'Scientific Strabismus' or two related pandemics: coronavirus disease and vitamin D deficiency

Prevalence of Vitamin D Deficiency Among Healthy Young Adults at Kuwait University

OBJECTIVE

 This study aims to investigate the prevalence of vitamin D deficiency among healthy young medical and dental students at Kuwait University.

METHODS

This cross-sectional study included a total of 201 medical and dental students (male = 99; female = 102) at Kuwait University. Blood samples were collected to assess 25-hydroxyvitamin D (25(OH)D) by electrochemiluminescence (ECL) immunoassay, and a questionnaire was distributed to address related qualitative data. P-values less than 0.05 were considered significant.

RESULTS

Vitamin D deficiency (<50 nmol/L) was reported in 171 (85.1%) of the participants. A total of 17 (8.5%) participants exhibited insufficient vitamin D (50.1-75 nmol/L), and only 13 (6.5%) students had optimal vitamin D (>75 nmol/L). According to gender, vitamin D deficiency was more common in male students (89, 89.9%) compared to females (82, 80.4%). Vitamin D levels for students in the clinical academic years (sixth and fifth years) were significantly higher (P < 0.001) compared to the non-clinical years (fourth, third, and second years).

CONCLUSION

 The prevalence of vitamin D deficiency was very high among medical and dental students of Kuwait University. The students with high academic years suffered more from vitamin D deficiency.

Promising role of Vitamin D and plant metabolites against COVID-19: Clinical trials review

Vitamin D possesses immunomodulatory qualities and is protective against respiratory infections. Additionally, it strengthens adaptive and cellular immunity and boosts the expression of genes involved in oxidation. Experts suggested taking vitamin D supplements to avoid and treat viral infection and also COVID-19, on the other hand, since the beginning of time, the use of plants as medicines have been vital to human wellbeing. The WHO estimates that 80 % of people worldwide use plants or herbs for therapeutic purposes. Secondary metabolites from medicinal plants are thought to be useful in lowering infections from pathogenic microorganisms due to their ability to inhibit viral protein and enzyme activity by binding with them. As a result, this manuscript seeks to describe the role of vitamin D and probable plant metabolites that have antiviral activities and may be complementary to the alternative strategy against COVID-19 in a single manuscript through reviewing various case studies.

An overview of regulation for nutraceuticals and concept of personalized nutraceuticals

Nutraceuticals are essentially nutritional components that have a vital role in developing and maintaining the body's regular functions, which keeps people healthy. The nutraceutical sector is also primarily driven by the existing global population and trends. Examples of foods considered as nutraceuticals include prebiotics, fibre, polyunsaturated fatty acids, probiotics, antioxidants, and other natural or herbal foods. Some of the most serious health problems of the 20th century, like COVID-19 and diabetes mellitus, are managed with the help of the preceding nutraceuticals. As we move into a time of health and medicine, the food industry as a whole has become more focused on research.

The relationship between vitamin D deficiency and mortality in older adults before and during COVID-19 pandemic

BACKGROUND

Vitamin D is an essential fat-soluble vitamin thought to be associated with chronic diseases, mortality and COVID-19.

OBJECTIVE

To investigate the association between 25(OH) vitamin D levels and mortality of chronic diseases in subjects aged ≥65 years before and during COVID-19 pandemic.

METHODS

A single-center, retrospective study was performed using the hospital database of subjects aged 65 years and older who had undergone vitamin D measurement between 01.01.2019 and 31.12.2021. All patients with vitamin D measurement (N = 2155) were followed as a cohort from the date of serum vitamin D analysis through death date or 01.01.2022. Age, gender, chronic diseases, survival status, date of death of the deceased, laboratory values including complete blood count, liver/renal functions and 25(OH) vitamin D levels were all noted. Subjects were classified into three groups according to their 25(OH) vitamin D levels; severe deficient group (<10 ng/ml), moderate deficient group (10-19.9 ng/ml), and control group (≥20 ng/ml).

RESULTS

Data of 1949 subjects were included in this retrospective analysis and 206 of them (10.6%) had at least two vitamin D measurements. Until the time of data collection (01.01.2022), 94 of the cases had died within the last three years, and only five of them had repeated measurements. While the mean vitamin D level was lower, age and frequency of dyslipidemia, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), arrhythmia, dementia and severe vitamin D deficiency (<10 ng/ml) were higher in subjectswho died (all p<0.05). According to the Cox proportional hazards model; age, presence of CAD, COPD, arrhythmia, dementia, anemia and severe vitamin D deficiency were independently related with mortality (all p<0.05). After adjusted by age, gender, and comorbidities, the probability of death was found to be 1.91 (95% CI=1.12-3.24) times higher in the severe vitamin D deficient group.

CONCLUSIONS

The results of this study have shown that - after having adjusted for potential factors - severe vitamin D deficiency (<10 ng/ml) seems to be an independent predictor for non-cancer mortality. Although vitamin D measurement/treatment is very easy and cheap where, on the contrary, severe vitamin D deficiency can be quite mortal.

Association between Vitamin D Status and Secondary Infections in Patients with Severe COVID-19 Admitted in the Intensive Care Unit of a Tertiary-Level Hospital in Turkey

There are several studies showing that the vitamin D status can determine risk of COVID-19 infections, severity and mortality from coronavirus disease 2019 (COVID-19). However, the association between vitamin D (25(OH)D) and secondary infections in the prognosis of COVID-19 patients has not been reported yet. The aim was to investigate whether the vitamin D status affects the rates of secondary infections in patients with severe COVID-19 hospitalized in the intensive care unit (ICU) of a tertiary-level hospital in Turkey. The data of 194 patients with diagnosis of severe COVID-19 who were admitted to the ICU from March 2020 to June 2021 and older than 18 years were evaluated in this retrospective study. The patients were divided into two groups according to total serum 25(OH)D level as normal group (≥20 ng/mL) and low group (<20 ng/mL). The 25(OH)D level was low in 118 (60.8%) and normal in 76 (39.2%) patients. The mean age of the low group was significantly higher than that of the normal group (67.02 ± 14.47 vs. 61.70 ± 14.38; p = 0.013). The systolic and diastolic blood pressure as well as the Glasgow coma scale score of the low group were significantly lower than that of the normal group (p = 0.004, 0.002 and 0.001, respectively). The intubation rate and APACHE (Acute Physiology and Chronic Health Evaluation) score of the low group was significantly higher than that of the normal group (p = 0.001). The platelets number and blood pH decreased, and the neutrophil/lymphocyte ratio, procalcitonin, lactate, urea, creatinine and lactate dehydrogenase concentrations increased significantly in the low group (p < 0.05). The mortality rate was 79.7% in the low group and 22.4% in the normal group (p < 0.001). Microbiological growth was observed in 68.6% of the normal group and 52.6% of the normal group (p = 0.025). The number of cultures with resistant bacteria was significantly higher in the low group (25.9%) than that in the normal group (17.5%) (p = 0.035). The severe COVID-19 patients hospitalized with vitamin D deficiency may have increased risks of poor prognosis and mortality due to secondary infections in the ICU.

Are persistent aircraft trails a threat to the environment and health?

According to most scientific studies, media and governments, the white trails that can be seen behind aircraft in flight, corresponding to condensation mixed with engine particulate emissions, only persist under specific atmospheric conditions. They are called condensation trails, and cirrus contrails when they remain for hours to reach several kilometers wide. The fact that they have gradually filled the skies over the last twenty years would be due to the increase in air traffic. However, other official documents link these persistent trails to a weather modification technology called solar geoengineering by stratospheric aerosol injection (SAI). These sprays would be mainly composed of metallic particles (Al, Ba, Sr, Fe, nanoparticles) and sulfur, which would considerably increase air, soil and water pollution. Many of the current environmental and health problems are consistent with those described in the literature on solar geoengineering by SAI if this method was employed. For example, metal particles used are well known environmental contaminants, ozone layer depletion, cardiorespiratory diseases, neurodegenerative diseases, sunburn. The observations (whiter skies, less solar power) also correspond to the same risks as those described in the solar geoengineering works. Patents show that this weather modification technology has been known and mastered for a long time. In addition, some scientific papers as well as policy documents suggest that solar geoengineering by SAI has been used for many years. The amount of official information presented in this review is intended to open new ways of investigation, free of conflicts of interest, about the growing global pollution of persistent aircraft trails and their possible links with solar geoengineering by SAI.

Vitamin D: a potentially important secosteroid for coping with COVID-19

COVID-19 is a disease that has caused a high number of deaths in the world, and despite being controlled, it requires attention and the search for new quick and economical therapeutic strategies. In this sense, vitamin D stands out, an immunomodulator that has shown beneficial effects in decreasing the risk and severity of acute respiratory tract infections, including COVID-19. Therefore, this review presents a number of experimental, observational and clinical studies on the importance of vitamin D against viral infections with an emphasis on COVID-19, highlighting the relationship between vitamin D, Renin-Angiotensin System and cytokine storms with decreased inflammatory lesions in patients with COVID-19. In addition, aspects of pathophysiology, metabolism, risk factors, sources and recommendations of vitamin D are described. We conclude that vitamin D plays a protective role against inflammatory lesions and can decrease the risk of infections and the severity of COVID-19. Therefore, it is essential to maintain adequate levels of vitamin D to avoid complications related to its deficiency.

Vitamin D assessment in patients with COVID-19 virus and correlation with severity

Background

Vitamin D may play a vital role in preventing the multi-system consequences of COVID-19 infections. The aim of this study is to evaluate the potential association between mean serum levels of vitamin D and COVID-19 and its correlation with severity and mortality.

Results

A case-control study conducted on 80 Egyptian patients admitted at Ain Shams University designated hospitals, Cairo, Egypt, from March 2021 to September 2021. Regarding the laboratory investigations, we found that COVID-19 cases have significantly lower lymphocytic counts than controls. Regarding vitamin D, this study showed a statistically significant positive correlation between vitamin D and lymphocytes, and there were statistically significant negative correlations between vitamin D, neutrophil-lymphocyte ratio, C-reactive protein, blood urea nitrogen, serum creatinine, aspartate aminotransferase, alanine aminotransferase, ferritin, lactate dehydrogenase, and D-dimer.

Conclusion

This study confirms that vitamin D deficiency is associated with the severity of COVID-19 clinically and laboratory.

Effective food hygiene principles and dietary intakes to reinforce the immune system for prevention of COVID-19: a systematic review

Background

This study aimed at reviewing effective food hygiene principles and dietary intakes to reinforce the immune system for prevention of corona virus disease 2019 (COVID-19).

Methods

The systematic literature search was performed in three databases from Jan. 2020 up to 10^th July 2020. English articles that focused on nutrition, food, immunity and corona virus were searched. Systematic and narrative reviews were included.

Results

After evaluation of search papers, 27 relevant articles were used in this review. The importance of nutrients, phytochemicals, probiotics and some spices were highlighted for enhancing immunity during the COVID-19 pandemic. A healthy dietary pattern with proper energy intake provides sufficient nutrients. The unhealthy dietary pattern is linked with inflammation and risk factors related to high mortality in patients with severe COVID-19 infection. Different thermal procedures have been used for the inactivation of viruses. It is recommended not to consume raw or undercooked animal products.

Conclusions

It is critical to ensure that the nutritional needs of the population are met and sustained based on standards during a COVID-19 pandemic. Clear advice on adequate calorie intake and an optimal healthy diet to support the immune function should be provided. Good hygiene practices must be performed by everyone and done in the food industry.

Vitamin D and COVID-19 Severity in Hospitalized Older Patients: Potential Benefit of Prehospital Vitamin D Supplementation

Studies involving the associations between vitamin D supplementation taken before the onset of COVID-19 infection and the clinical outcomes are still scarce and this issue remains controversial. This study aimed to assess the relationships between vitamin D (VitD) status and supplementation and coronavirus disease 2019 (COVID-19) severity in older adults (average age of 78 years) hospitalized for COVID-19. We conducted an observational retrospective cohort study with 228 older hospitalized patients during the first wave of the COVID-19 pandemic. The outcomes were in-hospital mortality secondary to COVID-19 or critically severe COVID-19. A logistic regression analysis was conducted to test whether pre-hospital VitD supplementation was independently associated with severity. In this study, 46% of patients developed a severe form and the overall in-hospital mortality was 15%. Sixty-six (29%) patients received a VitD supplement during the 3 months preceding the infection onset. Additionally, a VitD supplement was associated with fewer severe COVID-19 forms (OR = 0.426, p = 0.0135) and intensive care unit (ICU) admissions (OR = 0.341, p = 0.0076). As expected, age > 70 years, male gender and BMI ≥ 35 kg/m2 were independent risk factors for severe forms of COVID-19. No relationship between serum 25(OH)D levels and the severity of the COVID-19 was identified. VitD supplementation taken during the 3 months preceding the infection onset may have a protective effect on the development of severe COVID-19 forms in older adults. Randomized controlled trials and large-scale cohort studies are necessary to strengthen this observation.

The relationship between vitamin D deficiency, body composition, and physical/cognitive functions

Vitamin D deficiency is still an important subject due to its significant effects on various tissues and functions. We found a relationship between vitamin D deficiency and increase in adipose tissue thicknesses. This situation reveals the importance of vitamin D supplementation, the harms of weight gain and obesity, and the importance of a balanced diet.

PURPOSE

Although the relationship between vitamin D (VitD) levels with body composition and physical/cognitive functions have been investigated in various studies, however, there is no study evaluating all these parameters together. In accordance with, we aimed to evaluate the relationship between VitD deficiency with body composition (i.e., skin, subcutaneous fat, and muscle thicknesses) and physical/cognitive functions.

METHODS

A total of 203 adults (78 M, 125 F, aged 19-91 years) who had recent 25-OH-vitamin D measurements were included. Ultrasonographic (US) measurements (skin, subcutaneous fat, and muscle thicknesses) were made from the dorsum of the hand, and anterior sides of forearm, arm, and thigh. Handgrip strength, gait speed, Timed Up and Go Test, and Chair Stand Test were evaluated. Additionally, cognitive status was also evaluated with Mini-Mental State Exam.

RESULTS

Subjects were classified as VitD deficient group (< 20 ng/ml, N = 125) and control group (≥ 20 ng/ml, N = 78). The groups were not significantly different as regards age, gender, and anthropometric measurements (all p > 0.05). Subcutaneous fat tissues were thicker in the VitD deficient group (all p < 0.05). All the other US measurements and functional/cognitive tests were not significantly different between the groups (all p > 0.05). According to linear regression analyses, body mass index (BMI) was independently related with all subcutaneous fat thicknesses in both genders, and VitD deficiency was related with all subcutaneous fat thicknesses in females and anterior forearm subcutaneous fat thickness in males (all p < 0.05).

CONCLUSION

We imply that together with BMI, VitD deficiency is independently related with increased regional subcutaneous fat tissue. We also underscore the role of US measurements for evaluation of body composition in related clinical scenarios.

The Role of Immunomodulatory Nutrients in Alleviating Complications Related to SARS-CoV-2: A Scoping Review

The recent coronavirus disease 2019 (COVID-19) pandemic has warranted the need to investigate potential therapies or prophylaxis against this infectious respiratory disease. There is emerging evidence about the potential role of nutrients on COVID-19 in addition to using medications such as hydroxychloroquine and azithromycin. This scoping review aims to explore the literature evaluating the effect of immunomodulatory nutrients on the outcomes including hospitalization, intensive care unit admission, oxygen requirement, and mortality in COVID-19 patients. A literature search of databases including Medline, EMBASE, CINAHL, Web of Science, Cochrane, Scopus, and PubMed, as well as hand-searching in Google Scholar (up to 10 February 2021) was conducted. All human studies with different study designs and without limitation on publication year were included except for non-English-language and review articles. Overall, out of 4412 studies, 19 met our inclusion criteria. Four studies examined the impact of supplementation with vitamin C, 4 studies - zinc, 8 studies - vitamin D, and 3 studies investigated the combination of 2 (zinc and vitamin C) or 3 (vitamin D, vitamin B-12, and magnesium) nutrients. Although limited data exist, available evidence demonstrated that supplementation with immune-supportive micronutrients such as vitamins D and C and zinc may modulate immunity and alleviate the severity and risk of infection. The effectiveness of vitamin C, vitamin D, and zinc on COVID-19 was different based on baseline nutrient status, the duration and dosage of nutrient therapy, time of administration, and severity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease. This review indicated that supplementation with high-dose vitamin C, vitamin D, and zinc may alleviate the complications caused by COVID-19, including inflammatory markers, oxygen therapy, length of hospitalization, and mortality; however, studies were mixed regarding these effects. Further randomized clinical trials are necessary to identify the most effective nutrients and the safe dosage to combat SARS-CoV-2.

Anxiety Levels and Changes in Health and Hygiene Behaviors in Mothers of Children with Asthma in Early COVID-19 Lockdown in Turkey

Objective: The restrictions imposed by the coronavirus disease 2019 (COVID-19) pandemic have caused significant changes in people's lives. This study aimed to investigate anxiety levels and changes in health and hygiene behaviors in mothers of children with asthma in early COVID-19 lockdown in Turkey. Materials and Methods: This study was a cross-sectional survey conducted on children with asthma, 6 to 11 years of age, between June 1 and 30, 2020, in Turkey. A sociodemographic data form, health and hygiene behavior form, childhood asthma control test, and state-trait anxiety inventory were administered to the mothers of the children. Results: The asthma group included 123 children (Female: 39.0%) and median age, interquartile range (IQR) [minimum-maximum]: 8.0 (6) [6-12] years; the control group included 88 children (Female: 47.7%) median age, IQR [minimum-maximum]: 8.0 (7) [5-12] years. Increased hygiene behaviors and high compliance with social isolation measures were recorded in the early lockdown, with no difference between the groups. Before the pandemic, the most frequently used cleaning products were general-purpose cleaners. During the early lockdown, however, the most frequently used product was disinfectants and was similar in both groups. In both groups, the rate of using nutritional supplements increased during the pandemic period, but the rate was higher in children with asthma both before and during the early lockdown (P < 0.001). The anxiety levels of the mothers in asthma and control groups were similar. Conclusion: This study is the first in Turkey demonstrating that, in mothers of children with asthma, lifestyle changes related to health and hygiene and anxiety levels are similar to those of other children and their mothers during the early lockdown period of COVID-19 pandemic.

Pre-infection 25-hydroxyvitamin D3 levels and association with severity of COVID-19 illness

Objective

Studies have demonstrated a potential correlation between low vitamin D status and both an increased risk of infection with SARS-CoV-2 and poorer clinical outcomes. This retrospective study examines if, and to what degree, a relationship exists between pre-infection serum 25-hydroxyvitamin D (25(OH)D) level and disease severity and mortality due to SARS-CoV-2.

Participants

The records of individuals admitted between April 7^th, 2020 and February 4^th, 2021 to the Galilee Medical Center (GMC) in Nahariya, Israel, with positive polymerase chain reaction (PCR) tests for SARS-CoV-2 (COVID-19) were searched for historical 25(OH)D levels measured 14 to 730 days prior to the positive PCR test.

Design

Patients admitted to GMC with COVID-19 were categorized according to disease severity and level of 25(OH)D. An association between pre-infection 25(OH)D levels, divided between four categories (deficient, insufficient, adequate, and high-normal), and COVID-19 severity was ascertained utilizing a multivariable regression analysis. To isolate the possible influence of the sinusoidal pattern of seasonal 25(OH)D changes throughout the year, a cosinor model was used.

Results

Of 1176 patients admitted, 253 had records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients with the severe or critical disease (<20 ng/mL [87.4%]) than in individuals with mild or moderate disease (<20 ng/mL [34.3%] p < 0.001). Patients with vitamin D deficiency (<20 ng/mL) were 14 times more likely to have severe or critical disease than patients with 25(OH)D ≥40 ng/mL (odds ratio [OR], 14; 95% confidence interval [CI], 4 to 51; p < 0.001).

Conclusions

Among hospitalized COVID-19 patients, pre-infection deficiency of vitamin D was associated with increased disease severity and mortality.

COVID-19 Mortality in Europe, by Latitude and Obesity Status: A Geo-Spatial Analysis in 40 Countries

On 30 January 2020, the World Health Organization (WHO) declared the current novel coronavirus disease 2019 (COVID-19) as a public health emergency of international concern and later characterized it as a pandemic. New data show that excess body mass and vitamin D deficiency might be related to the disease severity and mortality. The aim of this study was to evaluate whether latitude, as a proxy of sunlight exposure and Vitamin D synthesis, and prevalent obesity among European populations, is related to COVID-19 spread and severity. European COVID-19 data (incidence and fatality), including information on the prevalence of obesity, social distancing, and others were obtained by the "Our World in Data" website on 17 April 2021. Adjusted analysis showed that higher COVID-19 incidence and fatality were pictured in countries being in higher latitude, both during the whole period, as well as, during the time period 1 November 2020-31 March 2021. Higher incidence and fatality of COVID-19 were observed where the prevalence of overweight/obesity was higher during the whole time period, whereas during the time period 1 November 2020-31 March 2021, only COVID-19 incidence was higher but not a fatality. The present results provide insights for targeted interventions and preventive strategies against COVID-19.

Biomarkers of ageing and frailty may predict COVID-19 severity

Coronavirus Disease 2019 (COVID-19) is caused by the novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) - the culprit of an ongoing pandemic responsible for the loss of over 3 million lives worldwide within a year and a half. While the majority of SARS-CoV-2 infected people develop no or mild symptoms, some become severely ill and may die from COVID-19-related complications. In this review, we compile and comment on a number of biomarkers that have been identified and are expected to enhance the detection, protection and treatment of individuals at high risk of developing severe illnesses, as well as enable the monitoring of COVID-19 prognosis and responsiveness to therapeutic interventions. Consistent with the emerging notion that the majority of COVID-19 deaths occur in older and frail individuals, we researched the scientific literature and report the identification of a subset of COVID-19 biomarkers indicative of increased vulnerability to developing severe COVID-19 in older and frail patients. Mechanistically, increased frailty results from reduced disease tolerance, a phenomenon aggravated by ageing and comorbidities. While biomarkers of ageing and frailty may predict COVID-19 severity, biomarkers of disease tolerance may predict resistance to COVID-19 with socio-economic factors such as access to adequate health care remaining as major non-biomolecular influencers of COVID-19 outcomes.

Formation of ideas about rational nutrition as an element of student’s environmental education

The aim of the work was to form ideas about rational nutrition as an element of ecological education of students by studying and discussing their eating behavior in relation to foods rich in vitamin D using quantitative descriptor-profile analysis. Quantitative descriptor-profile analysis showed that the “poorest” profiles have foods with the highest vitamin D. Thus, foods with a high vitamin D content do not fall into the circle of students’ dietary preferences. The results of the survey showed that the most frequently consumed foods for young people are fried potatoes, pizza, dumplings and cheese. Products such as cheese, butter, artificial red caviar, mushrooms (chanterelles) can be successfully used as a base for fortification with vitamin D, since they are positively perceived by students and affordable. It was shown that cheese is the only product that, when surveyed by 59 young people, was included both in the list of 5 most favorite and frequently consumed foods, and was selected from the list of 22 foods offered to the respondents containing significant amounts of vitamin D. The research carried out is the basis for forming students’ understanding of the importance of a balanced diet in the context of environmental education.

Vitamin D Dosing: Basic Principles and a Brief Algorithm (2021 Update)

Nowadays, in modern societies, many people can be at high risk to have low vitamin D levels. Therefore, testing of serum 25-hydroxy-vitamin D (25OH-D) levels should be performed before prescribing them vitamin D supplementation. However, in some cases the 25OH-D level assessment is not available at the right moment, e.g., due to mandatory quarantine of COVID-19 outpatients. Therefore, such patients could be advised to start taking moderate vitamin D doses (e.g., 4000 IU/day for adults), and their 25-OH-D levels could be checked later. The proposed algorithm also comprises vitamin D dosing principles when baseline 25OH-D levels are known.

Vitamin D and COVID-19 - Let's Explore the Relationship!

Introduction:Vitamin D plays a protective role against COVID-19. Patients with deficiency of vitamin D are more prone to severe SARS-CoV-2 infections. It is known to enhance human β-defensin 2 and antimicrobial peptide. Vitamin D can easily stabilise and manage immunological reactions against SARS-CoV-2. It can also suppress the cytokine storm by boosting the innate system. Material and methods: RT-PCR confirmed COVID-19 positive subjects were divided into two groups, one comprising asymptomatic subjects (Group 1) and the other one ICU admitted patients (Group 2). In both groups, various comorbidities such as obesity, diabetes mellitus, hypertension, cardiovascular disease, respiratory disease, renal disease and malignancy were taken into consideration. Vitamin D estimation was performed along with serum levels of interleukin-6 (IL-6) and ferritin using automated immunoassays on Siemens Advia Centaur XP. Results:On acknowledging the cut-off serum concentration level of vitamin D as < 30 ng/mL for establishing vitamin D deficiency the prevalence of vitamin D deficiency was 66.18% in Group 1 and 98.30% in Group 2. Diabetes mellitus, followed by hypertension was associated comorbidity in both groups. In total, 33 patients were found to be severely deficient (<10 ng/mL) in vitamin D, out of which 27 were critically ill and six asymptomatic. In both groups, diabetes mellitus, followed by hypertension were the highest comorbid associations. Fatality rate (discharge vs fatality) was 0% in Group 1 and 16.94% (10 patients died) in Group 2. Conclusion:To conclude, the present study addressed the significant relationship between vitamin D levels and clinical outcomes of COVID-19 patients. Vitamin D deficiency distinctly upswings the chance of disease severity as well as mortality after SARS-CoV-2 infection.

Comparing Serum Levels of Vitamin D and Zinc in Novel Coronavirus-Infected Patients and Healthy Individuals in Northeastern Iran, 2020

BACKGROUND

COVID-19 infection has recently become a pandemic disease around the world, and its risk factors have not fully evaluated. This study aimed to compare the serum vitamin D (Vit D) and zinc levels in patients infected with novel coronavirus and healthy volunteers (HVs).

METHODS

This was a single-center, cross-sectional study conducted on 56 patients (32 severe cases and 24 nonsevere) admitted to the COVID-19 ward and 46 HVs living in Esfarayen City, North Khorasan Province of Iran. Serum levels of Vit D and zinc in admitted patients to the COVID-19 ward and HVs were measured.

RESULTS

The average levels of serum Vit D in severe cases, nonsevere cases, and HVs were 31.03 ± 15.49, 37.25 ± 18.49, and 39.33 ± 14.83, respectively (P = 0.05). Moreover, the average concentrations of serum zinc in severe cases, nonsevere cases, and HVs were 31.03 ± 15.49, 37.25 ± 18.49, and 39.33 ± 14.83, respectively (P = 0.01). Mortality rate, reinfection (for 5 months), and length of hospital stay in severe cases were higher than in nonsevere cases (P > 0.05).

CONCLUSIONS

Results showed that severe cases had lower levels of Vit D than did other groups and were marginally significant. Also, severe cases had a significantly low level of zinc when compared with nonsevere cases and HVs. Levels of Vit D and zinc can affect the incidence of COVID-19 infection.

Relevance of vitamin D3 in COVID-19 infection

SARS-CoV-2 virus, the main culprit for COVID-19 disaster, has triggered a gust of curiosity both in the mechanism of action of this infection as well as potential risk factors for disease generation and regimentation. The prime focus of the present review, which is basically a narrative one, is in utilizing the current concepts of vitamin D3 as an agent with myriad functions, one of them being immunocompetence and a promising weapon for both innate and adaptive immunity against COVID-19 infection. Some of the manifestations of SARS-CoV-2 virus such as Acute Respiratory Distress Syndrome (ARDS) overlap with the pathophysiological effects that are overcome due to already established role of vitamin D3 e.g., amelioration of cytokine outburst. Additionally, the cardiovascular complications due to COVID-19 infection may also be connected to vitamin D3 levels and the activity of its active forms. Eventually, we summarise the clinical, observational and epidemiological data of the respiratory diseases including COVID-19 disease and try to bring its association with the potential role of vitamin D3, in particular, the activity of its active forms, circulating levels and its supplementation, against dissemination of this disease.

Putative Role of Vitamin D for COVID-19 Vaccination

Severe acute respiratory syndrome coronavirus 2 is a new, highly pathogenic virus that has recently elicited a global pandemic called the 2019 coronavirus disease (COVID-19). COVID-19 is characterized by significant immune dysfunction, which is caused by strong but unregulated innate immunity with depressed adaptive immunity. Reduced and delayed responses to interferons (IFN-I/IFN-III) can increase the synthesis of proinflammatory cytokines and extensive immune cell infiltration into the airways, leading to pulmonary disease. The development of effective treatments for severe COVID-19 patients relies on our knowledge of the pathophysiological components of this imbalanced innate immune response. Strategies to address innate response factors will be essential. Significant efforts are currently underway to develop vaccines against SARS-CoV-2. COVID-19 vaccines, such as inactivated DNA, mRNA, and protein subunit vaccines, have already been applied in clinical use. Various vaccines display different levels of effectiveness, and it is important to continue to optimize and update their composition in order to increase their effectiveness. However, due to the continuous emergence of variant viruses, improving the immunity of the general public may also increase the effectiveness of the vaccines. Many observational studies have demonstrated that serum levels of vitamin D are inversely correlated with the incidence or severity of COVID-19. Extensive evidence has shown that vitamin D supplementation could be vital in mitigating the progression of COVID-19 to reduce its severity. Vitamin D defends against SARS-CoV-2 through a complex mechanism through interactions between the modulation of innate and adaptive immune reactions, ACE2 expression, and inhibition of the renin-angiotensin system (RAS). However, it remains unclear whether Vit-D also plays an important role in the effectiveness of different COVID-19 vaccines. Based on analysis of the molecular mechanism involved, we speculated that vit-D, via various immune signaling pathways, plays a complementary role in the development of vaccine efficacy.

Essential sufficiency of zinc, ω-3 polyunsaturated fatty acids, vitamin D and magnesium for prevention and treatment of COVID-19, diabetes, cardiovascular diseases, lung diseases and cancer

Despite the development of a number of vaccines for COVID-19, there remains a need for prevention and treatment of the virus SARS-CoV-2 and the ensuing disease COVID-19. This report discusses the key elements of SARS-CoV-2 and COVID-19 that can be readily treated: viral entry, the immune system and inflammation, and the cytokine storm. It is shown that the essential nutrients zinc, ω-3 polyunsaturated fatty acids (PUFAs), vitamin D and magnesium provide the ideal combination for prevention and treatment of COVID-19: prevention of SARS-CoV-2 entry to host cells, prevention of proliferation of SARS-CoV-2, inhibition of excessive inflammation, improved control of the regulation of the immune system, inhibition of the cytokine storm, and reduction in the effects of acute respiratory distress syndrome (ARDS) and associated non-communicable diseases. It is emphasized that the non-communicable diseases associated with COVID-19 are inherently more prevalent in the elderly than the young, and that the maintenance of sufficiency of zinc, ω-3 PUFAs, vitamin D and magnesium is essential for the elderly to prevent the occurrence of non-communicable diseases such as diabetes, cardiovascular diseases, lung diseases and cancer. Annual checking of levels of these essential nutrients is recommended for those over 65 years of age, together with appropriate adjustments in their intake, with these services and supplies being at government cost. The cost:benefit ratio would be huge as the cost of the nutrients and the testing of their levels would be very small compared with the cost savings of specialists and hospitalization.

Nanotechnology Integration for SARS-CoV-2 Diagnosis and Treatment: An Approach to Preventing Pandemic

The SARS-CoV-2 outbreak is the COVID-19 disease, which has caused massive health devastation, prompting the World Health Organization to declare a worldwide health emergency. The corona virus infected millions of people worldwide, and many died as a result of a lack of particular medications. The current emergency necessitates extensive therapy in order to stop the spread of the coronavirus. There are various vaccinations available, but no validated COVID-19 treatments. Since its outbreak, many therapeutics have been tested, including the use of repurposed medications, nucleoside inhibitors, protease inhibitors, broad spectrum antivirals, convalescence plasma therapies, immune-modulators, and monoclonal antibodies. However, these approaches have not yielded any outcomes and are mostly used to alleviate symptoms associated with potentially fatal adverse drug reactions. Nanoparticles, on the other hand, may prove to be an effective treatment for COVID-19. They can be designed to boost the efficacy of currently available antiviral medications or to trigger a rapid immune response against COVID-19. In the last decade, there has been significant progress in nanotechnology. This review focuses on the virus's basic structure, pathogenesis, and current treatment options for COVID-19. This study addresses nanotechnology and its applications in diagnosis, prevention, treatment, and targeted vaccine delivery, laying the groundwork for a successful pandemic fight.

Obesity and severe coronavirus disease 2019: molecular mechanisms, paths forward, and therapeutic opportunities

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appears to have higher pathogenicity among patients with obesity. Obesity, termed as body mass index greater than 30 kg/m2, has now been demonstrated to be important comorbidity for disease severity during coronavirus disease 2019 (COVID-19) pandemic and associated with adverse events. Unraveling mechanisms behind this phenomenon can assist scientists, clinicians, and policymakers in responding appropriately to the COVID-19 pandemic. In this review, we systemically delineated the potential mechanistic links between obesity and worsening COVID-19 from altered physiology, underlying diseases, metabolism, immunity, cytokine storm, and thrombosis. Problematic ventilation caused by obesity and preexisting medical disorders exacerbate organ dysfunction for patients with obesity. Chronic metabolic disorders, including dyslipidemia, hyperglycemia, vitamin D deficiency, and polymorphisms of metabolism-related genes in obesity, probably aid SARS-CoV-2 intrusion and impair antiviral responses. Obesity-induced inadequate antiviral immunity (interferon, natural killer cells, invariant natural killer T cell, dendritic cell, T cells, B cell) at the early stage of SARS-CoV-2 infection leads to delayed viral elimination, increased viral load, and expedited viral mutation. Cytokine storm, with the defective antiviral immunity, probably contributes to tissue damage and pathological progression, resulting in severe symptoms and poor prognosis. The prothrombotic state, driven in large part by endothelial dysfunction, platelet hyperactivation, hypercoagulability, and impaired fibrinolysis in obesity, also increases the risk of severe COVID-19. These mechanisms in the susceptibility to severe condition also open the possibility for host-directed therapies in population with obesity. By bridging work done in these fields, researchers can gain a holistic view of the paths forward and therapeutic opportunities to break the vicious cycle of obesity and its devastating complications in the next emerging pandemic.

Vitamin D in the time of the coronavirus (COVID-19) pandemic - a clinical review from a public health and public mental health perspective

Individuals with serious mental disorders (SMD) may have a higher risk of vitamin D (VIT-D) deficiency. They also experience higher mortality because of coronavirus disease 2019 (COVID-19) infection. Therefore, we have conducted a comprehensive review to examine the significance of VIT-D for public health and public mental health during the ongoing COVID-19 pandemic. This review had three specific aims, from a global perspective to (a) create a profile of VIT-D and review the epidemiology of VIT-D deficiency, (b) explore VIT-D deficiency as risk factor for SMD and COVID-19 infections and (c) examine the effectiveness of VIT-D supplementation for both conditions. We found that, in terms of SMD, the evidence from laboratory and observational studies points towards some association between VIT-D deficiency and depression or schizophrenia. Mendelian randomisation studies, however, suggest no, or reverse, causality. The evidence from intervention studies is conflicting. Concerning COVID-19 infection, on proof of principle, VIT-D could provide a plausible defence against the infection itself and against an adverse clinical course. But data from observational studies and the first preliminary intervention studies remain conflicting, with stronger evidence that VIT-D may mitigate the clinical course of COVID-19 infection rather than the risk of infection in the first place. From a public health and public mental health point of view, based on the currently limited knowledge, for individuals with SMD, the benefits of VIT-D optimisation through supplementation seem to outweigh the risks. VIT-D supplementation, however, should not substitute for vaccination or medical care for COVID-19 infection.

Influence of 25-hydroxy-cholecalciferol levels on SARS-CoV-2 infection and COVID-19 severity: A systematic review and meta-analysis

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiological agent of coronavirus disease 19 (COVID-19), a respiratory infection that, starting from December 2019, has spread around the world in a few months, becoming a pandemic. The lack of initial knowledge on its management has led to a great effort in developing vaccines and in finding therapeutic weapons capable of improving the clinical outcome of the affected patients. In particular, the possible role of vitamin D status in the management of COVID-19 has been widely analysed, resulting in a great amount of data. This systematic review and meta-analysis aimed to assess whether hypovitaminosis D is a risk factor for developing SARS-CoV-2 infection and whether it affects the worsening of the clinical course of COVID-19.

METHODS

Data were extracted through extensive searches in the Pubmed, MEDLINE, Cochrane, Academic One Files, Google Scholar, and Scopus databases from December 2019 to January 2021, using the keywords: "Vitamin D", "25 hydroxy Vitamin D", "25 hydroxycholecalciferol", "cholecalciferol", "COVID 19″, "SARS-CoV-2″. We included observational cohort, cross-sectional, and case-control studies that evaluated differences in serum levels of 25‑hydroxy-cholecalciferol [25(OH)D] in patients who were positive or negative for SARS-CoV-2, in patients with mild or severe forms of COVID-19, and in patients who died or were discharged from the hospital. Finally, studies that evaluated the risk of developing severe illness or death in patients with vitamin D deficiency (VDD), defined as levels of 25(OH)D <20 ng/ml, were also included. We calculated the mean difference (MD) and the 95% confidence intervals (CI) for quantitative variables such as 25(OH)D levels in patients with or without SARS-CoV-2 infection, in those with mild vs. severe COVID-19, or those who have died vs. those who have been discharged. Instead, we calculated odds ratios and 95% CI for qualitative ones, such as the number of patients with severe illness/death in the presence of VDD vs. those with normal serum 25(OH)D levels. A p-value lower than 0.05 was considered statistically significant. The study was registered on PROSPERO (CRD42021241473).

FINDINGS

Out of 662 records, 30 articles met inclusion criteria and, therefore, were included in the meta-analysis. We found that the serum levels of 25(OH)D were significantly lower in patients with SARS-CoV-2 infection than in negative ones [MD -3.99 (-5.34, -2.64); p <0.00001; I2= 95%]. Furthermore, its levels were significantly lower in patients with severe disease [MD -6.88 (-9.74, -4.03); p <0.00001; I2=98%] and in those who died of COVID-19 [MD -8.01 (-12.50, -3.51); p = 0.0005; I2=86%]. Finally, patients with VDD had an increased risk of developing severe disease [OR 4.58 (2.24, 9.35); p <0.0001; I2=84%] but not a fatal outcome [OR 4.92 (0.83, 29.31); p = 0.08; I2=94%].

INTERPRETATION

This meta-analysis revealed a large heterogeneity of the studies included due to the different enrolment criteria of patient samples (age, body mass index, ethnicity, comorbidities), the country where they live, all factors influencing serum 25(OH)D levels, and the different criteria used to define the severity of COVID-19. Furthermore, the observational nature of these studies does not allow to establish a cause-effect relationship, even taking into account that 25(OH)D represents a marker of acute inflammation. Treatment with vitamin D might be considered for the primary prevention of SARS-CoV-2 infection and the management of patients with COVID-19. However, further intervention studies are needed to prove this hypothesis.

Cytokine storm modulation in COVID-19: a proposed role for vitamin D and DPP-4 inhibitor combination therapy (VIDPP-4i)

A dysregulated immune response characterized by the hyperproduction of several pro-inflammatory cytokines (a.k.a. 'cytokine storm') plays a central role in the pathophysiology of severe coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this Perspective article we discuss the evidence for synergistic anti-inflammatory and immunomodulatory properties exerted by vitamin D and dipeptidyl peptidase-4 (DPP-4) inhibitors, the latter being a class of antihyperglycemic agents used for the treatment of Type 2 diabetes, which have also been reported as immunomodulators. Then, we provide the rationale for investigation of vitamin D and DPP-4 inhibitor combination therapy (VIDPP-4i) as an immunomodulation strategy to ratchet down the virulence of SARS-CoV-2, prevent disease progression and modulate the cytokine storm in COVID-19.

The possible benefits of vitamin D in COVID-19

Molecular studies have demonstrated the importance of the exacerbated immune response to SARS-CoV-2 infection, called the cytokine storm, in more severe COVID-19. The pathophysiology is complex and involves several homeostatic factors; among them, a deficit of vitamin D draws attention because of its high frequency in the population. Some evidence suggests that people with low serum vitamin D levels have worse outcomes, often requiring intensive care. This review analyzed the studies available in the global literature addressing the benefits of vitamin D in COVID-19, relating serum levels to the severity of the disease, and indicating vitamin D as a possible prophylactic and therapy in infection.

Association between population vitamin D status and SARS-CoV-2 related serious-critical illness and deaths: An ecological integrative approach

BACKGROUND

Vitamin D population status may have possible unappreciated consequences to the coronavirus disease 2019 (COVID-19) pandemic. Α significant association between vitamin D sufficiency and reduction in clinical severity and inpatient mortality from COVID-19 disease has recently been shown, while a recent study has claimed lower COVID-19 cases in European countries with a better vitamin D status. Low serum 25-hydroxyvitamin-D [25(OH)D] was identified as an independent risk factor for COVID-19 infection and hospitalization, and administration of 0.532 mg (21280 IU) of calcifediol or 25(OH)D, followed by 0.266 mg on days 3 and 7 and then weekly until discharge or intensive care unit admission significantly reduced the need for intensive care unit treatment.

AIM

To elucidate the role of vitamin D European population status in the COVID-19 pandemic, data from the Worldometer were analyzed.

METHODS

Linear regression explored the correlation between published representative-standardized population vitamin D concentrations and the number of total cases/million (M), recovered/M, deaths/M and serious-critically ill/M from COVID-19 for 26 European countries populated > 4 M (Worldometer). Life expectancy was analyzed with semi-parametric regression. Weighted analysis of variance/analysis of covariance evaluated serious-critical/M and deaths/M by the vitamin D population status: Deficient < 50, insufficient: 50-62.5, mildly insufficient > 62.5-75 and sufficient > 75 nmol/L, while controlling for life expectancy for deaths/M. Statistical analyses were performed in XLSTAT LIFE SCIENCE and R (SemiPar Library).

RESULTS

Linear regression found no correlation between population vitamin D concentrations and the total cases-recovered/M, but negative correlations predicting a reduction of 47%-64%-80% in serious-critical illnesses/M and of 61%-82%-102.4% in deaths/M further enhanced when adapting for life expectancy by 133-177-221% if 25(OH)D concentrations reach 100-125-150 nmol/L, sustained on August 15, 2020, indicating a truthful association. Weighted analysis of variance was performed to evaluate serious-critical/M (r 2 = 0.22) by the vitamin D population status and analysis of covariance the deaths/M (r 2 = 0.629) controlling for life expectancy (r 2 = 0.47). Serious-critical showed a decreasing trend (P < 0.001) from population status deficient (P < 0.001) to insufficient by 9.2% (P < 0.001), to mildly insufficient by 47.6% (P < 0.044) and to sufficient by 100% (reference, P < 0.001). For deaths/M the respective decreasing trend (P < 0.001) was 62.9% from deficient (P < 0.001) to insufficient (P < 0.001), 65.15% to mildly insufficient (P < 0.001) and 78.8% to sufficient (P = 0.041).

CONCLUSION

Achieving serum 25(OH)D 100-150 nmol/L (40-60 ng/mL) (upper tolerable daily doses followed by maintenance proposed doses not requiring medical supervision, Endocrine Society) may protect from serious-critical illness/death from COVID-19 disease.

Immunological Aspects of SARS-CoV-2 Infection and the Putative Beneficial Role of Vitamin-D

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is still an ongoing global health crisis. Immediately after the inhalation of SARS-CoV-2 viral particles, alveolar type II epithelial cells harbor and initiate local innate immunity. These particles can infect circulating macrophages, which then present the coronavirus antigens to T cells. Subsequently, the activation and differentiation of various types of T cells, as well as uncontrollable cytokine release (also known as cytokine storms), result in tissue destruction and amplification of the immune response. Vitamin D enhances the innate immunity required for combating COVID-19 by activating toll-like receptor 2. It also enhances antimicrobial peptide synthesis, such as through the promotion of the expression and secretion of cathelicidin and β-defensin; promotes autophagy through autophagosome formation; and increases the synthesis of lysosomal degradation enzymes within macrophages. Regarding adaptive immunity, vitamin D enhances CD4+ T cells, suppresses T helper 17 cells, and promotes the production of virus-specific antibodies by activating T cell-dependent B cells. Moreover, vitamin D attenuates the release of pro-inflammatory cytokines by CD4+ T cells through nuclear factor κB signaling, thereby inhibiting the development of a cytokine storm. SARS-CoV-2 enters cells after its spike proteins are bound to angiotensin-converting enzyme 2 (ACE2) receptors. Vitamin D increases the bioavailability and expression of ACE2, which may be responsible for trapping and inactivating the virus. Activation of the renin-angiotensin-aldosterone system (RAS) is responsible for tissue destruction, inflammation, and organ failure related to SARS-CoV-2. Vitamin D inhibits renin expression and serves as a negative RAS regulator. In conclusion, vitamin D defends the body against SARS-CoV-2 through a novel complex mechanism that operates through interactions between the activation of both innate and adaptive immunity, ACE2 expression, and inhibition of the RAS system. Multiple observation studies have shown that serum concentrations of 25 hydroxyvitamin D are inversely correlated with the incidence or severity of COVID-19. The evidence gathered thus far, generally meets Hill's causality criteria in a biological system, although experimental verification is not sufficient. We speculated that adequate vitamin D supplementation may be essential for mitigating the progression and severity of COVID-19. Future studies are warranted to determine the dosage and effectiveness of vitamin D supplementation among different populations of individuals with COVID-19.

Respiratory Tract Infections and Antibiotic Resistance: A Protective Role for Vitamin D?

Upper and lower respiratory tract infections are among the most common infections globally, and in the United Kingdom, they account for about half of all oral antibiotics prescribed. Antibiotic overuse and the emergence of "superbugs" that are resistant to their effects is a global problem that is becoming a serious concern. Considering this, the potential role of immunonutrition as a "prehabilitation" in helping to tackle bacterial infections and reduce over-reliance on antibiotic usage is gaining interest. This narrative mini-review summarizes current knowledge on the roles of certain nutrients in helping to modulate immune function, with particular focus on vitamin D. Vitamin D supplementation appears to reduce the risk of acute respiratory tract infections and thus could have a valuable role to play in reducing over-reliance on antibiotics. Investment in high-quality trials is needed to further explore this field.

Vitamin D and COVID-19: It is time to act

Vitamin D (VitD) deficiency is considered a global problem and might be associated with increased susceptibility to COVID-19 illness. In the light of COVID-19 pandemic, VitD might be a promising agent for fighting the SARS-CoV-2, since VitD is involved in various pathophysiological mechanisms that occur during COVID-19 infection. High-dose VitD supplementation, particularly for risk groups, could be recommended to achieve and maintain optimal (range 40-60 ng/mL) serum 25-hydroxy vitamin D levels (marker of VitD status) both for COVID-19 prevention and treatment.

Low vitamin D status is associated with coronavirus disease 2019 outcomes: a systematic review and meta-analysis

BACKGROUND

Observational studies suggest that the risk and clinical prognosis of coronavirus disease 2019 (COVID-19) are related to low vitamin D status; however, the data are inconsistent.

OBJECTIVES

We conducted a systematic review and meta-analysis to assess the association between low vitamin D status and COVID-19.

METHODS

A systematic search was conducted with PubMed, Embase, and the Cochrane Library from database inception to September 25, 2020. The standardized mean difference (SMD) or odds ratio (OR) and corresponding 95% confidence interval (CI) was applied to estimate pooled results. Random - or fixed-effect models based on heterogeneity were used for the meta-analysis. Funnel plots and Egger regression tests were used to assess publication bias.

RESULTS

A total of ten articles with 361,934 participants were selected for meta-analysis. Overall, the pooled OR in the fixed-effect model showed that vitamin D deficiency or insufficiency was associated with an increased risk of COVID-19 (OR = 1.43, 95% CI 1.00-2.05). In addition, COVID-19-positive individuals had lower vitamin D levels than COVID-19-negative individuals (SMD = -0.37, 95% CI = -0.52 to -0.21). Significant heterogeneity existed in both endpoints. Funnel plots and Egger regression tests revealed significant publication bias.

CONCLUSIONS

This systematic review and meta-analysis indicated that low vitamin D status might be associated with an increased risk of COVID-19 infection. Further studies are needed to evaluate the impact of vitamin D supplementation on the clinical severity and prognosis in patients with COVID-19.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020216740.

Nanomedicine for COVID-19: the role of nanotechnology in the treatment and diagnosis of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the recent outbreak of coronavirus 2019 (COVID-19). Although nearly two decades have passed since the emergence of pandemics such as SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), no effective drug against the CoV family has yet been approved, so there is a need to find newer therapeutic targets. Currently, simultaneous research across the globe is being performed to discover efficient vaccines or drugs, including both conventional therapies used to treat previous similar diseases and emerging therapies like nanomedicine. Nanomedicine has already proven its value through its application drug delivery and nanosensors in other diseases. Nanomedicine and its components can play an important role in various stages of prevention, diagnosis, treatment, vaccination, and research related to COVID-19. Nano-based antimicrobial technology can be integrated into personal equipment for the greater safety of healthcare workers and people. Various nanomaterials such as quantum dots can be used as biosensors to diagnose COVID-19. Nanotechnology offers benefits from the use of nanosystems, such as liposomes, polymeric and lipid nanoparticles, metallic nanoparticles, and micelles, for drug encapsulation, and facilitates the improvement of pharmacological drug properties. Antiviral functions for nanoparticles can target the binding, entry, replication, and budding of COVID-19. The toxicity-related inorganic nanoparticles are one of the limiting factors of its use that should be further investigated and modified. In this review, we are going to discuss nanomedicine options for COVID-19 management, similar applications for related viral diseases, and their gap of knowledge.

Putative roles of vitamin D in modulating immune response and immunopathology associated with COVID-19

The first incidence of COVID-19 was reported in the Wuhan city of Hubei province in China in late December 2019. Because of failure in timely closing of borders of the affected region, COVID-19 spread across like a wildfire through air travel initiating a pandemic. It is a serious lower respiratory track viral infection caused by highly contagious, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Coronavirus including COVID-19 causing SARS-CoV-2 causes zoonotic diseases and thought to be originated from bats. Since its first incidence, the virus has spread all across the world, causing serious human casualties, economic losses, and disrupting global supply chains. As with SARS-CoV, COVID-19 causing SARS-CoV-2 follows a similar path of airborne infection, but is less lethal and more infectious than SARS and MERS. This review focusses on the pathogenesis of SARS-CoV-2, especially on the dysfunctional immune responses following a cytokine storm in severely affected persons. The mode of entry of SARS-CoV-2 is via the angiotensin converting enzyme 2 (ACE-2) receptors present on the epithelial lining of lungs, gastrointestinal tract, and mucus membranes. Older persons with weaker immune system and associated co-morbidities are more vulnerable to have dysfunctional immune responses, as most of them concomitantly have severe hypovitaminosis D. Consequently, causing severe damage to key organs of the body including lungs and the cardiovascular system. Since, vast majority of persons enters to the intensive care units and died, had severe vitamin D deficiency, thus, this area must be investigated seriously. In addition, this article assesses the role of vitamin D in reducing the risk of COVID-19. Vitamin D is a key regulator of the renin-angiotensin system that is exploited by SARS-CoV-2 for entry into the host cells. Further, vitamin D modulates multiple mechanisms of the immune system to contain the virus that includes dampening the entry and replication of SARS-CoV-2, reduces concentration of pro-inflammatory cytokines and increases levels of anti-inflammatory cytokines, enhances the production of natural antimicrobial peptide and activates defensive cells such as macrophages that could destroy SARS-CoV-2. Thus, this article provides the urgency of needed evidences through large population based randomized controlled trials and ecological studies to evaluate the potential role of vitamin D in COVID-19.

Effects of Vitamin D on COVID-19 Infection and Prognosis: A Systematic Review

INTRODUCTION

Vitamin D status is related to risks of influenza and respiratory tract infections. Vitamin D has direct antiviral effects primarily against enveloped viruses, and coronavirus is an enveloped virus. The 2019 coronavirus disease had a high mortality rate and impacted the whole population of the planet, with severe acute respiratory syndrome the principal cause of death. Vitamin D can adequately modulate and regulate the immune and oxidative response to infection with COVID-19. The goal of this systematic review was thus to summarize and decide if there were a link between vitamin D status and COVID-19 infection and prognosis.

METHODS

The protocol of this study is documented in the Prospero database and can be accessed with the protocol number CRD42020201283. PubMed and Google Scholar were used for a literature search from August 2020 to September 2020. We restricted the year of publication of reviewed articles to 2019-2020, and the selected language was English. Studies that used secondary data, feedback, or analysis of reviews were removed. To assess the standard of studies included, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method was used.

RESULTS

Of the nine studies reviewed, seven (77.8%) showed that COVID-19 infection, prognosis, and mortality were correlated with vitamin D status.

CONCLUSION

Most of the articles reviewed showed that blood vitamin D status can determine the risk of being infected with COVID-19, seriousness of COVID-19, and mortality from COVID-19. Therefore, maintaining appropriate levels of Vitamin D through supplementation or natural methods, eg, sunlight on the skin, is recommended for the public to be able to cope with the pandemic.

Grip strength as a predictor of disease severity in hospitalized COVID-19 patients

BACKGROUND

Grip strength is one of the main components for the physical functioning in sarcopenia and physical frailty.

OBJECTIVES

To explore the role of grip strength measurement at admission for predicting disease severity in COVID-19.

METHODS

Demographic data, smoking status, comorbidities, COVID-19 related symptoms, grip strength, laboratory and computed tomography (CT) findings at admission were all noted. Using a Smedley hand dynamometer, the maximum grip strength value (kg) after three measurements on the dominant side was recorded. Low grip strength was defined as two standard deviations below the gender-specific peak mean value of the healthy young adults (<32 kg for males, <19 kg for females). Patients were categorized into three groups according to clinical and CT findings. Severe illness group had pneumonia with a respiratory rate >30/min, oxygen saturation ≤90%, or extensive lung involvement in CT. Moderate illness group had pneumonia with CT score ≤11. Mild illness group had normal CT findings.

RESULTS

The study population included 312 patients (140 F, 172 M). The distribution of mild, moderate and severe disease groups were 36.9%, 51.0% and 12.2%, respectively. Cough, fever, dyspnea, hypertension, obesity, cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) were most frequent, and C-reactive protein (CRP), ferritin, D-dimer, and neutrophil levels were highest in the severe group (all p<.05). Absolute grip strength values were lowest and the frequency of having low grip strength were highest in the severe group (both p<.01). Since we found that the significant differences were stemming from the severe group, we combined the mild and moderate group as non-severe, and compared severe vs. non-severe groups with binary logistic regression analyses. When age, gender, body mass index, smoking status, presence of comorbidities and low grip strength, and abnormal laboratory findings were taken into analyses; age (odds ratio [OR]: 1.054 [95% confidence interval (CI): 1.020-1.089]), obesity (OR: 2.822 [95% CI: 1.143-6.966]), COPD (OR: 5.699 [95 %CI: 1.231-26.383]), CRP level (OR: 1.023 [95% CI: 1.010-1.036]) and low grip strength (OR: 3.047 [95% CI: 1.146-8.103]) were observed to be independent predictors for severe COVID-19 disease (all p<.05).

CONCLUSIONS

In addition to the well-known independent risk factors (i.e. age, obesity, COPD, and CRP level), low grip strength independently increased (about three times) the severity of COVID-19.

Perspective Adjunctive Therapies for COVID-19: Beyond Antiviral Therapy

The coronavirus disease 2019 (COVID-19) pandemic is the largest health crisis ever faced worldwide. It has resulted in great health and economic costs because no effective treatment is currently available. Since infected persons vary in presentation from healthy asymptomatic mild symptoms to those who need intensive care support and eventually succumb to the disease, this illness is considered to depend primarily on individual immunity. Demographic distribution and disease severity in several regions of the world vary; therefore, it is believed that natural inherent immunity provided through dietary sources and traditional medicines could play an important role in infection prevention and disease progression. People can boost their immunity to prevent them from infection after COVID-19 exposure and can reduce their inflammatory reactions to protect their organ deterioration in case suffering from the disease. Some drugs with in-situ immunomodulatory and anti-inflammatory activity are also identified as adjunctive therapy in the COVID-19 era. This review discusses the importance of COVID-19 interactions with immune cells and inflammatory cells; and further emphasizes the possible pathways related with traditional herbs, medications and nutritional products. We believe that such pathophysiological pathway approach treatment is rational and important for future development of new therapeutic agents for prevention or cure of COVID-19 infection.

Impact of Serum 25(OH) Vitamin D Level on Mortality in Patients with COVID-19 in Turkey

BACKGROUND

Because of the lack of sufficient data, we aimed to investigate the role of serum 25(OH) vitamin D level on COVID severity and related mortality.

METHODS

This was a retrospective observational study. Data, including sociodemographic features, clinical characteristics, and laboratory data, and 25(OH) vitamin D levels were recorded for each study participant. Patients were stratified into different vitamin D groups; Normal (Serum 25(OH) vitamin D level >30 ng/mL), Vitamin D insufficiency (21-29 ng/mL), and deficiency (<20 ng/mL). The severity of COVID was classified according to the Chinese Clinical Guideline for classification of COVID-19 severity. Mortality data were determined for participants. Univariate and multivariate Logistic regression analysis was performed to determine independent predictors of in-hospital mortality.

RESULTS

Overall, 149 COVID-19 patients (females 45.6%, mean age 63.5 ± 15.3 (range 24-90 years) years) were included. Forty-seven patients (31.5%) had moderate COVID-19, whereas 102 patients (68.5%) had severe-critical COVID-19. The mean 25(OH) vitamin D level was 15.2 ± 10.3 ng/mL. Thirty-four (22.8%) and 103 (69.1%) patients had vitamin D insufficiency and deficiency, respectively. Mean serum 25(OH) vitamin D level was significantly lower in patients with severe-critical COVID-19 compared with moderate COVID-19 (10.1 ± 6.2 vs. 26.3 ± 8.4 ng/mL, respectively, p<0.001). Vitamin D insufficiency was present in 93.1% of the patients with severe-critical COVID-19. Multivariate logistic regression analysis revealed that only lymphocyte count, white blood cell count, serum albumin and, 25(OH) vitamin D level were independent predictors of mortality.

CONCLUSION

Serum 25(OH) vitamin D was independently associated with mortality in COVID-19 patients.

Immune-boosting role of vitamins D, C, E, zinc, selenium and omega-3 fatty acids: Could they help against COVID-19?

The world is currently in the grips of the coronavirus disease (COVID-19) pandemic, caused by the SARS-CoV-2 virus, which has mutated to allow human-to-human spread. Infection can cause fever, dry cough, fatigue, severe pneumonia, respiratory distress syndrome and in some instances death. COVID-19 affects the immune system by producing a systemic inflammatory response, or cytokine release syndrome. Patients with COVID-19 have shown a high level of pro-inflammatory cytokines and chemokines. There are currently no effective anti-SARS-CoV-2 viral drugs or vaccines. COVID-19 disproportionately affects the elderly, both directly, and through a number of significant age-related comorbidities. Undoubtedly, nutrition is a key determinant of maintaining good health. Key dietary components such as vitamins C, D, E, zinc, selenium and the omega 3 fatty acids have well-established immunomodulatory effects, with benefits in infectious disease. Some of these nutrients have also been shown to have a potential role in the management of COVID-19. In this paper, evidence surrounding the role of these dietary components in immunity as well as their specific effect in COVID-19 patients are discussed. In addition, how supplementation of these nutrients may be used as therapeutic modalities potentially to decrease the morbidity and mortality rates of patients with COVID-19 is discussed.

The association between the level of serum 25(OH) vitamin D, obesity, and underlying diseases with the risk of developing COVID-19 infection: A case-control study of hospitalized patients in Tehran, Iran

BACKGROUND AND OBJECTIVES: The outbreak of COVID-19 has created a global public health crisis. Little is known about the predisposing factors of this infection. The aim of this study was to explore an association between the serum vitamin D level, obesity, and underlying health conditions, as well as the vulnerability to COVID-19 in the Iranian population.

METHODS

We conducted a case-control study of 201 patients with coronavirus infection and 201 controls. Cases and controls were matched for age and gender. The study was carried out for 2 months (February 2020-April 2020) at Imam Khomeini Hospital Complex, Tehran, Iran. Serum 25(OH) vitamin D was measured using the enzyme-linked immunosorbent assay method. Information containing age, gender, clinical symptoms, body mass index, computed tomography scan findings, and underlying health conditions related to each participant were elicited from health records.

RESULTS

A significant negative correlation (p = .02) was observed between the serum vitamin D level and developing coronavirus infection. Also, the results showed that the COVID-19 cases were more likely to be overweight than the controls (p = .023). Diabetes mellitus, hypertension, and respiratory infections were found in 20.89%, 9.65%, and 6.96% of cases, respectively. These underlying health conditions were not significantly different between cases and controls (p = .81).

CONCLUSIONS

Vitamin D deficiency and obesity are two main predisposing factors associated with the vulnerability to coronavirus infection in the Iranian population.

[The role of vitamin D in seasonal acute respiratory viral infections and COVID-19]

A link between vitamin D deficiency and susceptibility to infectious diseases was suggested over a hundred years ago. Epidemiological studies show a strong association between seasonal fluctuations in vitamin D levels and the incidence of various infectious diseases, including septic shock, acute respiratory infections, and influenza. Our understanding of vitamin D metabolism and its extra-skeletal functions has improved significantly over the past three decades, and the discovery that the vitamin D receptor and 1a-hydroxylase, an enzyme needed to convert vitamin D to its active form, is present in the cells of the immune system, revolutionized in this area. Recent studies have shown that vitamin D regulates the expression of specific endogenous antimicrobial peptides in immune cells, modulates the immune response and the course of autoimmune processes; these actions indicate the potential role of vitamin D in modulating the immune response to various infectious diseases. This publication reviews the literature on the effects of vitamin D on immunity, its potential in the prevention and treatment of viral diseases, with a particular focus on COVID-19.

The potential link between inherited G6PD deficiency, oxidative stress, and vitamin D deficiency and the racial inequities in mortality associated with COVID-19

There is a marked variation in mortality risk associated with COVID-19 infection in the general population. Low socioeconomic status and other social determinants have been discussed as possible causes for the higher burden in African American communities compared with white communities. Beyond the social determinants, the biochemical mechanism that predisposes individual subjects or communities to the development of excess and serious complications associated with COVID-19 infection is not clear. Virus infection triggers massive ROS production and oxidative damage. Glutathione (GSH) is essential and protects the body from the harmful effects of oxidative damage from excess reactive oxygen radicals. GSH is also required to maintain the VD-metabolism genes and circulating levels of 25-hydroxyvitamin D (25(OH)VD). Glucose-6-phosphate dehydrogenase (G6PD) is necessary to prevent the exhaustion and depletion of cellular GSH. X-linked genetic G6PD deficiency is common in the AA population and predominantly in males. Acquired deficiency of G6PD has been widely reported in subjects with conditions of obesity and diabetes. This suggests that individuals with G6PD deficiency are vulnerable to excess oxidative stress and at a higher risk for inadequacy or deficiency of 25(OH)VD, leaving the body unable to protect its 'oxidative immune-metabolic' physiological functions from the insults of COVID-19. An association between subclinical interstitial lung disease with 25(OH)VD deficiencies and GSH deficiencies has been previously reported. We hypothesize that the overproduction of ROS and excess oxidative damage is responsible for the impaired immunity, secretion of the cytokine storm, and onset of pulmonary dysfunction in response to the COVID-19 infection. The co-optimization of impaired glutathione redox status and excess 25(OH)VD deficiencies has the potential to reduce oxidative stress, boost immunity, and reduce the adverse clinical effects of COVID-19 infection in the AA population.

Effects of Comorbid Factors on Prognosis of Three Different Geriatric Groups with COVID-19 Diagnosis

Coronavirus disease 2019 (COVID-19) is a new zoonotic infectious disease that was first reported to the World Health Organization (WHO) on December 31, 2019, and declared as a pandemic by WHO on March 11, 2020. Due to the increased incidence of multimorbidity in geriatric age groups, COVID-19 disease leads to more severe consequences in the elderly. We aimed to determine the effects of age, comorbidity factors, symptoms, laboratory findings, and radiological results on prognosis by dividing our patients into 3 different geriatric age groups, using a retrospective descriptive analysis method. Patients included in the retrospective study (n = 483) were divided into the following three different geriatric age groups: young-old (65-74 years), middle-aged (75-84 years), and the oldest-elderly (85 years and over).The length of stay in the intensive care unit of the patients between the ages of 75-84 was higher than the other two groups (p = 0.013). Mortality rates were lowest in patients aged 65-74 years (p < 0.001). The rate of ground glass opacity in thorax CT was higher in patients with mortality (p < 0.001). While the rate of COPD-bronchial asthma was higher in surviving patients (p = 0.001), malignancy (p = 0.005) and cerebrovascular disease (p < 0.001) were higher in patients who died. Patients aged between 75 and 84 (OR: 2.602; 95% CI: 1.306-5.183; p = 0.007) or ≥ 85 (OR: 4.086; 95% CI: 1.687-9.9; p = 0.002) had higher risk for mortality compared to patients aged between 65 and 74. The lowest mortality rates were observed in patients aged 65-74 years. Among the supportive diagnostic methods in 3 different geriatric age groups, PCR positivity has no effect on mortality, while the ground glass opacity on tomography is closely related to the need for intensive care and increased mortality. In patients with COPD-bronchial asthma comorbidity and those with symptoms of fatigue, dry cough, and sore throat, transfer to intensive care and mortality rates were lower, while patients who were transferred to intensive care and who developed mortality had higher malignancy and cerebrovascular disease comorbidities and dyspnea symptoms.

Vitamin D Deficiency Is Associated with COVID-19 Incidence and Disease Severity in Chinese People [corrected]

BACKGROUND

Vitamin D might have beneficial potential in influencing the natural history of the coronavirus disease 2019 (COVID-19) due to its immunomodulatory and anti-inflammatory properties.

OBJECTIVE

The aim was to investigate whether vitamin D deficiency is associated with COVID-19 incidence and disease severity in Chinese people.

METHODS

In a cross-sectional study we retrospectively analyzed 335 COVID-19 patients (median: 56.0; IQR: 43.0-64.0 y) who were admitted to the Wuhan Tongji Hospital between 27 February and 21 March 2020. We also included an age- and sex-matched population of 560 individuals (median: 55; IQR: 49.0-60.0 y) who underwent the physical examination program. Their serum 25-hydroxyvitamin D [25(OH)D] concentrations were measured during the same period from 2018-2019. Serum 25(OH)D concentrations were measured for all COVID-19 patients on admission. Severity of COVID-19 was determined based on the level of respiratory involvement. A general linear model with adjustment for covariates was used to compare 25(OH)D concentrations between the COVID-19 and 2018-2019 control groups. Adjusted ORs with 95% CIs for associations between vitamin D status and COVID-19 severity were estimated via multivariable logistic regression.

RESULTS

In the general linear model adjusted for age, sex, comorbidities, and BMI, serum 25(OH)D concentrations were significantly lower among COVID-19 patients than the 2018-2019 controls [ln transformed values of 3.32 ± 0.04 vs. 3.46 ± 0.022 ln (nmol/L), P = 0.014]. Multivariable logistic regression showed that male sex (OR: 2.26; 95% CI: 1.06, 4.82), advanced age (≥65 y) (OR: 4.93; 95% CI: 1.44, 16.9), and vitamin D deficiency (<30 nmol/L) (OR: 2.72; 95% CI: 1.23, 6.01) were significantly associated with COVID-19 severity (all P < 0.05).

CONCLUSIONS

These findings suggested that vitamin D deficiency impacts COVID-19 hospitalization and severity in the Chinese population.

Evidence Regarding Vitamin D and Risk of COVID-19 and Its Severity

Vitamin D deficiency co-exists in patients with COVID-19. At this time, dark skin color, increased age, the presence of pre-existing illnesses and vitamin D deficiency are features of severe COVID disease. Of these, only vitamin D deficiency is modifiable. Through its interactions with a multitude of cells, vitamin D may have several ways to reduce the risk of acute respiratory tract infections and COVID-19: reducing the survival and replication of viruses, reducing risk of inflammatory cytokine production, increasing angiotensin-converting enzyme 2 concentrations, and maintaining endothelial integrity. Fourteen observational studies offer evidence that serum 25-hydroxyvitamin D concentrations are inversely correlated with the incidence or severity of COVID-19. The evidence to date generally satisfies Hill's criteria for causality in a biological system, namely, strength of association, consistency, temporality, biological gradient, plausibility (e.g., mechanisms), and coherence, although experimental verification is lacking. Thus, the evidence seems strong enough that people and physicians can use or recommend vitamin D supplements to prevent or treat COVID-19 in light of their safety and wide therapeutic window. In view of public health policy, however, results of large-scale vitamin D randomized controlled trials are required and are currently in progress.

A Basic Review of the Preliminary Evidence That COVID-19 Risk and Severity Is Increased in Vitamin D Deficiency

As the world's attention has been riveted upon the growing COVID-19 pandemic, many researchers have written brief reports supporting the hypothesis that vitamin D deficiency is related to the incidence and severity of COVID-19. The clear common thread among the top risk groups-vitamin D deficiency-may be being overlooked because of previous overstated claims of vitamin D benefits. However, the need to decrease COVID-19 fatalities among high-risk populations is urgent. Early researchers reported three striking patterns. Firstly, the innate immune system is impaired by vitamin D deficiency, which would predispose sufferers to viral infections such as COVID-19. Vitamin D deficiency also increases the activity of the X-chromosome-linked "Renin-Angiotensin" System, making vitamin D deficient individuals (especially men) more susceptible to COVID-19's deadly "cytokine storm" (dramatic immune system overreaction). Secondly, the groups who are at highest risk for severe COVID-19 match those who are at highest risk for severe vitamin D deficiency. This includes the elderly, men, ethnic groups whose skin is naturally rich in melanin (if living outside the tropics), those who avoid sun exposure for cultural and health reasons, those who live in institutions, the obese, and/or those who suffer with hypertension, cardiovascular disease, or diabetes. And thirdly, the pattern of geographical spread of COVID-19 reflects higher population vitamin D deficiency. Both within the USA and throughout the world, COVID-19 fatality rates parallel vitamin D deficiency rates. A literature search was performed on PubMed, Google Scholar, and RSMLDS, with targeted Google searches providing additional sources. Although randomized controlled trial results may be available eventually, the correlational and causal study evidence supporting a link between vitamin D deficiency and COVID-19 risks is already so strong that it supports action. The 141 author groups writing primarily about biological plausibility detailed how vitamin D deficiency can explain every risk factor and every complication of COVID-19, but agreed that other factors are undoubtedly at work. COVID-19 was compared with dengue fever, for which oral vitamin D supplements of 4,000 IU for 10 days were significantly more effective than 1,000 IU in reducing virus replication and controlling the "cytokine storm" (dramatic immune system over-reaction) responsible for fatalities. Among the 47 original research studies summarized here, chart reviews found that serum vitamin D levels predicted COVID-19 mortality rates (16 studies) and linearly predicted COVID-19 illness severity (8 studies). Two causal modeling studies and several analyses of variance strongly supported the hypothesis that vitamin D deficiency is a causal, rather than a bystander, factor in COVID-19 outcomes. Three of the four studies whose findings opposed the hypothesis relied upon disproven assumptions. The literature review also found that prophylactically correcting possible vitamin D deficiency during the COVID-19 pandemic is extremely safe. Widely recommending 2,000 IU of vitamin D daily for all populations with limited ability to manufacture vitamin D from the sun has virtually no potential for harm and is reasonably likely to save many lives.

Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease

AIMS

CoV-19/SARS-CoV-2 is a highly pathogenic virus that is causing a global pandemic with a high number of deaths and infected people. To contain the diffusion of infection, several governments have enforced restrictions on outdoor activities or even collective quarantine on the population. The present commentary briefly analyzes the effects of quarantine on lifestyle, including nutrition and physical activity and the impact of new technologies in dealing with this situation.

DATA SYNTHESIS

Quarantine is associated with stress and depression leading to unhealthy diet and reduced physical activity. A diet poor in fruit and vegetables is frequent during isolation, with a consequent low intake of antioxidants and vitamins. However, vitamins have recently been identified as a principal weapon in the fight against the Cov-19 virus. Some reports suggest that Vitamin D could exert a protective effect on such infection. During quarantine, strategies to further increase home-based physical activity and to encourage adherence to a healthy diet should be implemented. The WHO has just released guidance for people in self-quarantine, those without any symptoms or diagnosis of acute respiratory illness, which provides practical advice on how to stay active and reduce sedentary behavior while at home.

CONCLUSION

Quarantine carries some long-term effects on cardiovascular disease, mainly related to unhealthy lifestyle and anxiety. Following quarantine, a global action supporting healthy diet and physical activity is mandatory to encourage people to return to a good lifestyle routine.