (p = 0.11).

CONCLUSION

This systematic review and meta-analysis demonstrate a considerable burden of mental health issues, including depression, anxiety, and sleep disorders, among individuals recovering from COVID-19. The findings emphasize the need for comprehensive mental health support and tailored interventions for patients experiencing persistent symptoms after COVID-19 recovery.

Cognitive impairments and mental health of patients with post-COVID-19: A cross-sectional study

BACKGROUND

Persistent cognitive complaints belong to the most frequent symptoms after COVID-19. This study explored the neuropsychological profile, mental health and risk factors for cognitive impairment in post-COVID-19 patients.

METHODS

The patients were recruited consecutively in the Post COVID Center of the University Hospital of Erlangen between 12/2022 and 05/2023. They underwent an extensive neuropsychological assessment including the Verbal Learning Memory Test (VLMT), the digit span backwards from the Wechsler Memory Scale-Revised (WMS-R), the Trail Making Test (TMT) Part A and B, the d2 Test of Attention and the Regensburger Verbal Fluency Test (RWT). For each cognitive domain we calculated the frequency of age-adjusted scores below the measure-specific norms. Depressive symptoms were measured with the Patient-Health-Questionnaire-9 (PHQ-9). Logistic regression analyses were computed.

RESULTS

In 110 patients (mean age: 42.5 ± 11.9 years; 68.2% women), the most frequent cognitive deficits were observed for verbal fluency, working speed, delayed recall and attention. In almost every cognitive domain high education levels were associated with a decreased risk for cognitive impairment. Higher age was a risk factor for working speed and delayed recall and a protective factor for verbal fluency. Clinically relevant depressive symptoms were associated with an elevated risk for an impairment regarding some cognitive functions.

CONCLUSION

Cognitive dysfunctions were common among the post-COVID-19 patients. Differentiated exploration of cognitive impairments is crucial for a proper characterization of the post-COVID syndrome. In future research parameters of cognitive impairment should be correlated to alterations in biological markers of the disease like markers of immunological and microcirculation change.

Hamster model for post-COVID-19 alveolar regeneration offers an opportunity to understand post-acute sequelae of SARS-CoV-2

COVID-19 survivors often suffer from post-acute sequelae of SARS-CoV-2 infection (PASC). Current evidence suggests dysregulated alveolar regeneration as a possible explanation for respiratory PASC, which deserves further investigation in a suitable animal model. This study investigates morphological, phenotypical and transcriptomic features of alveolar regeneration in SARS-CoV-2 infected Syrian golden hamsters. We demonstrate that CK8+ alveolar differentiation intermediate (ADI) cells occur following SARS-CoV-2-induced diffuse alveolar damage. A subset of ADI cells shows nuclear accumulation of TP53 at 6- and 14-days post infection (dpi), indicating a prolonged arrest in the ADI state. Transcriptome data show high module scores for pathways involved in cell senescence, epithelial-mesenchymal transition, and angiogenesis in cell clusters with high ADI gene expression. Moreover, we show that multipotent CK14+ airway basal cell progenitors migrate out of terminal bronchioles, aiding alveolar regeneration. At 14 dpi, ADI cells, peribronchiolar proliferates, M2-macrophages, and sub-pleural fibrosis are observed, indicating incomplete alveolar restoration. The results demonstrate that the hamster model reliably phenocopies indicators of a dysregulated alveolar regeneration of COVID-19 patients. The results provide important information on a translational COVID-19 model, which is crucial for its application in future research addressing pathomechanisms of PASC and in testing of prophylactic and therapeutic approaches for this syndrome.

Fatigue outcomes following COVID-19: a systematic review and meta-analysis

OBJECTIVES

Fatigue is a pervasive clinical symptom in coronaviruses and may continue beyond the acute phase, lasting for several months or years. This systematic review and meta-analysis aimed to incorporate the current evidence for postinfection fatigue among survivors of SARS-CoV-2 and investigate associated factors.

METHODS

Embase, PsyINFO, Medline, CINAHL, CDSR, Open Grey, BioRxiv and MedRxiv were systematically searched from January 2019 to December 2021. Eligible records included all study designs in English. Outcomes were fatigue or vitality in adults with a confirmed diagnosis of SARS-CoV-2 measured at >30 days post infection. Non-confirmed cases were excluded. JBI risk of bias was assessed by three reviewers. Random effects model was used for the pooled proportion with 95% CIs. A mixed effects meta-regression of 35 prospective articles calculated change in fatigue overtime. Subgroup analyses explored specific group characteristics of study methodology. Heterogeneity was assessed using Cochran's Q and I2 statistic. Egger's tests for publication bias.

RESULTS

Database searches returned 14 262 records. Following deduplication and screening, 178 records were identified. 147 (n=48 466 participants) were included for the meta-analyses. Pooled prevalence was 41% (95% CI: 37% to 45%, k=147, I2=98%). Fatigue significantly reduced over time (-0.057, 95% CI: -107 to -0.008, k=35, I2=99.3%, p=0.05). A higher proportion of fatigue was found in studies using a valid scale (51%, 95% CI: 43% to 58%, k=36, I2=96.2%, p=0.004). No significant difference was found for fatigue by study design (p=0.272). Egger's test indicated publication bias for all analyses except valid scales. Quality assessments indicated 4% at low risk of bias, 78% at moderate risk and 18% at high risk. Frequently reported associations were female gender, age, physical functioning, breathlessness and psychological distress.

CONCLUSION

This study revealed that a significant proportion of survivors experienced fatigue following SARS-CoV-2 and their fatigue reduced overtime. Non-modifiable factors and psychological morbidity may contribute to ongoing fatigue and impede recovery.

PROSPERO REGISTRATION NUMBER

CRD42020201247.

Association between COVID-19 symptoms, COVID-19 vaccine, and somatization among a sample of the Lebanese adults

Objectives

Long COVID syndrome, the poorly defined illness, has been increasingly mentioned in recent studies yet is still poorly understood especially when it comes to precipitating and modulating factors, the high prevalence of mental health problems associated with the COVID-19 pandemic has brought to light the hypothesis of the existence of a psychological component associated with the persistence of symptoms and if vaccination may serve as a modulating factor. This study aims to examine the prevalence of somatization disorders and association between persistent COVID-19 symptoms and COVID-19 vaccine with somatization among a sample of the Lebanese general population.

Methods

A cross-sectional study was carried out between September and October 2021. The snowball sampling technique was picked to choose a sample that addressed all Lebanese Mohafazat. Patient Health Questionnaire-15 (PHQ-15) was used to assess somatization.

Results

A total of 403 participants was enrolled in this study, with a mean age of 32.76 ± 13.24 years, 108 (26.8%) had medium somatization symptoms (PHQ-15 scores ≥10). Having persistent COVID symptoms (β=2.15) was significantly associated with more somatization, whereas the intake of COVID vaccine (β=-1.17) was significantly associated with less somatization.

Conclusion

Long lasting COVID-19 symptoms were closely related to somatization, although the administration of the COVID-19 vaccine was associated with less somatization. However, further studies are needed to provide a better understanding of the relationship between long COVID and somatization, on one hand, and the modulating factors on the other hand.

Psychiatric and neurological complications of long COVID

COVID-19 was primarily considered a pulmonary disease with extrapulmonary manifestations. As the pandemic spread, there has been growing evidence that the disease affects various organs/systems, including the central and peripheral nervous systems. Accumulation of clinical data demonstrates that in a large population of survivors impairments in the function of one or more organs may persist for a long time, a phenomenon commonly known as post COVID or long COVID. Fatigue and cognitive dysfunction, such as concentration problems, short-term memory deficits, general memory loss, a specific decline in attention, language and praxis abilities, encoding and verbal fluency, impairment of executive functions, and psychomotor coordination, are amongst the most common and debilitating features of neuropsychatric symptoms of post COVID syndrome. Several patients also suffer from compromised sleep, depression, anxiety and post-traumatic stress disorder. Patients with long COVID may demonstrate brain hypometabolism, hypoperfusion of the cerebral cortex and changes in the brain structure and functional connectivity. Children and adolescents represent a minority of COVID-19 cases, so not surprisingly data on the long-term sequelae after SARS-CoV-2 infections in these age groups are scarce. Although the pathogenesis, clinical characteristics, epidemiology, and risk factors of the acute phase of COVID-19 have been largely explained, these areas are yet to be explored in long COVID. This review aims to provide an update on what is currently known about long COVID effects on mental health.

Sequelae of COVID-19 among previously hospitalized patients up to 1 year after discharge: a systematic review and meta-analysis

OBJECTIVE

Although complications and clinical symptoms of COVID-19 have been elucidated, the prevalence of long-term sequelae of COVID-19 is less clear in previously hospitalized COVID-19 patients. This review and meta-analysis present the occurrence of different symptoms up to 1 year of follow-up for previously hospitalized patients.

METHODS

We performed a systematic review from PubMed and Web of Science using keywords such as "COVID-19", "SARS-CoV-2", "sequelae", "long-term effect" and included studies with at least 3-month of follow-up. Meta-analyses using random-effects models were performed to estimate the pooled prevalence for different sequelae. Subgroup analyses were conducted by different follow-up time, regions, age and ICU admission.

RESULTS

72 articles were included in the meta-analyses after screening 11,620 articles, identifying a total of 167 sequelae related to COVID-19 from 88,769 patients. Commonly reported sequelae included fatigue (27.5%, 95% CI 22.4-33.3%, range 1.5-84.9%), somnipathy (20.1%, 95% CI 14.7-26.9%, range 1.2-64.8%), anxiety (18.0%, 95% CI 13.8-23.1%, range 0.6-47.8%), dyspnea (15.5%, 95% CI 11.3-20.9%, range 0.8-58.4%), PTSD (14.6%, 95% CI 11.3-18.7%, range 1.2-32.0%), hypomnesia (13.4%, 95% CI 8.4-20.7%, range 0.6-53.8%), arthralgia (12.9%, 95% CI 8.4-19.2%, range 0.0-47.8%), depression (12.7%, 95% CI 9.3-17.2%, range 0.6-37.5%), alopecia (11.2%, 95% CI 6.9-17.6%, range 0.0-47.0%) over 3-13.2 months of follow-up. The prevalence of most symptoms reduced after > 9 months of follow-up, but fatigue and somnipathy persisted in 26.2% and 15.1%, respectively, of the patients over a year. COVID-19 patients from Asia reported a lower prevalence than those from other regions.

CONCLUSIONS

This review identified a wide spectrum of COVID-19 sequelae in previously hospitalized COVID-19 patients, with some symptoms persisting up to 1 year. Management and rehabilitation strategies targeting these symptoms may improve quality of life of recovered patients.

Management and treatment of long COVID symptoms in general practices: An online-based survey

Independent from initial severity, many patients develop persistent symptoms after infection with SARS-CoV-2, described as long COVID syndrome. Most of these patients are treated by general practitioners (GPs). As evidence-based treatment recommendations are still sparse, GPs must make their therapy decisions under uncertainty. We investigated (1) the most frequently observed long COVID symptoms in general practices and (2) GPs' applied treatment and rehabilitation plans for these symptoms. In total, 143 German GPs participated in an online-based survey between 05/2021 and 07/2021. We found that each GP practice was treating on average 12 patients with long COVID symptoms. Most frequently seen symptoms were fatigue and reduced performance. Current therapy options were rated as poor and loss of smell and taste, fatigue, or lack of concentration were perceived to be especially difficult to treat. The use of drug and non-drug therapies and specialist referrals focused primarily on physiological and less on psychosomatic/psychological rehabilitation and followed guidelines of similar conditions. Our results provide first insights into how GPs approach a newly emerging condition in the absence of guidelines, evidence-based recommendations, or approved therapies, and might inform about GP preparedness in future pandemics. Our results also emphasize a gap between the current knowledge of the long COVID manifestation and knowledge about effective rehabilitation.

Pulmonary function and chest computed tomography abnormalities 6-12 months after recovery from COVID-19: a systematic review and meta-analysis

Background

Some coronavirus disease 2019 (COVID-19) survivors experience prolonged and varying symptoms, a condition termed post-acute COVID-19 syndrome (PACS). However, the prevalence of chronic pulmonary sequelae of PACS during long-term follow-up remains unclear. Several studies have examined this issue and reported heterogeneous results.

Methods

We conducted a systematic review and meta-analysis using a random-effects model to estimate the pooled prevalence of the pulmonary sequelae of COVID-19, as demonstrated by pulmonary function testing (PFT) and chest computed tomography (CT) performed at least 6 months after initial infection. PubMed, Embase, and Cochrane Library databases were searched from January 1, 2020 to December 31, 2021 to identify related studies. We investigated whether the prevalence of pulmonary sequelae decreased over time and attempted to identify the factors associated with their development by performing multiple subgroup and meta-regression analyses.

Results

Of the 18,062 studies identified, 30 met our eligibility criteria. Among these studies, 25 and 22 had follow-up PFT and chest CT data, respectively. The follow-up durations were approximately 6 and 12 months in 18 and 12 studies, respectively. Impaired diffusion capacity was the most common abnormality on PFT (pooled prevalence 35%, 95% confidence interval [CI] 30–41%) with a prevalence of 39% (95% CI 34–45%) and 31% (95% CI 21–40%) in the 6-month and 12-month follow-up studies, respectively (P = 0.115). Restrictive pulmonary dysfunction evident as reduced forced vital capacity was less frequent (pooled prevalence 8%, 95% CI 6–11%); however, its prevalence was lower in the 12-month follow-up studies than in the 6-month follow-up studies (5% [95% CI 3–7%] vs. 13% [95% CI 8–19%], P = 0.006). On follow-up chest CT, the pooled prevalence of persistent ground-glass opacities and pulmonary fibrosis was 34% (95% CI 24–44%) and 32% (95% CI 23–40%), respectively, and the prevalence did not decrease over time. As every meta-analysis showed significant between-study heterogeneity, subgroup and meta-regression analyses were performed to identify potential effect modifiers; the severity of index infection was associated with the prevalence of impaired diffusion capacity and pulmonary fibrosis.

Conclusions

A substantial number of COVID-19 survivors displayed pulmonary sequelae as part of PACS. Except for restrictive pulmonary dysfunction, the prevalence of these sequelae did not decrease until 1 year after initial infection. Considering the association between the severity of acute COVID-19 and risk of pulmonary sequelae, patients who recover from severe COVID-19 require close respiratory follow-up.

Systematic review registration number PROSPERO CRD42021234357

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02163-x.

Health outcomes in people 2 years after surviving hospitalisation with COVID-19: a longitudinal cohort study

BACKGROUND

With the ongoing COVID-19 pandemic, growing evidence shows that a considerable proportion of people who have recovered from COVID-19 have long-term effects on multiple organs and systems. A few longitudinal studies have reported on the persistent health effects of COVID-19, but the follow-up was limited to 1 year after acute infection. The aim of our study was to characterise the longitudinal evolution of health outcomes in hospital survivors with different initial disease severity throughout 2 years after acute COVID-19 infection and to determine their recovery status.

METHODS

We did an ambidirectional, longitudinal cohort study of individuals who had survived hospitalisation with COVID-19 and who had been discharged from Jin Yin-tan Hospital (Wuhan, China) between Jan 7 and May 29, 2020. We measured health outcomes 6 months (June 16-Sept 3, 2020), 12 months (Dec 16, 2020-Feb 7, 2021), and 2 years (Nov 16, 2021-Jan 10, 2022) after symptom onset with a 6-min walking distance (6MWD) test, laboratory tests, and a series of questionnaires on symptoms, mental health, health-related quality of life (HRQoL), return to work, and health-care use after discharge. A subset of COVID-19 survivors received pulmonary function tests and chest imaging at each visit. Age-matched, sex-matched, and comorbidities-matched participants without COVID-19 infection (controls) were introduced to determine the recovery status of COVID-19 survivors at 2 years. The primary outcomes included symptoms, modified British Medical Research Council (mMRC) dyspnoea scale, HRQoL, 6MWD, and return to work, and were assessed in all COVID-19 survivors who attended all three follow-up visits. Symptoms, mMRC dyspnoea scale, and HRQoL were also assessed in controls.

FINDINGS

2469 patients with COVID-19 were discharged from Jin Yin-tan Hospital between Jan 7 and May 29, 2020. 1192 COVID-19 survivors completed assessments at the three follow-up visits and were included in the final analysis, 1119 (94%) of whom attended the face-to-face interview 2 years after infection. The median age at discharge was 57·0 years (48·0-65·0) and 551 (46%) were women. The median follow-up time after symptom onset was 185·0 days (IQR 175·0-197·0) for the visit at 6 months, 349·0 days (337·0-360·0) for the visit at 12 months, and 685·0 days (675·0-698·0) for the visit at 2 years. The proportion of COVID-19 survivors with at least one sequelae symptom decreased significantly from 777 (68%) of 1149 at 6 months to 650 (55%) of 1190 at 2 years (p<0·0001), with fatigue or muscle weakness always being the most frequent. The proportion of COVID-19 survivors with an mMRC score of at least 1 was 168 (14%) of 1191 at 2 years, significantly lower than the 288 (26%) of 1104 at 6 months (p<0·0001). HRQoL continued to improve in almost all domains, especially in terms of anxiety or depression: the proportion of individuals with symptoms of anxiety or depression decreased from 256 (23%) of 1105 at 6 months to 143 (12%) 1191 at 2 years (p<0·0001). The proportion of individuals with a 6MWD less than the lower limit of the normal range declined continuously in COVID-19 survivors overall and in the three subgroups of varying initial disease severity. 438 (89%) of 494 COVID-19 survivors had returned to their original work at 2 years. Survivors with long COVID symptoms at 2 years had lower HRQoL, worse exercise capacity, more mental health abnormality, and increased health-care use after discharge than survivors without long COVID symptoms. COVID-19 survivors still had more prevalent symptoms and more problems in pain or discomfort, as well as anxiety or depression, at 2 years than did controls. Additionally, a significantly higher proportion of survivors who had received higher-level respiratory support during hospitalisation had lung diffusion impairment (43 [65%] of 66 vs 24 [36%] of 66, p=0·0009), reduced residual volume (41 [62%] vs 13 [20%], p<0·0001), and total lung capacity (26 [39%] vs four [6%], p<0·0001) than did controls.

INTERPRETATION

Regardless of initial disease severity, COVID-19 survivors had longitudinal improvements in physical and mental health, with most returning to their original work within 2 years; however, the burden of symptomatic sequelae remained fairly high. COVID-19 survivors had a remarkably lower health status than the general population at 2 years. The study findings indicate that there is an urgent need to explore the pathogenesis of long COVID and develop effective interventions to reduce the risk of long COVID.

Clinical, sociodemographic and environmental factors impact post-COVID-19 syndrome

Background

Sociodemographic and environmental factors are associated with incidence, severity, and mortality of COVID-19. However, little is known about the role of such factors in persisting symptoms among recovering patients. We designed a cohort study of hospitalized COVID-19 survivors to describe persistent symptoms and identify factors associated with post-COVID-19 syndrome.

Methods

We included patients hospitalized between March to August 2020 who were alive six months after hospitalization. We collected individual and clinical characteristics during hospitalization and at follow-up assessed ten symptoms with standardized scales, 19 yes/no symptoms, a functional status and a quality-of-life scale and performed four clinical tests. We examined individual exposure to greenspace and air pollution and considered neighbourhood´s population density and socioeconomic conditions as contextual factors in multilevel regression analysis.

Results

We included 749 patients with a median follow-up of 200 (IQR = 185-235) days, and 618 (83%) had at least one of the ten symptoms measured with scales. Pain (41%), fatigue (38%) and posttraumatic stress disorder (35%) were the most frequent. COVID-19 severity, comorbidities, BMI, female sex, younger age, and low socioeconomic position were associated with different symptoms. Exposure to ambient air pollution was associated with higher dyspnoea and fatigue scores and lower functional status.

Conclusions

We identified a high frequency of persistent symptoms among COVID-19 survivors that were associated with clinical, sociodemographic, and environmental variables. These findings indicate that most patients recovering from COVID-19 will need post-discharge care, and an additional burden to health care systems, especially in LMICs, should be expected.

Brief Research Report: Quantitative Analysis of Potential Coronary Microvascular Disease in Suspected Long-COVID Syndrome

Background

Case series have reported persistent cardiopulmonary symptoms, often termed long-COVID or post-COVID syndrome, in more than half of patients recovering from Coronavirus Disease 19 (COVID-19). Recently, alterations in microvascular perfusion have been proposed as a possible pathomechanism in long-COVID syndrome. We examined whether microvascular perfusion, measured by quantitative stress perfusion cardiac magnetic resonance (CMR), is impaired in patients with persistent cardiac symptoms post-COVID-19.

Methods

Our population consisted of 33 patients post-COVID-19 examined in Berlin and London, 11 (33%) of which complained of persistent chest pain and 13 (39%) of dyspnea. The scan protocol included standard cardiac imaging and dual-sequence quantitative stress perfusion. Standard parameters were compared to 17 healthy controls from our institution. Quantitative perfusion was compared to published values of healthy controls.

Results

The stress myocardial blood flow (MBF) was significantly lower [31.8 ± 5.1 vs. 37.8 ± 6.0 (μl/g/beat), P < 0.001] and the T2 relaxation time was significantly higher (46.2 ± 3.6 vs. 42.7 ± 2.8 ms, P = 0.002) post-COVID-19 compared to healthy controls. Stress MBF and T1 and T2 relaxation times were not correlated to the COVID-19 severity (Spearman r = −0.302, −0.070, and −0.297, respectively) or the presence of symptoms. The stress MBF showed a U-shaped relation to time from PCR to CMR, no correlation to T1 relaxation time, and a negative correlation to T2 relaxation time (Pearson r = −0.446, P = 0.029).

Conclusion

While we found a significantly reduced microvascular perfusion post-COVID-19 compared to healthy controls, this reduction was not related to symptoms or COVID-19 severity.