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Stickler K, Morrone B, Brown A, Franks AM, Johnson P, Lacmichanne R, Rupp D. Analysis of a Division I Sports Medicine Program's COVID-19 Protocol: Identifying Factors that Predict Testing Demands and Positive Rates During a Pandemic. Clin J Sport Med 2024; 34:135-143. [PMID: 37432329 DOI: 10.1097/jsm.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 06/10/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To determine factors indicating testing frequency and positive test results in a Division I sports department intrapandemic. DESIGN Retrospective analysis. SETTING A single Division I collegiate sports department. PATIENTS All student-athlete (n = 437), student staff (n = 89), and adult staff (n = 202) members of the sports department. Total cohort (n = 728). INTERVENTIONS The authors analyzed the independent variables of local positive rates, sport characteristics, and campus events for impact on the volume of the departmental testing and positive rates. MAIN OUTCOME MEASURES Measured dependent variables of the volume of departmental testing and positive rates were analyzed. RESULTS Positive predictive rates (PPRs) largely differed from local, off-campus rates in timing and duration (59.52%: P < 0.05). Overall, 20633 tests were administered with 201 positive results (0.97% PPR). Student-athlete numbers were highest in all categories, followed by adult then student staff. Greater proportions of contact sports became positive (53.03%: P < 0.001) and all-male sports (47.69%: P < 0.001). No comparative difference was seen for teams using fomites (19.15%: P = 0.403). Spring sports teams had the lowest percentage of the team positive (22.22%: P < 0.001). Winter sports had the highest PPR (1.15%), all occurring during team-controlled activities. Playing sports indoors did not increase inside team-controlled activity positive rates ( P = 0.066). CONCLUSIONS Longitudinal changes in local, off-campus infection rates partially affected sports departmental positive results while testing rates were more influenced by sport and university schedule. Testing resources should be directed toward high-risk sports, which included contact sports (football, basketball, and soccer), all-male teams, both Winter and indoor sports inside team-controlled activities, and sports with long periods of time outside team-controlled activities.
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Affiliation(s)
- Kasey Stickler
- Division of Sports Medicine, Department of Family and Community Health, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia
| | - Blass Morrone
- Joan C. Edwards SOM at Marshall University, Huntington, West Virginia
| | - Andrew Brown
- Department of Family and Community Health, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia; and
| | - Adam M Franks
- Department of Family and Community Health, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia; and
| | - Paris Johnson
- Department of Family and Community Health, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia; and
| | - Rajan Lacmichanne
- Department of Clinical and Translational Sciences, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia
| | - David Rupp
- Division of Sports Medicine, Department of Family and Community Health, Joan C. Edwards SOM at Marshall University, Huntington, West Virginia
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Charles J, Ploplis VA. COVID-19 Induces Cytokine Storm and Dysfunctional Hemostasis. Curr Drug Targets 2022; 23:1603-1610. [PMID: 36284376 DOI: 10.2174/1389450124666221025102929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infection with SARS-CoV-2 leads to COVID-19 which can manifest in various ways from asymptomatic or mild disease to acute respiratory distress syndrome. The occurrence of dysregulated inflammatory responses in the form of a cytokine storm has been reported in patients with severe COVID-19. Infection can also lead to dysfunctional hemostasis reflected in elevated circulating D-dimer and fibrin degradation products. Components of hemostasis and the immune system during infection can result in a procoagulation and/or proinflammatory state. The interplay between coagulation and inflammation has been elucidated in a number of diseases. OBJECTIVE In this article, we discuss the occurrence of cytokine storms and dysfunctional hemostasis induced in COVID-19. METHODS This review was written using literature from the past two to three years investigating coagulation and inflammation in COVID-19. Additional literature, both clinical and basic research, related to pathogen infection and host responses were also considered in this review. RESULTS/CONCLUSIONS Infection with SARS-CoV-2 can lead to dysregulated inflammatory responses that may be detrimental to the host. The increased expression of various inflammatory factors can ultimately create an environment that promotes thrombosis.
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Affiliation(s)
- Jermilia Charles
- W.M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, IN 46556, USA
| | - Victoria A Ploplis
- W.M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, IN 46556, USA
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Atypical follicular hyperplasia with light chain-restricted germinal centers after COVID-19 booster: a diagnostic pitfall. Virchows Arch 2022; 482:905-910. [PMID: 36098816 PMCID: PMC9469053 DOI: 10.1007/s00428-022-03400-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 10/26/2022]
Abstract
There has been a surge in COVID-19 vaccine-associated lymphadenopathy (LAD), including after the booster dose of vaccine. This can create diagnostic dilemmas in oncology patients as the relatively sudden LAD can mimic metastasis or cancer recurrence, at a risk of leading to additional but unnecessary anti-neoplastic therapy. Here we report the histopathologic features in a case of persistent LAD occurring in a patient with history of breast invasive ductal carcinoma which followed a COVID-19 vaccine booster. A needle core and then excisional biopsy showed atypical follicular hyperplasia with features that histologically and phenotypically could mimic follicular lymphoma, but the findings were ultimately interpreted to be reactive in nature and related temporally to COVID-19 vaccine. To our knowledge, this is the first case of an atypical lymphoproliferative lesion with features potentially mimicking lymphoma associated with COVID-19 vaccine.
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Wais T, Hasan M, Rai V, Agrawal DK. Gut-brain communication in COVID-19: molecular mechanisms, mediators, biomarkers, and therapeutics. Expert Rev Clin Immunol 2022; 18:947-960. [PMID: 35868344 PMCID: PMC9388545 DOI: 10.1080/1744666x.2022.2105697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/21/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Infection with COVID-19 results in acute respiratory symptoms followed by long COVID multi-organ effects presenting with neurological, cardiovascular, musculoskeletal, and gastrointestinal (GI) manifestations. Temporal relationship between gastrointestinal and neurological symptoms is unclear but warranted for exploring better clinical care for COVID-19 patients. AREAS COVERED We critically reviewed the temporal relationship between gut-brain axis after SARS-CoV-2 infection and the molecular mechanisms involved in neuroinvasion following GI infection. Mediators are identified that could serve as biomarkers and therapeutic targets in SARS-CoV-2. We discussed the potential therapeutic approaches to mitigate the effects of GI infection with SARS-CoV-2. EXPERT OPINION Altered gut microbiota cause increased expression of various mediators, including zonulin causing disruption of tight junction. This stimulates enteric nervous system and signals to CNS precipitating neurological sequalae. Published reports suggest potential role of cytokines, immune cells, B(0)AT1 (SLC6A19), ACE2, TMRSS2, TMPRSS4, IFN-γ, IL-17A, zonulin, and altered gut microbiome in gut-brain axis and associated neurological sequalae. Targeting these mediators and gut microbiome to improve immunity will be of therapeutic significance. In-depth research and well-designed large-scale population-based clinical trials with multidisciplinary and collaborative approaches are warranted. Investigating the temporal relationship between organs involved in long-term sequalae is critical due to evolving variants of SARS-CoV-2.
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Affiliation(s)
- Tameena Wais
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences. Pomona, CA 91766
| | - Mehde Hasan
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences. Pomona, CA 91766
| | - Vikrant Rai
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences. Pomona, CA 91766
| | - Devendra K. Agrawal
- Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences. Pomona, CA 91766
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DAIA C, IONESCU A, IONESCU EV, ILIESCU MG, STANCIU LE, CAMBREA SC, ILIESCU DM, ARGHIR OC, GEORGEANU V, VOINEA F, BAZ R, PAZARA L, ONOSE G. Complex respiratory and motor rehabilitation program in a patient with post-pulmonary tuberculosis conditions and multiple sequelae after SARS-CoV-2 infection: case report. BALNEO AND PRM RESEARCH JOURNAL 2021. [DOI: 10.12680/balneo.2021.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: A great variety of medical issues can occur after the COVID-19 infection including fatigue, muscle weakness, locomotor disability, self-care dysfunction, polyneuropathy, persistent dyspnea on exertion and a hypercoagulable state.
Materials and methods: This paper presents the case of a nonsmoker 49-year-old male with right lung lower lobe lobectomy for post tuberculosis bronchiectasis and diabetes mellitus, who developed multiple serious physicals, neurological, hematological and respiratory consequences, related to critical COVID-19 infection and prolonged hospitalization,
Results: A favorable evolution of the patient’s respiratory sequels and motor impairment on both lower limbs was noticed after a complex individualized rehabilitation program started in the post COVID-19 Rehabilitation Department of Balneal and Rehabilitation Sanatorium, Techirghiol, Romania, consisting in better functional parameters and exercise tolerance, significant improvement in daily activities, remission of exertional dyspnea, social and family reintegration.
Conclusions: multidisciplinary approach and complex individualized programs of rehabilitation is required after a critical form of COVID in a patients known with tuberculosis, and other complex pathologies, in order to restore physical function and mobility and optimize respiratory parameters.
Keywords: COVID-19, Rehabilitation, Tuberculosis,
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Affiliation(s)
- Cristina DAIA
- Department of Medical Rehabilitation, “Carol Davila” University of Medicine and Pharmacy, 041914, Bucharest, Romania
| | - Anca IONESCU
- Department of Medical Rehabilitation, “Carol Davila” University of Medicine and Pharmacy, 041914, Bucharest, Romania
| | - Elena Valentina IONESCU
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Mădălina Gabriela ILIESCU
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Liliana Elena STANCIU
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Simona Claudia CAMBREA
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Dan Marcel ILIESCU
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Oana Cristina ARGHIR
- Balneal Rehabilitation Sanatorium of Techirghiol, 900610,Techirghiol, Constanta County, Romania
| | - Vlad GEORGEANU
- Balneal Rehabilitation Sanatorium of Techirghiol, 900610,Techirghiol, Constanta County, Romania
| | - Felix VOINEA
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Radu BAZ
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Loredana PAZARA
- Faculty of Medicine, «Ovidius» University of Constanta, 1 University Alley, Campus, Corp B, 900470, Constanta, Romania
| | - Gelu ONOSE
- Department of Medical Rehabilitation, “Carol Davila” University of Medicine and Pharmacy, 041914, Bucharest, Romania
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Göbel CH, Heinze A, Karstedt S, Morscheck M, Tashiro L, Cirkel A, Hamid Q, Halwani R, Temsah MH, Ziemann M, Görg S, Münte T, Göbel H. Headache Attributed to Vaccination Against COVID-19 (Coronavirus SARS-CoV-2) with the ChAdOx1 nCoV-19 (AZD1222) Vaccine: A Multicenter Observational Cohort Study. Pain Ther 2021; 10:1309-1330. [PMID: 34313952 PMCID: PMC8314854 DOI: 10.1007/s40122-021-00296-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/15/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The most frequently reported neurological adverse event of ChAdOx1 nCoV-19 (AZD1222) vaccine is headache in 57.5%. Several cases of cerebral venous thrombosis (CVT) have developed after vaccination. Headache is the leading symptom of CVT. For the differential diagnosis of headaches attributed to this vaccine and headaches attributed to CVT, it is of central clinical importance whether and, if so, how the phenotypes and course of these headaches can be differentiated. The study aims to examine in detail the phenotype of headache attributed to this vaccine. METHODS Data on the clinical features and corresponding variables were recorded using a standardized online questionnaire in this multicenter observational cohort study. The primary outcomes of this study are the clinical features of headaches after vaccination. FINDINGS A total of 2464 participants reported headaches after vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine. On average, headaches occurred 14.5 ± 21.6 h after vaccination and lasted 16.3 ± 30.4 h. A bilateral location was described by 75.8% of participants. This is most often found on the forehead (40.0%) and temples (31.4%); 50.4% reported a pressing and 37.7% a dull pain character. Headache intensity was most often severe (38.7%), moderate (35.2%), or very severe (15.5%). Accompanying symptoms were most commonly fatigue (44.8%), chills (36.1%), exhaustion (34.9%), and fever (30.4%). CONCLUSION Headaches attributed to COVID-19 vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine demonstrate an extensive and characteristic complex of symptoms. The findings have several important clinical implications for the differentiation of post-vaccinal headache and other primary as well as secondary headaches.
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Affiliation(s)
- Carl H. Göbel
- grid.412468.d0000 0004 0646 2097Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany ,Kiel Migraine and Headache Centre, Kiel, Germany
| | - Axel Heinze
- Kiel Migraine and Headache Centre, Kiel, Germany
| | | | | | | | - Anna Cirkel
- grid.412468.d0000 0004 0646 2097Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany ,Kiel Migraine and Headache Centre, Kiel, Germany
| | - Qutyaba Hamid
- grid.412789.10000 0004 4686 5317Sharjah Institute of Medical Research, University of Sharjah, Sharjah, United Arab Emirates ,grid.412789.10000 0004 4686 5317Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Rabih Halwani
- grid.412789.10000 0004 4686 5317Sharjah Institute of Medical Research, University of Sharjah, Sharjah, United Arab Emirates ,grid.412789.10000 0004 4686 5317Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Mohamad-Hani Temsah
- grid.56302.320000 0004 1773 5396College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Malte Ziemann
- grid.412468.d0000 0004 0646 2097Institute of Transfusion Medicine, University Hospital Schleswig-Holstein, Campus, Lübeck, Germany
| | - Siegfried Görg
- grid.412468.d0000 0004 0646 2097Institute of Transfusion Medicine, University Hospital Schleswig-Holstein, Campus, Lübeck, Germany
| | - Thomas Münte
- grid.412468.d0000 0004 0646 2097Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Magesh S, John D, Li WT, Li Y, Mattingly-app A, Jain S, Chang EY, Ongkeko WM. Disparities in COVID-19 Outcomes by Race, Ethnicity, and Socioeconomic Status: A Systematic-Review and Meta-analysis. JAMA Netw Open 2021; 4:e2134147. [PMID: 34762110 PMCID: PMC8586903 DOI: 10.1001/jamanetworkopen.2021.34147] [Citation(s) in RCA: 354] [Impact Index Per Article: 118.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear. OBJECTIVE To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants. DATA SOURCES A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021. STUDY SELECTION Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria. DATA EXTRACTION AND SYNTHESIS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The main measures were RRs, ORs, and combined prevalence values. RESULTS A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P < .001). The area deprivation index was positively correlated with mortality rates in Asian American and Hispanic individuals (P < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals (P < .001) and African American individuals (P < .001). CONCLUSIONS AND RELEVANCE In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.
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Affiliation(s)
- Shruti Magesh
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Daniel John
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Wei Tse Li
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Yuxiang Li
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Aidan Mattingly-app
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Sharad Jain
- The University of California Davis School of Medicine, Sacramento
| | - Eric Y. Chang
- Department of Radiology, University of California, San Diego
- Radiology Service, VA San Diego Healthcare System, San Diego, California
| | - Weg M. Ongkeko
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of California, San Diego
- Research Service, VA San Diego Healthcare System, San Diego, California
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He Y, Bai X, Zhu T, Huang J, Zhang H. What can the neurological manifestations of COVID-19 tell us: a meta-analysis. J Transl Med 2021; 19:363. [PMID: 34425827 PMCID: PMC8381866 DOI: 10.1186/s12967-021-03039-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background Covid-19 became a global pandemic in 2019. Studies have shown that coronavirus can cause neurological symptoms, but clinical studies on its neurological symptoms are limited. In this meta-analysis, we aimed to summarize the various neurological manifestations that occurred in COVID-19 patients and calculate the incidence of various neurological manifestations. At the same time, we further explored the mechanism of nervous system injury and prognosis in COVID-19 patients in combination with their nervous system manifestations. This study provides a reference for early clinical identification of COVID-19 nervous system injury in the future, so as to achieve early treatment and reduce neurological sequelae. Methods We systematically searched all published English literature related to the neurological manifestations of COVID-19 from January 1, 2020, to April 30, 2021, in Pubmed, Embase, and Cochrane Library. The keywords used were COVID-19 and terminology related to the nervous system performance. All included studies were selected by two independent reviewers using EndNote and NoteExpress software, any disagreement was resolved by consensus or by a third reviewer, and the selected data were then collected for meta-analysis using a random-effects model. Results A total of 168 articles (n = 292,693) were included in the study, and the meta-analysis showed that the most common neurological manifestations of COVID-19 were myalgia(33%; 95%CI 0.30–0.37; I2 = 99.17%), smell impairment(33%; 95%CI 0.28–0.38; I2 = 99.40%), taste dysfunction(33%; 95%CI 0.27–0.39; I2 = 99.09%), altered mental status(32%; 95%CI 0.22–0.43; I2 = 99.06%), headache(29%; 95%CI 0.25–0.33; I2 = 99.42%), encephalopathy(26%; 95%CI 0.16–0.38; I2 = 99.31%), alteration of consciousness(13%; 95%CI 0.08–0.19; I2 = 98.10%), stroke(12%; 95%CI 0.08–0.16; I2 = 98.95%), dizziness(10%; 95%CI 0.08–0.13; I2 = 96.45%), vision impairment(6%; 95%CI 0.03–0.09; I2 = 86.82%), intracerebral haemorrhage(5%; 95%CI 0.03–0.09; I2 = 95.60%), seizure(4%; 95%CI 0.02 -0.05; I2 = 98.15%), encephalitis(2%; 95%CI 0.01–0.03; I2 = 90.36%), Guillan-Barré Syndrome (GBS) (1%; 95%CI 0.00–0.03; I2 = 89.48%). Conclusions Neurological symptoms are common and varied in Covid-19 infections, and a growing number of reports suggest that the prevalence of neurological symptoms may be increasing. In the future, the role of COVID-19 neurological symptoms in the progression of COVID-19 should be further studied, and its pathogenesis and assessment methods should be explored, to detect and treat early neurological complications of COVID-19 and reduce mortality.
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Affiliation(s)
- Yuanyuan He
- Department of Emergency Medicine, The First Affiliated Hospital of Anhui Medical University, 218 jixi road, shushan district, Hefei, Anhui, China
| | - Xiaojie Bai
- Department of Emergency Medicine, The First Affiliated Hospital of Anhui Medical University, 218 jixi road, shushan district, Hefei, Anhui, China
| | - Tiantian Zhu
- Department of Emergency Medicine, The First Affiliated Hospital of Anhui Medical University, 218 jixi road, shushan district, Hefei, Anhui, China
| | - Jialin Huang
- Department of Emergency Medicine, The First Affiliated Hospital of Anhui Medical University, 218 jixi road, shushan district, Hefei, Anhui, China
| | - Hong Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Anhui Medical University, 218 jixi road, shushan district, Hefei, Anhui, China.
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Singh A, Gupta V. SARS-CoV-2 therapeutics: how far do we stand from a remedy? Pharmacol Rep 2021; 73:750-768. [PMID: 33389724 PMCID: PMC7778692 DOI: 10.1007/s43440-020-00204-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/20/2020] [Accepted: 11/29/2020] [Indexed: 02/07/2023]
Abstract
The SARS-CoV-2 has affected millions worldwide and has posed an immediate need for effective pharmacological interventions. Ever since the outbreak was declared, the medical fraternity across the world is facing a unique situation of offering assistance and simultaneously generating reliable data with high-quality evidence to extend the scope of finding a treatment. With no proven vaccine or other interventions available hitherto, there is a frenzied urgency of sharing preliminary data from laboratories and trials to shape a global response against the virus. Several clinical trials with investigational and approved repurposed therapeutics have shown promising results. This review aims to compile the information of the reported molecules approved for emergency use and those under clinical trials and still others with good results in the studies conducted so far. Being an RNA virus, SARS-CoV-2 is prone to mutation; thus, the possibility of gaining resistance to available drugs is high. Consequently, a cocktail therapy based on drug interaction with different stages of its replicative cycle is desirable to reduce the chances of evolving drug resistance. Since this virus encodes several proteins, including 16 nonstructural and 4 structural proteins, this review also offers an insight into potential drug targets within SARS-CoV-2.
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Affiliation(s)
- Anurag Singh
- Department of Microbiology, Ram Lal Anand College, University of Delhi, Benito Juarez Road, New Delhi, 110021, India
| | - Vandana Gupta
- Department of Microbiology, Ram Lal Anand College, University of Delhi, Benito Juarez Road, New Delhi, 110021, India.
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COVID-19's natural course among ambulatory monitored outpatients. Sci Rep 2021; 11:10124. [PMID: 33980931 PMCID: PMC8115337 DOI: 10.1038/s41598-021-89545-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Research objective was to detail COVID-19's natural trajectory in relation to the Czech population's viral load. Our prospective detailed daily questionnaire-based telemonitoring study evaluated COVID-19's impact among 105 outpatients. In accordance with government quarantine requirements, outpatients were divided into a cohort with two negative tests at the end of the disease (40 patients) and a cohort with a new algorithm (65 patients) following a 14-day quarantine. Median follow-up differed significantly between the 2 groups (23 days vs. 16 days). Only 6% of patients were asymptomatic during the entire telemonitoring period. Another 13% of patients were diagnosed asymptomatic, as suspected contacts, yet later developed symptoms, while the remaining 81% were diagnosed as symptomatic on average 6 days following symptom onset. Telemonitoring enabled precise symptom status chronicling. The most frequently reported complaints were fevers, respiratory issues, and anosmia. Six patients were eventually hospitalized for complications detected early after routine telemonitoring. During the extended follow-up (median 181 days), anosmia persisted in 26% of patients. 79% of patients in the new quarantine algorithm cohort reported no symptoms on day 11 compared to just 56% of patients in the two negative test cohort upon first testing negative (median-19 days). The highest viral load occurred within 0-2 days of initial symptom onset. Both the PCR viral load and two consecutive PCR negative sample realizations indicated high interindividual variability with a surprisingly fluctuating pattern among 43% of patients. No definitive COVID-19 symptoms or set of symptoms excepting anosmia (59%) and/or ageusia (47%) were identified. No preexisting medical conditions specifically foreshadowed disease trajectory in a given patient. Without a PCR negativity requirement for quarantine cessation, patients could exhibit fewer symptoms. Our study therefore highlights the urgent need for routine ambulatory patient telemedicine monitoring, early complication detection, intensive mass education connecting disease demeanor with subsequent swift diagnostics, and, notably, the need to reevaluate and modify quarantine regulations for better control of SARS-CoV-2 proliferation.
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Jantzen R, Noisel N, Camilleri-Broët S, Labbé C, Malliard TD, Payette Y, Broët P. Epidemiological characteristics of the COVID-19 spring outbreak in Quebec, Canada: a population-based study. BMC Infect Dis 2021; 21:435. [PMID: 33971843 PMCID: PMC8107425 DOI: 10.1186/s12879-021-06002-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 03/22/2021] [Indexed: 01/08/2023] Open
Abstract
Background By mid-July 2020, more than 108,000 COVID-19 cases had been diagnosed in Canada with more than half in the province of Quebec. In this context, we launched a study to analyze the epidemiological characteristics and the socio-economic impact of the spring outbreak in the population. Method We conducted an online survey of the participants of the CARTaGENE population-based cohort, composed of middle-aged and older adults. We collected information on socio-demographic, lifestyle, health condition, COVID-19 related symptoms and COVID-19 testing. We studied the association between these factors and two outcomes: the status of having been tested for SARS-CoV-2 and the status of having received a positive test. These associations were measured with univariate and multivariate analyses using a hybrid tree-based regression model. Results Among the 8,129 respondents from the CARTaGENE cohort, 649 were tested for COVID-19 and 41 were positive. Medical workers and individuals having a contact with a COVID-19 patient had the highest probabilities of being tested (32% and 42.4%, respectively) and of being positive (17.2% and 13.0%, respectively) among those tested. Approximately 8% of the participants declared that they have experienced at least one of the four COVID-19 related symptoms chosen by the Public Health authorities (fever, cough, dyspnea, anosmia) but were not tested. Results from the tree-based model analyses adjusted on exposure factors showed that the combination of dyspnea, dry cough and fever was highly associated with being tested whereas anosmia, fever, and headache were the most discriminant factors for having a positive test among those tested. During the spring outbreak, more than one third of the participants have experienced a decrease in access to health services. There were gender and age differences in the socio-economic and emotional impacts of the pandemic. Conclusion We have shown some discrepancies between the symptoms associated with being tested and being positive. In particular, the anosmia is a major discriminant symptom for positivity whereas ear-nose-throat symptoms seem not to be COVID-19 related. The results also emphasize the need of increasing the accessibility of testing for the general population. Supplementary Information The online version contains supplementary material available at (10.1186/s12879-021-06002-0).
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Affiliation(s)
- Rodolphe Jantzen
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada. .,Université de Montréal, Montréal, Canada.
| | - Nolwenn Noisel
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada.,Université de Montréal, Montréal, Canada
| | | | - Catherine Labbé
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada
| | - Thibault de Malliard
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada
| | - Yves Payette
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada
| | - Philippe Broët
- CARTaGENE, CHU Ste-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, H3T1C5, Canada.,Université de Montréal, Montréal, Canada.,Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Villejuif, 94807, France.,Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital Paul Brousse, 12 Avenue Paul Vaillant Couturier, Villejuif, 94807, France
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12
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Characteristics of work-related COVID-19 in Croatian healthcare workers: a preliminary report. Arh Hig Rada Toksikol 2021; 72:36-41. [PMID: 33787182 PMCID: PMC8191434 DOI: 10.2478/aiht-2021-72-3530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/01/2021] [Indexed: 01/28/2023] Open
Abstract
Healthcare workers (HCWs) are considered to run a higher occupational risk of becoming infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and develop coronavirus disease (COVID-19) than the rest of the population. The aim of this study was to describe and analyse the characteristics of work-related COVID-19 in Croatian HCWs. Study participants were HCWs who contacted their occupational physician between 1 May 2020 and 12 November 2020 with a request for the registration of COVID-19 as an occupational disease. All participants filled out our online Occupational COVID-19 in Healthcare Workers Questionnaire. The study included 59 HCWs (median age 45.0, interquartile range 36.0-56.0 years). Most (78 %) were nurses or laboratory technicians, and almost all (94.9 %) worked in hospitals. Hierarchical cluster analysis revealed three clusters of COVID-19-related symptoms: 1) elevated body temperature with general weakness and fatigue, 2) diarrhoea, and 3) headache, muscle and joint pain, anosmia, ageusia, and respiratory symptoms (nasal symptoms, burning throat, cough, dyspnoea, tachypnoea). Almost half (44.6 %) reported comorbidities. Only those with chronic pulmonary conditions were more often hospitalised than those without respiratory disorders (57.1 % vs. 2.5 %, respectively; P=0.001). Our findings suggest that work-related COVID-19 among Croatian HCWs is most common in hospital nurses/laboratory technicians and takes a mild form, with symptoms clustering around three clinical phenotypes: general symptoms of acute infection, specific symptoms including neurological (anosmia, ageusia) and respiratory symptoms, and diarrhoea as a separate symptom. They also support evidence from other studies that persons with chronic pulmonary conditions are at higher risk for developing severe forms of COVID-19.
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13
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Tsuchiya H. Oral Symptoms Associated with COVID-19 and Their Pathogenic Mechanisms: A Literature Review. Dent J (Basel) 2021; 9:32. [PMID: 33799583 PMCID: PMC7999671 DOI: 10.3390/dj9030032] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 12/15/2022] Open
Abstract
Since the worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, management of coronavirus disease 2019 (COVID-19) has been challenging for healthcare providers. The oral cavity is referred to as a target of SARS-CoV-2. The aim of this study was to review oral symptoms specific to COVID-19 patients from the point of view of symptom prevalence and pathogenesis and to speculate the pathogenic mechanisms underlying them. Scientific articles were retrieved by searching PubMed/MEDLINE, Google Scholar, medRxiv, and bioRxiv from 3 February 2020 to 31 December 2020, and they were reviewed by title, abstract, and text for relevance. The literature search indicated that COVID-19 patients frequently present with gustatory dysfunction, xerostomia, and oral mucosal lesions, while their prevalence is likely to vary by country, age, gender, and disease severity. Gustatory dysfunction and xerostomia appear at an early stage of SARS-CoV-2 infection and last relatively long. One of possible pathogenic mechanisms of both symptoms is attributed to the expression of viral cellular entry-relevant receptors in taste cells and salivary glands. Dental professionals who can first become aware of oral symptoms associated with COVID-19 will play a more active role in and make a greater contribution to diagnosis and prevention of COVID-19.
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14
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Antonelli M, Capdevila J, Chaudhari A, Granerod J, Canas LS, Graham MS, Klaser K, Modat M, Molteni E, Murray B, Sudre CH, Davies R, May A, Nguyen LH, Drew DA, Joshi A, Chan AT, Cramer JP, Spector T, Wolf J, Ourselin S, Steves CJ, Loeliger AE. Optimal symptom combinations to aid COVID-19 case identification: analysis from a community-based, prospective, observational cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2020.11.23.20237313. [PMID: 33269364 PMCID: PMC7709185 DOI: 10.1101/2020.11.23.20237313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health. METHODS UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity. FINDINGS UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC. INTERPRETATION We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.
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Affiliation(s)
- M Antonelli
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | - A Chaudhari
- Coalition for Epidemic Preparedness Innovations, London, UK
| | - J Granerod
- Coalition for Epidemic Preparedness Innovations, London, UK
| | - L S Canas
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - M S Graham
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - K Klaser
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - M Modat
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - E Molteni
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - B Murray
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - C H Sudre
- MRC Unit for Lifelong Health and Ageing at UCL/Centre for Medical Image Computing, Department of Computer Science, UCL, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | | | - L H Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D A Drew
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A Joshi
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - J P Cramer
- Coalition for Epidemic Preparedness Innovations, London, UK
| | - T Spector
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | | | - S Ourselin
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - C J Steves
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - A E Loeliger
- Coalition for Epidemic Preparedness Innovations, London, UK
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Álvarez-Mon M, Ortega MA, Gasulla Ó, Fortuny-Profitós J, Mazaira-Font FA, Saurina P, Monserrat J, Plana MN, Troncoso D, Moreno JS, Muñoz B, Arranz A, Varona JF, Lopez-Escobar A, Barco AAD. A Predictive Model and Risk Factors for Case Fatality of COVID-19. J Pers Med 2021; 11:36. [PMID: 33430129 PMCID: PMC7827846 DOI: 10.3390/jpm11010036] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
This study aimed to create an individualized analysis model of the risk of intensive care unit (ICU) admission or death for coronavirus disease 2019 (COVID-19) patients as a tool for the rapid clinical management of hospitalized patients in order to achieve a resilience of medical resources. This is an observational, analytical, retrospective cohort study with longitudinal follow-up. Data were collected from the medical records of 3489 patients diagnosed with COVID-19 using RT-qPCR in the period of highest community transmission recorded in Europe to date: February-June 2020. The study was carried out in in two health areas of hospital care in the Madrid region: the central area of the Madrid capital (Hospitales de Madrid del Grupo HM Hospitales (CH-HM), n = 1931) and the metropolitan area of Madrid (Hospital Universitario Príncipe de Asturias (MH-HUPA) n = 1558). By using a regression model, we observed how the different patient variables had unequal importance. Among all the analyzed variables, basal oxygen saturation was found to have the highest relative importance with a value of 20.3%, followed by age (17.7%), lymphocyte/leukocyte ratio (14.4%), CRP value (12.5%), comorbidities (12.5%), and leukocyte count (8.9%). Three levels of risk of ICU/death were established: low-risk level (<5%), medium-risk level (5-20%), and high-risk level (>20%). At the high-risk level, 13% needed ICU admission, 29% died, and 37% had an ICU-death outcome. This predictive model allowed us to individualize the risk for worse outcome for hospitalized patients affected by COVID-19.
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Affiliation(s)
- Melchor Álvarez-Mon
- Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain; (M.N.P.); (J.S.M.); (B.M.); (A.A.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcalá de Henares, Spain
| | - Óscar Gasulla
- Hospital Universitari de Bellvitge–Universitat de Barcelona, 08907 L´Hospitalet de Llobregat, Spain;
| | | | - Ferran A. Mazaira-Font
- Departament d’Econometria, Estadística I Economia Aplicada–Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Pablo Saurina
- Universidad Complutense de Madrid, 28040 Madrid, Spain;
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - María N. Plana
- Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain; (M.N.P.); (J.S.M.); (B.M.); (A.A.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Daniel Troncoso
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
| | - José Sanz Moreno
- Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain; (M.N.P.); (J.S.M.); (B.M.); (A.A.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (J.M.); (D.T.)
| | - Benjamin Muñoz
- Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain; (M.N.P.); (J.S.M.); (B.M.); (A.A.)
| | - Alberto Arranz
- Service of Internal Medicine and Immune System Diseases-Rheumatology, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain; (M.N.P.); (J.S.M.); (B.M.); (A.A.)
| | - Jose F. Varona
- Service of Internal Medicine, Hospital Universitario HM Montepríncipe, HM Hospitales, 28660 Boadilla del Monte, Spain;
- Faculty of Medicine, Universidad San Pablo-CEU, CEU Universities, Fundación de Investigación HM Hospitales, 28003 Madrid, Spain;
| | - Alejandro Lopez-Escobar
- Faculty of Medicine, Universidad San Pablo-CEU, CEU Universities, Fundación de Investigación HM Hospitales, 28003 Madrid, Spain;
- Service of Pediatrics, Hospital Universitario HM Puerta del Sur, 28938 Móstoles, Spain
| | - Angel Asúnsolo-del Barco
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, University of New York, New York, NY 10027, USA
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