Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection

COVIVA: Effect of transcutaneous auricular vagal nerve stimulation on fatigue-syndrome in patients with Long Covid - A placebo-controlled pilot study protocol

BACKGROUND

Up to 80% of patients who develop coronavirus disease-2019 (Covid-19) infection subsequently experience long covid/post-covid syndrome. The World Health Organization (WHO) has estimated that >770 million patients have been infected with Covid-19 globally. Even if only 10% of these patients develop long covid, > 75 million patients will suffer for a long period. Among the various symptoms of post-covid syndrome, fatigue is common, affecting up to 60% of the patients. As observed in other viral infections, elevated levels of inflammatory cytokines may play a role. Transcutaneous auricular vagal nerve stimulation (taVNS) is a noninvasive method that modulates the immune system via the central nervous system and has shown promising effects in autoimmune diseases and improving fatigue. In this pilot study, we investigated the feasibility of daily taVNS in patients with long covid-related fatigue. Additionally, the effects of taVNS on fatigue and quality of life will be analyzed.

METHODS

A total of 45 adult patients with long covid associated fatigue syndrome will be enrolled in this study, and will be randomized to the above-threshold-stimulation, below-threshold-stimulation, or sham-stimulation arms, after being informed that they will feel the stimulation. The above-threshold-group will receive a 4-week-long left-sided cymba conchae taVNS with 25 Hz, 250 µs pulse width 28s/32s on/off paradigm for 4 h throughout the day. The below-threshold group will receive stimulation below the sensational threshold, whereas the sham group will receive no stimulation following application of a non-functional electrode. The daily stimulation protocol will be recorded either manually or using the provided app. Three well-established questionnaires, the Multidimensional-Fatigue-Inventory-20, Short-Form-36, and Beck-Depression-Inventory, and the newly established Post-Covid-Syndrome-Score will be completed both before and after 4 weeks of stimulation.

DISCUSSION

The primary endpoint has been set as the patients' average daily stimulation time after 4 weeks, while secondary endpoints include the effects of taVNS on fatigue and Quality of Live (QoL). As a non-invasive treatment option, taVNS may be a notable alternative for patients with post-covid related fatigue.

TRIAL REGISTRATION

This study was approved by the local ethics committee (23/7798) and registered (DRKS00031974) (see supporting information files).

ETHICS & DISSEMINATION

The ethical justifiability of this study was supported by prior research demonstrating the safety of taVNS. Patients will be recruited by general practitioners, and written informed consent will be obtained. All data will be pseudonymized for collection and storage. The study results will be published in peer-reviewed journals with the aim of providing evidence of the potential of taVNS in long covid management. The study will be conducted in accordance with the principles of the Declaration of Helsinki.

Effect of telerehabilitation on post-COVID-19 individuals with long-term dyspnea: A randomized controlled study

ObjectiveThis study aimed to determine the effectiveness of telerehabilitation in managing ongoing dyspnea and associated issues following coronavirus disease 2019 (COVID-19), and observe changes over time.DesignThe study included 36 participants who previously had COVID-19 but continued to experience dyspnea (mean age, 42.44 ± 15.51 years). The participants were randomly allocated into three groups: telerehabilitation (TRG), home exercise (HEG), and control (CG). Dyspnea level, exercise capacity, muscle oxygenation, respiratory function, and fatigue were evaluated at baseline, at 6th, and at 12th weeks. Telerehabilitation was performed supervised and synchronously via video-calls.ResultsAt the 6-week assessment, TRG showed significant improvements in dyspnea, fatigue (p < 0.001), exercise capacity (p = 0.001), and respiratory muscle strength (p < 0.001). By the 12th week, these gains were maintained, with no further changes from week 6. In HEG, dyspnea and fatigue improved at weeks 6 and 12 (p < 0.001), with no additional changes between these time points. In CG, only dyspnea improved at both assessments (p < 0.001); other parameters remained unchanged. TRG achieved greater benefits compared to CG in reducing dyspnea and fatigue at week 6 (p = 0.001 and p = 0.003, respectively), but no group differences were found at week 12 (p > 0.05). No changes in muscle oxygenation were observed in any groups or evaluation points (p > 0.05).ConclusionsTelerehabilitation effectively improved and sustained dyspnea, fatigue, respiratory muscle strength, and exercise capacity in patients with post-COVID, while home-based exercises only reduced dyspnea and fatigue. Supervised and structured telerehabilitation may be a viable approach to managing post-COVID-19 symptoms.

Long-term consequences of COVID-19 on sleep, mental health, fatigue, and cognition: a preliminary study

INTRODUCTION

Post-COVID-19 Syndrome (PCS) is defined as symptoms persisting beyond 12 weeks from the onset of symptoms. Notably, COVID-19 has been associated with long-term effects on the brain and mental health. This cross-sectional study aims to investigate depression, fatigue, sleep quality, and cognitive dysfunction, particularly working memory, in individuals with PCS compared to a healthy control group.

MATERIAL AND METHODS

Between April and December 2021, 45 COVID-19 individuals and 60 healthy individuals met the eligibility criteria. Demographic information and the Montreal Cognitive Assessment were collected. Two visual working memory tasks, Delayed Match-to-Sample (DMS) and n-back, were performed, along with self-report questionnaires: Beck Depression Inventory, Modified Fatigue Impact Scale, and Pittsburgh Sleep Quality Index.

RESULTS

A total of 105 participants were enrolled. Findings reveal that the PCS group exhibited notably higher levels of cognitive impairment (13.3% vs. 1.6%, p = 0.04), depression (53.9% vs. 25.9%, p = 0.03), and sleep disturbances (53.9% vs. 18.6%, p = 0.01) compared to the healthy control group. Sleep latency and sleep duration were particularly affected. No significant differences in working memory function were observed between the two groups (p = 0.90 for DMS and p = 0.98 for n-back).

CONCLUSION

The study highlights the higher prevalence of sleep disturbance, depression, and cognitive impairment in the PCS phase, with inflammation likely playing a significant role. Moreover, the study suggests that untreated depression and sleep disturbances may pose long-term risks for dementia. Understanding the underlying mechanisms is crucial for developing effective interventions and support for individuals recovering from the infection. Prospective longitudinal studies with larger and more diverse samples are warranted to confirm and expand upon these findings.

Chronic fatigue syndrome post-COVID-19: triple-blind randomised clinical trial of Astragalus root extract

OBJECTIVE

This study aimed to evaluate the effect of Astragalus root extract on nurses suffering from post-COVID-19 chronic fatigue syndrome.

MATERIALS AND METHODS

The study was designed as a triple-blind, randomised, controlled trial in Iran in 2023. 64 chronic fatigue syndrome nurses were randomly assigned to one of two groups: an intervention group (n=32) that received Astragalus root extract (500 mg two times per day) or a control group (n=32) that received a placebo. Changes in chronic fatigue syndrome scores were measured before to, at the end of and 1 month after the intervention. Data were analysed using descriptive and analytical statistics (T-tests, χ2, analysis of variances, Cochran's Q tests, McNemar and generalised estimating equations).

RESULTS

In comparison to before, chronic fatigue prevalence decreased statistically significantly at the end of the intervention group (13.8%) and 1 month later (17.2%). Further, the frequency differed between before and after (p=0.0001) and 1 month later (p=0.0001). In the control group, chronic fatigue was statistically significantly different before and after the intervention (72.2%; p=0.003). Having an underlying disease (B=0.84, OR=2.33; p=0.04) and being in the control group (B=2.15, OR=12.36; p=0.01) increased the risk of chronic fatigue, whereas increasing the length of time decreased it (B=-0.67, OR=0.50; p=0.0001).

CONCLUSION

Astragalus root extract has been shown to reduce chronic fatigue in nurses. Therefore, this herbal extract can be used to reduce the incidence and treatment of chronic fatigue in nurses.

Physical activity and sedentariness levels in patients with post-exertional malaise resulting from post-COVID-19 syndrome

BackgroundPost-exertional malaise (PEM) is a complex phenomenon characterized by extreme fatigue, reduced endurance, and muscular and joint pains. Physical activity (PA) has recognized health benefits, including reducing the risks of chronic diseases and mortality. During the pandemic, a general decline in PA was measured, but the profile of the various components of PA and sedentariness in patients with PEM resulting from post-COVID-19 syndrome (PCS-19) remains scarce. It is relevant to observe the impact of these discomforts on PQ after their occurrence.ObjectiveThis study examines the detailed PA and sedentary profile of individuals affected by PEM associated with PCS-19.MethodsAn online questionnaire disseminated via social media platform evaluated PA and sedentariness before and after COVID-19 diagnostic.ResultsIndividuals with PEM (n = 154) became more sedentary and inactive post-COVID-19. Specifically, PA at work decreased in women and those whose last infection occurred over a year ago. Walk decreased for women but increased for men. Bike journeys generally decreased after COVID-19. The severity of PEM, the pace of recovery, and fear of malaise influenced PA changes.ConclusionsThe PCS-19 leads to increased sedentary behavior and a decline in PA, particularly at work, and is more pronounced among women and those more severely affected by PEM. These findings are critical for post-COVID PA resumption, including for workers who go back to work and who regain normal duties while being potentially deconditioned.

Immunophenotyping of bronchoalveolar lavage and functional impairment in post-COVID syndrome : Insights from a prospective cohort trial

OBJECTIVE

Following recovery from COVID-19, there is evidence for pulmonary sequelae and functional impairment. Data regarding the immunopathological mechanisms are limited. This study aimed to investigate the relationship between bronchoalveolar lavage fluid (BALF) cellularity, lung function impairment and high-resolution computed tomography (HRCT) changes in post-COVID syndrome patients.

METHODS

Patients with post-COVID syndrome were enrolled in this Austrian single-center prospective observational cohort study. All patients underwent a pulmonary function test (PFT) and chest HRCT. Those with pathological HRCT findings underwent bronchoscopy with BALF sampling for differential cell count and fluorescence-activated cell sorting analysis.

RESULTS

In this study 26 patients with post-COVID syndrome underwent bronchoscopy with BAL. The HRCT showed ground-glass opacifications (69.2%), organizing pneumonia (7.7%) or both (11.5%). The PFT revealed restrictive lung disease in 38.5% and reduced diffusion capacity in 68%, 19.2% showed a pathological BAL cell pattern predominantly consisting of CD4+ T‑cells. The BALF lymphocyte count was associated with reduced forced vital capacity (p = 0.016) and an elevated alveolar-arterial oxygen gradient (p = 0.04).

CONCLUSION

A notable percentage of patients with post-COVID syndrome with persistent HRCT changes showed T‑helper lymphocytic inflammation in the lungs. The degree of alveolar lymphocytosis was associated with lung function impairment. This could suggest that a prolonged inflammatory response in the alveolar compartment contributes to the pathogenesis of post-COVID syndrome.

Outcomes in Patients with Long COVID-19 One Year After their Discharge from Intensive Care Units

Introduction Survivors of prolonged severe COVID-19 who are treated at ICUs are at risk for physical and psychological complications, including lung injury and multi-organ dysfunction. As the number of survivors of severe COVID-19 increases, it is necessary to understand the trajectory of the disease and the patient care needed after discharge from the ICU. This study tries to efficiently assess the long-term clinical sequelae among patients with prolonged severe COVID-19 who were admitted to the ICU, one year after their discharge. The parameters tested included the chronic obstructive pulmonary disease assessment test (CAT) score, pulmonary function tests, and laboratory data. Materials and methods The study population included 454 patients who were followed up one year after surviving ICU admission for severe COVID-19. All the patients who presented with signs and symptoms to the hospital were examined further. They underwent the necessary investigations, assessments, and systemic examinations. The results of all the laboratory and radiological investigations were reviewed. During the SARS-CoV-2 pandemic, all the patient details were entered into a hospital information management system from which the data was retrieved. Mean with standard deviation (SD) or median or interquartile ranges (IQR) were used to assess the continuous variables, whereas numbers and percentages were used for categorical variables. Statistical significance was calculated by the Chi-square test. Results The median age of the study population was 64 (IQR 57-74) years and 64.7% (294/454) were male patients. The median follow-up time was 367 days. During the follow-up period, 14.9% (68/454) of the patients were readmitted to the ICU. The mean length of hospital stay was 12 days (IQR 8-20 days). Among the readmitted patients (n=68), 17.6% (12/68) were on mechanical ventilation and the remaining 82.3% (56/68) received oxygen therapy. One patient underwent extracorporeal membrane oxygenation. The hospital mortality rate observed among these ICU survivors was 10.2%. The Health-Related Quality of Life (HRQOL) score at baseline i.e. before the ICU admission (52.5 (SD, 9.2); p<0.001) was better than that observed at the one-year follow-up (44.3 (SD, 9.5); p<0.001). Moreover, the clinical frailty scale and cognitive symptoms were significantly different at the follow up assessment versus the baseline (p<0.001). The proportion of patients with a grade of 0-2 on the Modified Medical Research Council (mMRC) dyspnea scale was almost similar at baseline and the one-year follow-up, whereas a breathlessness grade of 3-4 on the scale was observed in 39.8% of the study population. Conclusion The management of ICU survivors after severe COVID requires a multi-disciplinary approach. It includes preventive measures and rehabilitation services along with appropriate treatment strategies to relieve the residual symptoms.

Identifying risk factors and predicting long COVID in a Spanish cohort

Many studies have investigated symptoms, comorbidities, demographic factors, and vaccine effects in relation to long COVID (LC-19) across global populations. However, a number of these studies have shortcomings, such as inadequate LC-19 categorisation, lack of sex disaggregation, or a narrow focus on certain risk factors like symptoms or comorbidities alone. We address these gaps by investigating the demographic factors, comorbidities, and symptoms present during the acute phase of primary COVID-19 infection among patients with LC-19 and comparing them to typical non-Long COVID-19 patients. Additionally, we assess the impact of COVID-19 vaccination on these patients. Drawing on data from the Regional Health System of the Region of Murcia in southeastern Spain, our analysis includes comprehensive information from clinical and hospitalisation records, symptoms, and vaccination details of over 675126 patients across 10 hospitals. We calculated age and sex-adjusted odds ratios (AOR) to identify protective and risk factors for LC-19. Our findings reveal distinct symptomatology, comorbidity patterns, and demographic characteristics among patients with LC-19 versus those with typical non-Long COVID-19. Factors such as age, female sex (AOR = 1.39, adjusted p < 0.001), and symptoms like chest pain (AOR > 1.55, adjusted p < 0.001) or hyposmia (AOR > 1.5, adjusted p < 0.001) significantly increase the risk of developing LC-19. However, vaccination demonstrates a strong protective effect, with vaccinated individuals having a markedly lower risk (AOR = 0.10, adjusted p < 0.001), highlighting the importance of vaccination in reducing LC-19 susceptibility. Interestingly, symptoms and comorbidities show no significant differences when disaggregated by type of LC-19 patient. Vaccination before infection is the most important factor and notably decreases the likelihood of long COVID. Particularly, mRNA vaccines offer more protection against developing LC-19 than viral vector-based vaccines (AOR = 0.48). Additionally, we have developed a model to predict LC-19 that incorporates all studied risk factors, achieving a balanced accuracy of 73% and ROC-AUC of 0.80. This model is available as a free online LC-19 calculator, accessible at ( LC-19 Calculator ).

Persistent Symptoms and Associated Risk Factors of COVID-19: A Cross-Sectional Study in Minia, Upper Egypt

Background: A significant number of COVID-19 survivors around the world have been reporting persistent symptoms following their recovery. Long COVID is recognized as a condition affecting not only the respiratory but also the gastrointestinal, cardiovascular, neurological, immune, and hematopoietic systems. Objective: This study aimed to describe persistent symptoms in COVID-19 survivors six months post-infection in Minia, Upper Egypt, and investigate associated risk factors. Methods: This observational cross-sectional study included 189 hospitalized and non-hospitalized patients previously diagnosed with COVID-19. Demographic data, symptom severity, comorbidities, and persistent symptoms were collected. A logistic regression analysis was used to identify risk factors associated with long COVID, with statistical significance set at p < 0.05. Results: In total, 68.8% of participants were women, and 83.5% of patients reported at least one ongoing symptom. The most self-reported symptoms were fatigue (73.5%) and myalgia (45.5%), followed by dyspnea (43.3%). Age was associated with an increased risk of developing long COVID (OR 1.028, 95% CI 1.003-1.054, p = 0.030). Patients who were hospitalized during the acute phase had more than twice the risks of having persistent symptoms (OR 2.384, 95% CI 1.055-5.387, p = 0.037). Conclusions: A substantial proportion of COVID-19 survivors in Minia, Upper Egypt, continues to experience persistent symptoms, primarily constitutional and neurological manifestations. Many patients reported self-medicating with unprescribed antibiotics, highlighting a need for public awareness regarding viral infections and the risks associated with improper antibiotic use.

Clinically Significant Functional Impairments and Symptoms in COVID-19 Survivors: Empirical Research Quantitative

BACKGROUND

COVID-19 survivors may experience complex, distressing and persistent symptoms, referred to as long COVID, lasting months or years after diagnosis. More evidence is needed for effective long COVID screening and management.

AIM

To explore the clinical profile of long COVID and factors associated with its development.

DESIGN

A multicentre correlational study using a cross-sectional design.

METHODS

Adults diagnosed with COVID-19 6-9 months earlier were recruited via social media and referrals from three facilities. Participants provided demographic data and assessed their symptoms and functional status using validated questionnaires. Data were analysed using descriptive statistics and binomial logistic regression.

RESULTS

Among 102 participants, 13%-30% reported significant impairments in cognitive, emotional and physical functioning. Over 10% experienced symptoms such as diarrhoea, sleep problems, dyspnoea, nausea, fatigue and pain. These impairments and symptoms were associated with acute symptom severity, chronic disease, overweight status, regular exercise and living without partners.

CONCLUSION

This study adds to the literature by examining long-term functional status and symptoms in omicron survivors using comprehensive, validated tools. The findings highlight the prevalence and clinical significance of long COVID symptoms, aiding in the identification of functional impairments requiring medical and nursing interventions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Nurses should recognise these symptoms and educate survivors about potential challenges. Policies addressing long-term issues, including research, health services and education, are essential.

REPORTING METHOD

This study follows the STROBE guideline (Table S1).

PATIENT OR PUBLIC CONTRIBUTION

Patients self-reported symptoms for this study.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05303103).

Prospective cohort study of fatigue before and after SARS-CoV-2 infection in the Netherlands

Fatigue is one of the most common persistent symptoms of SARS-CoV-2 infection. We aimed to assess fatigue during and after a SARS-CoV-2 infection by age, sex, presence of a medical risk condition, SARS-CoV-2 variant and vaccination status, accounting for pre-infection fatigue and compared with uninfected individuals. We used data from an ongoing prospective cohort study in the Netherlands (VASCO). We included 22,705 first infections reported between 12 July 2021 and 9 March 2024. Mean fatigue scores increased during infection, declined rapidly in the first 90 days post-infection, but remained elevated until at least 270 days for Delta and 120 days for Omicron infections. Prevalence of severe fatigue was 18.5% before first infection. It increased to 24.4% and 22.5% during acute infection and decreased to 21.2% and 18.9% at 90 days after Delta and Omicron infection, respectively. The prevalence among uninfected participants was lower than among matched Delta-infected participants during the acute phase of the infection and 90 days post-infection. For matched Omicron-infected individuals this was only observed during the acute phase. We observed no differences in mean post- vs pre-infection fatigue scores at 90-270 days post-infection by vaccination status. The impact of SARS-CoV-2 infection on the prevalence of severe fatigue was modest at population level, especially for Omicron.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

Japan Registry of Clinical Trials Identifier: jRCT 2031220510.

Machine learning models predict long COVID outcomes based on baseline clinical and immunologic factors

The post-acute sequelae of SARS-CoV-2 (PASC), also known as long COVID, remain a significant health issue that is incompletely understood. Predicting which acutely infected individuals will go on to develop long COVID is challenging due to the lack of established biomarkers, clear disease mechanisms, or well-defined sub-phenotypes. Machine learning (ML) models offer the potential to address this by leveraging clinical data to enhance diagnostic precision. We utilized clinical data, including antibody titers and viral load measurements collected at the time of hospital admission, to predict the likelihood of acute COVID-19 progressing to long COVID. Our machine learning models achieved median AUROC values ranging from 0.64 to 0.66 and AUPRC values between 0.51 and 0.54, demonstrating their predictive capabilities. Feature importance analysis revealed that low antibody titers and high viral loads at hospital admission were the strongest predictors of long COVID outcomes. Comorbidities, including chronic respiratory, cardiac, and neurologic diseases, as well as female sex, were also identified as significant risk factors for long COVID. Our findings suggest that ML models have the potential to identify patients at risk for developing long COVID based on baseline clinical characteristics. These models can help guide early interventions, improving patient outcomes and mitigating the long-term public health impacts of SARS-CoV-2.

Assessment of psychosocial aspects in adults in post-COVID-19 condition: the EURONET-SOMA recommendations on core outcome domains for clinical and research use

BACKGROUND

Harmonizing core outcome domains allows for pooling data, comparing interventions, and streamlining research evaluation. At the same time clinicians require concise and feasible measures for routine practice. Considering the heterogeneity of post-COVID-19 condition, a biopsychosocial approach requires sufficient coverage of the psychosocial dimension with assessments. Previous recommendations for core outcome sets have serious limitations regarding the psychosocial aspects of post-COVID-19 condition. This paper specifically focuses on psychosocial outcomes for adults with post-COVID-19 condition, providing both a comprehensive set of outcome domains for research and a streamlined clinical core set tailored for routine clinical use.

METHODS

In a structured Consensus Development Approach, the European Network to improve diagnostic, treatment, and healthcare for patients with persistent somatic symptoms (EURONET-SOMA) developed psychosocial core outcome domains and assessments regarding post-COVID-19 condition. The experts identified variables and instruments which should be considered in studies on adults suffering from post-COVID-19 condition, and which are feasible in the clinical setting and relevant for research.

RESULTS

We identified three higher-order dimensions with each encompassing several domains: The first higher-order dimension, "outcomes", encompasses (1) the classification/ diagnostics of post-COVID-19 condition, (2) somatic symptoms (including fatigue), (3) the psychopathological status and mental comorbidities, (4) the physical status and somatic comorbidities, (5) neurocognitive symptoms, and (6) illness consequences. The second higher-order domain "mechanisms" encompasses (7) cognitive components, (8) affective components, (9) behavioral components, (10) social components, and (11) psychobiological bridge markers (e.g., neuroimmunological and psychoneuroendocrinological variables). The third higher-order domain, "risk factors", includes factors such as (12) socioeconomic status and sociocultural factors, (13) pre-existing mental and somatic health issues, (14) personality factors (e.g., neuroticism), (15) adverse childhood experiences, (16) ongoing disability or pension claim, and (17) social media use. For each domain, specific instruments are suggested for research purposes and clinical use.

CONCLUSIONS

The recommended core domains help to increase consistency in a biopsychosocial approach to post-COVID-19 condition across investigations, improve synergies, and facilitate decision-making when comparing different interventional approaches. It allows to better identify relevant subgroups in heterogeneous post-COVID-19 condition populations offering practical tools for routine clinical practice through the clinical core set.

Energy management education for persons living with long COVID-related fatigue (EMERGE): protocol of a two-parallel arms target trial emulation study in a multicentre outpatient intervention setting with an online control group register

INTRODUCTION

Energy management education (EME) is a manualised, evidence-based self-management education programme developed and delivered by occupational therapists for persons living with chronic disease-related fatigue. Studies have shown that EME can positively affect self-efficacy, fatigue impact and quality of life in persons with chronic conditions, while data on persons with long COVID are lacking.The primary aim is to evaluate if adding EME to the standard care improves outcomes in persons with long COVID-related fatigue. The secondary aim is to explore the energy management behavioural strategies applied in daily routines and investigate the influencing factors of implementing behavioural changes. The third aim is to perform a cost-effectiveness analysis of EME.

METHODS AND ANALYSIS

Using observational data, we will emulate a prospective two-parallel arms target trial to assess whether adding EME to the standard care is associated with improved outcomes in patients with long COVID-related fatigue. The estimated sample size to detect a post-intervention difference of 1.5 points in self-efficacy to implement energy conservation strategies with 90% power (0.05 alpha) is 122 people (1:1 ratio).Persons with long COVID-related fatigue who follow EME as part of their standard care will be recruited and included in the experimental group (EG), while potential participants for the control group (CG) will be recruited from a register and prospectively matched to a participant in the EG by applying the propensity score technique. The 'standard of care' of the CG will include any intervention, except occupational therapy-based EME in peer groups. The causal contrast of interest will be the per-protocol effect. Four self-reported questionnaires (fatigue impact, self-efficacy in performing energy management strategies, competency in performing daily activities, health-related quality of life) will be administered at baseline (T0; week 0), after lesson 7 (T1; week 6), post-intervention (T2; week 14) and follow-up (T3, week 24). Our main assessment will be at T2. Disease-related and productivity cost data will be collected, and a cost-effectiveness profile of the EME intervention will be compared with standard care.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the competent Swiss ethics commission.Findings will be reported (1) to the study participants; (2) to patient organisations and hospitals supporting EMERGE; (3) to funding bodies; (4) to the national and international occupational therapy community and healthcare policy; (5) will be presented at local, national, and international conferences and (6) will be disseminated by peer-review publications.

Long COVID for the Rheumatologist: Current Understanding and Approach to Management

There are estimated tens of millions of individuals throughout the world suffering from a variety of postinfectious sequela following infection with severe acute respiratory syndrome coronavirus 2 also commonly referred to as long coronavirus disease (COVID). Long COVID is providing an opportunity for the field of rheumatology to explore the relationship between similar syndromes including fibromyalgia seen in patients with underlying inflammatory and noninflammatory rheumatic diseases, as well as other postacute infectious sequela and bring our field's traditional skill sets to bear on improving our understanding of these disorders and the care of such patients.

History of Alcohol Use Disorder and Housing Instability as Predictors of Fatigue and Mental Health Problems During the COVID-19 Pandemic

Mental health and alcohol problems are significant public health concerns amid the COVID-19 pandemic. Housing instability and symptoms of fatigue are understudied aspects of the pandemic. This study examined history of Alcohol Use Disorder (AUD), history of COVID-19 infection, and housing instability as correlates of fatigue, anxiety, and depression symptoms. Data were drawn from 250 adults enrolled in an online survey within the NIAAA COVID-19 Pandemic Impact on Alcohol Study in between April 6 and June 2 of 2022. Participants completed self-report measures of housing stability, fatigue, and mental health symptoms. Multivariable analyses controlling for age, sex, race, ethnicity, and household income were conducted. Individuals with a history of AUD reported higher mental fatigue, anxiety symptoms, and depressive symptoms when compared to those with no history of AUD. Individuals with "other" housing arrangements (not renting or owning) reported higher mental fatigue, pandemic fatigue, anxiety symptoms, and depressive symptoms relative to homeowners. Individuals who worried about not having a place to live in the past 6 months reported higher physical fatigue, mental fatigue, anxiety symptoms, and depressive symptoms when compared to individuals without housing worry. History of COVID-19 infection was neither associated with mental health nor fatigue symptoms. Housing instability, as captured by housing worry and having "other" housing arrangements, was associated with greater fatigue and mental health problems, even after controlling for household income. Housing instability uniquely contributed to mental health symptoms, warranting further research and targeted prevention and intervention efforts.

Neuroimaging markers of cognitive fatigue in individuals with post-acute sequelae of SARS-CoV-2 infection

Persistent cognitive fatigue (CF) is the most reported symptom in Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), but little is known about its underlying neural basis. This pilot study examined fMRI brain activation patterns during a fatiguing task in those with and without PASC. We hypothesized that individuals with PASC would show changes in CF-related brain activation within fatigue network. Participants were 10 adults with PASC and persistent CF and 10 age- and gender-matched healthy controls. The 2-back working memory task was used during fMRI to induce CF. Patients with PASC reported greater CF, as measured using a Visual Analogue Scale of Fatigue (VAS-F), throughout the task. The relationship of brain activation in the fatigue network to increased CF during the fatiguing task did not differ between groups. There were, however, more areas inside and outside the fatigue network that were activated in the PASC group as reported CF increased. The relationship between brain activation and scores on the 2-back did differ between groups, with the PASC group showing more frontal activation. Findings suggest that individuals with PASC and CF may need to exert greater mental effort during demanding cognitive tasks, reflected in recruitment of a broader network of brain regions.

Fatigue in intensive care unit survivors with COVID-19: An observational cohort study

•Fatigue was highly prevalent one year after ICU admission in ICU survivors with COVID-19.•Younger age, pain/discomfort, dyspnoea, and mental health symptoms were associated with reports of fatigue.•COVID-19 ICU survivors should be assessed with comprehensive symptom screening during follow-up care.

Assessment of Autonomic Nervous System Function in Patients with Chronic Fatigue Syndrome and Post-COVID-19 Syndrome Presenting with Recurrent Syncope

Background/Objectives: Chronic fatigue syndrome and post-COVID-19 syndrome are associated with dysfunction of the autonomic nervous system, which may manifest as syncope and orthostatic intolerance. This study aimed to compare autonomic nervous system function in patients with chronic fatigue syndrome of unknown etiology and those with chronic fatigue syndrome secondary to post-COVID-19 syndrome using multiple diagnostic modalities, and to assess the prevalence and characteristics of syncope in these populations. Methods: This cross-sectional study included 440 patients examined at the Neurocardiological Laboratory of the Institute for Cardiovascular Diseases "Dedinje". Patients were divided into three groups: chronic fatigue syndrome of unknown etiology (Group 1, n = 210), chronic fatigue syndrome secondary to post-COVID-19 syndrome (Group 2, n = 137), and healthy controls (Group 3, n = 91). Diagnostic modalities included cardiovascular reflex tests, the head-up tilt test, beat-to-beat analysis, 24 h Holter electrocardiogram monitoring, and 24 h ambulatory blood pressure monitoring. Statistical analyses were performed using analysis of variance, Tukey's honestly significant difference test, and the Mann-Whitney U test. Results: Both chronic fatigue syndrome groups demonstrated significant autonomic nervous system dysfunction compared to healthy controls (p < 0.05), including reduced baroreceptor sensitivity and impaired heart rate variability parameters. Syncope prevalence was high in both chronic fatigue syndrome groups, with extreme blood pressure variability observed in 45-47% of patients during the head-up tilt test. Patients with post-COVID-19 chronic fatigue syndrome exhibited greater blood pressure increases during the head-up tilt test than those with chronic fatigue syndrome of unknown etiology (p < 0.05). Conclusions: Patients with chronic fatigue syndrome, irrespective of etiology, exhibit significant autonomic nervous system dysfunction and a high prevalence of syncope. Post-COVID-19 chronic fatigue syndrome demonstrates distinct hemodynamic patterns, suggesting unique pathophysiological mechanisms that warrant further investigation.

Exploring Hypercoagulability in Post-COVID Syndrome (PCS): An Attempt at Unraveling the Endothelial Dysfunction

Background: The lingering effects of SARS-CoV-2 infection, collectively known as post-COVID syndrome (PCS), affect a significant proportion of recovered patients, manifesting as persistent symptoms like fatigue, cognitive dysfunction, and exercise intolerance. Increasing evidence suggests that endothelial dysfunction and coagulation abnormalities play a central role in PCS pathophysiology. This study investigates hypercoagulability and endothelial dysfunction in PCS through thrombin generation and the von Willebrand factor (VWF)/ADAMTS13 axis. Methods: Plasma samples from 97 PCS patients recruited since October 2020 by the clinical research unit of the Brugmann University Hospital were analyzed. A thrombin generation test was performed on a St-Genesia® analyzer (Stago) using the Thromboscreen kit; VWF antigen was determined on a CS-2500 analyzer (Siemens); and ADAMTS-13 activity was determined using an ELISA kit (Technozym®) on an ElX808 plate reader. Results: Thrombin generation testing revealed elevated thrombin production in PCS patients, particularly when thrombomodulin was included. Although most PCS patients showed normalized VWF/ADAMTS13 ratios, 11.3% exhibited elevated ratios (≥1.5), associated with advanced age. Conclusions: Patients with PCS show a consistent pattern of prolonged thrombo-inflammatory dysregulation, highlighted by elevated in vitro thrombin generation and the persistence of abnormal VWF/ADAMTS-13 ratios in a subset of patients.

Chronic fatigue and headache in post-COVID-19 syndrome: a radiological and clinical evaluation

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused millions of infections and deaths globally. Post-COVID-19 syndrome, or long COVID is characterized by lingering symptoms such as chronic fatigue, headaches, and sleep disturbances. This study aimed to investigate the correlation between these symptoms and T2-hyperintense white matter lesions detected on magnetic resonance imaging (MRI) of the brain and spine in patients with post-COVID-19 syndrome.

Methods

This retrospective, single-center study analyzed a sample of 96 patients from Bern University Hospital in Switzerland who presented with suspected post-COVID-19 syndrome between 2020 and 2022. Patients completed self-report questionnaires evaluating fatigue, emotional wellbeing, and daytime sleepiness. Brain and spine MRIs were independently rated by 2 neuroradiologists for T2-hyperintense lesions. The correlation between these lesions and symptoms of fatigue and headache was assessed.

Results

The cohort consisted predominantly of women (73%) with an average age of 46 years. Chronic fatigue (90%), sleep disorders (51%), and headache (57%) were the most prevalent symptoms. The fatigue questionnaires indicated high levels of fatigue. Brain MRI revealed T2-hyperintense lesions in 72% of patients, whereas spine MRI showed these lesions in only 16%. There was no statistically significant correlation between the presence of cerebral T2-hyperintense lesions and symptoms of fatigue (p = 0.815) or headaches (p = 0.178). Similarly, no significant correlation was found when considering numbers of pathological brain lesions (fatigue: p = 0.557; headaches: p = 0.820).

Conclusion

While T2-hyperintense lesions are common in patients with post-COVID-19 syndrome, their presence does not correlate significantly with symptoms of fatigue or headaches. These findings suggest that T2-hyperintense brain lesions may not be directly related to the subjective experience of these symptoms. Further research with larger sample sizes and adjustment for potential confounding factors is necessary to better understand the relationship between MRI findings and post-COVID-19 syndrome symptoms.

Predicting work ability impairment in post COVID-19 patients: a machine learning model based on clinical parameters

The Post COVID-19 condition (PCC) is a complex disease affecting health and everyday functioning. This is well reflected by a patient's inability to work (ITW). In this study, we aimed to investigate factors associated with ITW (1) and to design a machine learning-based model for predicting ITW (2) twelve months after baseline. We selected patients from the post COVID care study (PCC-study) with data on their ability to work. To identify factors associated with ITW, we compared PCC patients with and without ITW. For constructing a predictive model, we selected nine clinical parameters: hospitalization during the acute SARS-CoV-2 infection, WHO severity of acute infection, presence of somatic comorbidities, presence of psychiatric comorbidities, age, height, weight, Karnofsky index, and symptoms. The model was trained to predict ITW twelve months after baseline using TensorFlow Decision Forests. Its performance was investigated using cross-validation and an independent testing dataset. In total, 259 PCC patients were included in this analysis. We observed that ITW was associated with dyslipidemia, worse patient reported outcomes (FSS, WHOQOL-BREF, PHQ-9), a higher rate of preexisting psychiatric conditions, and a more extensive medical work-up. The predictive model exhibited a mean AUC of 0.83 (95% CI: 0.78; 0.88) in the 10-fold cross-validation. In the testing dataset, the AUC was 0.76 (95% CI: 0.58; 0.93). In conclusion, we identified several factors associated with ITW. The predictive model performed very well. It could guide management decisions and help setting mid- to long-term treatment goals by aiding the identification of patients at risk of extended ITW.

Self-reported health, persistent symptoms, and daily activities 2 years after hospitalization for COVID-19

Introduction

Since the onset of the COVID-19 pandemic, 775 million cases have been reported globally. While many individuals recover fully, a significant proportion develop persistent symptoms. Numerous studies have investigated the long-term symptoms of COVID-19; however, the full extent and impact of these symptoms remain inadequately understood. The aim of this study was to investigate the prevalence of self-reported persistent symptoms, focusing on respiratory symptoms and fatigue and the impact on functional status 2 years after hospitalization for COVID-19.

Methods

This study is prospective and includes participants from a longitudinal multi-center cohort that follows patients previously hospitalized due to COVID-19 (n = 211). The current study encompasses the 2-year follow-up, using post-hospitalization questionnaire surveys. Analyzed data were collected before discharge and at the 2-year follow-up. Participants were grouped by age, sex and COVID-19 severity and group comparisons where conducted. Logistic regression analysis was used to study functional impairment.

Results

Two years after hospital discharge due to COVID-19, 125 participants completed the 2-year follow-up. The mean age of participants was 66 years (SD 12.2), and 68% were male. The majority of participants reported present respiratory symptoms (n = 83, 69%) and fatigue (n = 98, 78%) at the 2-year follow-up. Persistent respiratory symptoms and fatigue impacted functional status substantially (p = <0.001, p = 0.028, respectively). No significant differences were observed among groups depending on age, sex, or severity of COVID-19.

Conclusion

For some individuals regardless of age, sex or COVID-19 severity, respiratory symptoms and fatigue may persist for up to 2 years following COVID-19. Hence, having available support from professionals knowledgeable about COVID-19 is imperative. Further research is important to unravel the mechanisms of long-term symptoms following COVID-19 and to develop effective therapeutic and rehabilitative interventions.

Long COVID: A risk factor for anxiety, depression, and suicidality?

In many COVID-19 survivors, symptoms continue for a long time. This study aims to examine the relationship between the long-term effects of COVID-19, levels of anxiety and depression, and suicidal ideation with sociodemographic factors and symptoms. A cross-sectional study was conducted on patients who came for control at least 3 months after having COVID-19 disease, in the stable period, and still have symptoms after COVID-19. Demographic characteristics, symptoms, The Beck Depression Scale (BDS), The Beck Anxiety Scale (BAS), and suicidal ideation were assessed with face-to-face questionnaires. A total of 490 patients participated in the study. Thirty percent of patients scored positive on the BDS and 46% scored high on the BAS. Female sex was found to be a risk factor. Anxiety and depression were found to be significantly associated with long COVID symptoms. Both BAS and BDS scores were significantly higher in people with suicidality compared to others, and long-term symptoms were found to be statistically associated with this situation. Depression and anxiety are common in cases of long COVID. It is important for healthcare professionals to be aware of these potential mental health consequences, especially suicidality, and to provide appropriate support and interventions for individuals with long COVID.

Jitter and muscle fiber conduction velocity in long COVID fatigue

BACKGROUND

 Long coronavirus disease (long COVID, LC) is defined as the continuation or development of new symptoms 3 months after the acute stage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In LC, the rate of fatigue/postexertional malaise (F-PEM) has been described to be as high as 70%, regardless of age or severity of the acute symptoms.

OBJECTIVE

 To evaluate the neuromuscular junction (NMJ) function and the isolated muscle fiber conduction velocity (MFCV) in situ in LC cases and controls.

METHODS

 We studied 37 subjects without SARS-CoV-2 (controls) and 32 cases of SARS-CoV-2 infection, half with LC symptoms (LC-yes) and half without them (LC-no). Single-fiber electromyography (jitter measured with a concentric electrode), MFCV, the fast-to-slow MFCV ratio (F/S ratio), and the motor unit potentials (MUPs) were taken in the tibialis anterior muscle.

RESULTS

 At least 1 jitter parameter was abnormal in 1/37 controls, in 1/16 LC-no patients, and in 2/16 LC-yes patients, without significant differences among them. None of the subjects with abnormal jitter presented fluctuation symptoms or positive acetylcholine-receptor antibody. The MFCV and F/S ratios did not show abnormalities in any of the participants. The MUPs did not show myopathic or neurogenic abnormality in needle electromyography. The most frequent symptom in LC was F-PEM, which occurred in all LC-yes patients and was significantly different from the other groups.

CONCLUSION

 Fatigue/postexertional malaise was found in all cases of LC, and the electrophysiological findings did not indicate the muscle fiber or the NMJ as a relevant factor in this condition.

The Influence of Long COVID on the Cardiovascular System and Predictors of Long COVID in Females: Data from the Polish Long COVID Cardiovascular (PoLoCOV-CVD) Study

Background/Objectives: Female sex is one of the Long COVID (LC) risk factors; however, the LC predictors in females have not been established. This study was conducted to assess the influence of LC on the cardiovascular system and to assess the age-independent predictors of LC in females. Methods: Patient information and the course of the disease with symptoms were collected in women at least 12 weeks after COVID-19 recovery. The study participants were followed for 12 months. ECG monitoring, 24 h ECG monitoring, 24 h blood pressure monitoring, echocardiography, and biochemical tests were performed. Results: We studied 1946 consecutive female patients (age 53.0 [43.0-63.0] vs. 52.5 [41.0-63.0], p = 0.25). A more frequent occurrence of LC was observed in females with a severe SARS-CoV-2 infection (p = 0.0001). Women with LC compared to the control group had higher body mass index (p = 0.001), lower level of HDL cholesterol (p = 0.015), higher level of TG (p < 0.001) and higher TG/HDL ratio (p < 0.001), more often myocardial damage (p < 0.001), and lower LVEF (p = 0.01). LC women had more often QRS fragmentation, longer QTcB, and one of the ECG abnormalities. In a multivariate analysis in younger females with BMI > 24.8 kg/m2, TG/HDL ratio > 1.89 and severe course of COVID-19 and in older females, TG/HDL ratio > 1.89, lower LVEF, and also severe course of infection were independent LC predictors. Conclusions: Independent predictors of LC occurrence in women, regardless of age, are severe course of COVID-19 and TG/HDL ratio > 1.89. The presence of comorbidities and lifestyle before COVID-19 had no impact on the occurrence of LC in females regardless of age.

Comprehensive Risk Assessment of Infection Induced by SARS-CoV-2

The pandemic COVID-19 (coronavirus disease 2019) is caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), which devastated the global economy and healthcare system. The infection caused an unforeseen rise in COVID-19 patients and increased the mortality rate globally. This study gives an overall idea about host-pathogen interaction, immune responses to COVID-19, recovery status of infection, targeted organs and complications associated, and comparison of post-infection immunity in convalescent subjects and non-infected individuals. The emergence of the variants and episodes of COVID-19 infections made the situation worsen. The timely introduction of vaccines and precautionary measures helped control the infection's severity. Later, the population that recovered from COVID-19 grew significantly. However, understanding the impact of healthcare issues resulting after infection is paramount for improving an individual's health status. It is now recognised that COVID-19 infection affects multiple organs and exhibits a broad range of clinical manifestations. So, post COVID-19 infection creates a high risk in individuals with already prevailing health complications. The identification of post-COVID-19-related health issues and their appropriate management is of greater importance to improving patient's quality of life. The persistence, sequelae and other medical complications that normally last from weeks to months after the recovery of the initial infection are involved with COVID-19. A multi-disciplinary approach is necessary for the development of preventive measures, techniques for rehabilitation and strategies for clinical management when it comes to long-term care.

Is there a rationale for hyperbaric oxygen therapy in the patients with Post COVID syndrome? : A critical review

The SARS-CoV-2 pandemic has resulted in 762 million infections worldwide from 2020 to date, of which approximately ten percent are suffering from the effects after infection in 2019 (COVID-19) [1, 40]. In Germany, it is now assumed that at least one million people suffer from post-COVID condition with long-term consequences. These have been previously reported in diseases like Myalgic Encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS). Symptoms show a changing variability and recent surveys in the COVID context indicate that 10-30 % of outpatients, 50 to 70% of hospitalised patients suffer from sequelae. Recent data suggest that only 13% of all ill people were completely free of symptoms after recovery [3, 9]. Current hypotheses consider chronic inflammation, mitochondrial dysfunction, latent viral persistence, autoimmunity, changes of the human microbiome or multilocular sequelae in various organ system after infection. Hyperbaric oxygen therapy (HBOT) is applied since 1957 for heart surgery, scuba dive accidents, CO intoxication, air embolisms and infections with anaerobic pathogens. Under hyperbaric pressure, oxygen is physically dissolved in the blood in higher concentrations and reaches levels four times higher than under normobaric oxygen application. Moreover, the alternation of hyperoxia and normoxia induces a variety of processes at the cellular level, which improves oxygen supply in areas of locoregional hypoxia. Numerous target gene effects on new vessel formation, anti-inflammatory and anti-oedematous effects have been demonstrated [74]. The provision of intermittently high, local oxygen concentrations increases repair and regeneration processes and normalises the predominance of hyperinflammation. At present time only one prospective, randomized and placebo-controlled study exists with positive effects on global cognitive function, attention and executive function, psychiatric symptoms and pain interference. In conclusion, up to this date HBO is the only scientifically proven treatment in a prospective randomized controlled trial to be effective for cognitive improvement, regeneration of brain network and improvement of cardiac function. HBOT may have not only theoretical but also potential impact on targets of current pathophysiology of Post COVID condition, which warrants further scientific studies in patients.

Brain Fog: a Narrative Review of the Most Common Mysterious Cognitive Disorder in COVID-19

It has been more than three years since COVID-19 impacted the lives of millions of people, many of whom suffer from long-term effects known as long-haulers. Notwithstanding multiorgan complaints in long-haulers, signs and symptoms associated with cognitive characteristics commonly known as "brain fog" occur in COVID patients over 50, women, obesity, and asthma at excessive. Brain fog is a set of symptoms that include cognitive impairment, inability to concentrate and multitask, and short-term and long-term memory loss. Of course, brain fog contributes to high levels of anxiety and stress, necessitating an empathetic response to this group of COVID patients. Although the etiology of brain fog in COVID-19 is currently unknown, regarding the mechanisms of pathogenesis, the following hypotheses exist: activation of astrocytes and microglia to release pro-inflammatory cytokines, aggregation of tau protein, and COVID-19 entry in the brain can trigger an autoimmune reaction. There are currently no specific tests to detect brain fog or any specific cognitive rehabilitation methods. However, a healthy lifestyle can help reduce symptoms to some extent, and symptom-based clinical management is also well suited to minimize brain fog side effects in COVID-19 patients. Therefore, this review discusses mechanisms of SARS-CoV-2 pathogenesis that may contribute to brain fog, as well as some approaches to providing therapies that may help COVID-19 patients avoid annoying brain fog symptoms.

Long COVID and pituitary dysfunctions: a bidirectional relationship?

Long COVID is a novel emerging syndrome known to affect multiple health areas in patients previously infected by SARS-CoV-2 markedly impairing their quality of life. The pathophysiology of Long COVID is still largely poorly understood and multiple mechanisms were proposed to underlie its occurrence, including alterations in the hormonal hypothalamic-pituitary axes. Aim of this review is to present and discuss the potential negative implications of these hormonal dysfunctions in promoting and influencing the Long COVID syndrome. To date, the hypothalamic-pituitary-adrenal axis is the mostly investigated and several studies have reported a prolonged impairment leading to mild and subclinical forms of central adrenal insufficiency. Few data are also available regarding central hypogonadism, central hypothyroidism and growth hormone (GH) deficiency. A high prevalence of central hypogonadism in COVID-19 survivors several months after recovery was consistently reported in different cohorts. Conversely, very few data are available on the hypothalamic-pituitary-thyroid axis function that was mainly shown to be preserved in COVID-19 survivors. Finally, a potential impairment of the hypothalamic-GH axis in Long COVID has also been reported. These data altogether may suggest a novel possible pituitary-centred pathophysiological view of Long COVID syndrome which if confirmed by large clinical studies may have relevant implication for the diagnostic and therapeutic approach at least in a subset of patients with the syndrome.

Clinical features and predictive nomogram for fatigue sequelae in non-severe patients infected with SARS-CoV-2 Omicron variant in Shanghai, China

Background

Patients with coronavirus disease 2019(COVID-2019) infections may still experience long-term effects, with fatigue being one of the most frequent ones. Clinical research on the long COVID in the Chinese population after infection is comparatively lacking.

Objective

To collect and analyze the long-term effects of non-severe COVID-19 infection patients and to develop a model for the prediction of fatigue symptoms.

Methods

223 non-severe COVID-19 patients admitted to one designated hospital were enrolled after finish all the self-designed clinical information registration form and nine-month follow-up. We explored the frequency and symptom types of long COVID. Correlation analysis was done on the neuropsychological scale results. After cluster analysis, lasoo regression and logistic regressions, a nomogram prediction model was produced as a result of investigating the risk factors for fatigue.

Results

A total of 108 (48.4%) of the 223 non-severe COVID-19 patients reported sequelae for more than 4 weeks, and of these, 35 (15.7%) had fatigue sequelae that were scale-confirmed. Other sequelae of more than 10% were brain fog (n = 37,16.6%), cough (n = 26,11.7%) and insomnia (n = 23,10.3%). A correlation between depression and fatigue was discovered following the completion of neuropsychological scale. The duration of hospitalization, the non-use of antiviral medications in treatment, IL-6 and CD16+CD56+ cell levels in blood are the main independent risk factors and predictors of fatigue sequelae in long COVID. Additionally, the neurology diseases and vaccination status may also influence the fatigue sequelae.

Conclusion

Nearly half of the patients infected with COVID-19 Omicron variant complained of sequelae, and fatigue was the most common symptom, which was correlated with depression. Significant predictors of fatigue sequelae included length of hospitalization, non-use of antiviral drug, and immune-related serum markers of IL-6 and CD16+CD56+ NK cell levels. The presence of neurology diseases and a lack of vaccination could also predict the occurrence of fatigue sequelae.

Conception and development of a neurological registry of patients with persistent health impairments following work-related COVID-19 disease in Germany

Background

Healthcare and social workers had an increased occupational risk of contracting SARS-CoV-2 during the pandemic. Some developed long-lasting symptoms known as post-COVID syndrome (PCS). To assess the consequences of COVID-19 for individuals insured by the German Social Accident Insurance, the BG hospitals (Berufsgenossenschaftliche Kliniken: clinics for occupational accident insurance) established an interdisciplinary diagnostic programme. Data collected during routine clinical practice are transmitted to a multicenter post-COVID registry to enhance knowledge of the long-term consequences related to COVID-19 and to optimize diagnostics, treatment, and rehabilitation. The design of the post-COVID registry, along with a description of the study population, is detailed in this paper.

Methods

The registry includes patients with an occupational disease or accident. Depending on the severity and complexity of the symptoms, patients received an outpatient post-COVID examination or an inpatient post-COVID check (PCC). The collected data comprise demographics, occupational and social history, disease progression, pre-existing conditions, utilization of health services, persistent symptoms, and psychosocial and neuropsychological assessments. Further investigations are carried out in response to symptoms and needs, using clinical assessment, instrumental and imaging techniques, as well as questionnaires. In addition, serum and cerebrospinal fluid samples are preserved for biomarker analysis.

Results

By September 2024, 1,957 patients from six BG hospitals were included. An interim analysis of 1,150 cases shows that patients are predominantly female (77%) and the average age is 51 years (standard deviation [SD] 10.5). Around 43% worked in nursing at the time of infection. In 63% of cases, an inpatient post-COVID check was carried out. About 20% were hospitalized during acute COVID-19 infection, with an average stay of 14.6 days (SD 18.4). More than half were still unable to work at the time of examination, with no significant differences between hospitalized and non-hospitalized patients. Common pre-existing conditions included heart disease (48%), allergies (45%), and lung disease (33%). PCS symptoms mainly consisted of reduced physical capacity (95%), concentration difficulties (79%), and shortness of breath (69%). 81% had previously received outpatient and/or inpatient rehabilitation.

Conclusion

The outpatient and the inpatient PCC are essential in managing the recovery process for patients with PCS. Data analysis will provide insights into the need for medical care and rehabilitation. In addition, longitudinal analyses will be used to track the progress of the post-COVID registry over time and monitor the effectiveness of the recommended measures.

The effects of 3-month supplementation with synbiotic on patient-reported outcomes, exercise tolerance, and brain and muscle metabolism in adult patients with post-COVID-19 chronic fatigue syndrome (STOP-FATIGUE): a randomized Placebo-controlled clinical trial

PURPOSE

Considering the observed gastrointestinal issues linked to post-COVID-19 myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), beneficially modulating the gut microbiota could offer a safe, cost-effective nutritional strategy. This trial aimed to evaluate the effects of medium-term synbiotic supplementation on patient-reported outcomes, exercise tolerance, and tissue metabolism in patients with post-COVID-19 ME/CFS.

METHODS

Between September 2022 and December 2023, we investigated the impact of 3-month supplementation with a synbiotic mixture including L. rhamnosus DSM 32550, Humiome® L. plantarum DSM 34532, B. lactis DSM 32269, B. longum DSM 32946, fructooligosaccharides and zinc, on predetermined primary and secondary outcome measures in twenty six post-COVID-19 ME/CFS patients utilizing a parallel-group, randomized, placebo-controlled, double-blind design.

RESULTS

Both the synbiotic and placebo intake resulted in a significant reduction in general fatigue after 3 months compared to the baseline values (P ≤ 0.05). This was accompanied by a significant interaction effect (time vs. treatment) for post-exercise malaise (P = 0.02), with synbiotic superior to placebo to attenuate post-exercise malaise. The synbiotic also demonstrated a significant advantage over placebo in increasing choline levels at the thalamus (P = 0.02), and creatine levels at left frontal white matter (P = 0.05) and left frontal grey matter (P = 0.04).

CONCLUSION

Taking the synbiotic mixture for three months improves tissue metabolism and mitigates clinical features of post-COVID-19 fatigue syndrome. The presented data show promise in addressing the widespread issue of ME/CFS following the COVID-19 pandemic; however, further validation is needed before endorsing the synbiotics within this clinical context. The study is registered at ClinicalTrials.gov (NCT06013072).

Exploring Physical Activity, Sleep, and Nutrition's Role in Fatigue Among Post-COVID-19 Patients

Background/Objectives: A significant number of patients experience prolonged symptoms following COVID-19 in particular cases of fatigue. Yet, pathomechanisms of COVID-19-related fatigue remain unclear. Methods: This study investigated patients after confirmed SARS-CoV-2 infection (PC) with relevant fatigue according to the Fatigue Assessment Scale (≥22 points) to rule out malnutrition as a driving factor for fatigue and to evaluate daily activity and sleep characteristics. Dietary behavior was recorded through food diaries and physical activity by self-reported (questionnaires) and objective (activity tracker) outcomes. Data were collected over a 7-day period and compared with a healthy control group (HC). A subgroup analysis of patients with fatigue and severe fatigue, as well as a sex-specific analysis, were included. Results: No significant differences in dietary intake were observed, but an indication toward a healthier Mediterranean diet in PC patients with a median Mediterranean Diet Score of 4 (IQR 3, 5) in HC vs. 5 (IQR 3, 6) in PC (p = 0.24). There were also no differences in physical activity, either by objective or subjective measures. However, the median sleep duration was 49 min longer in PC patients (p = 0.003). Conclusions: In conclusion, malnutrition did not significantly contribute to fatigue, yet patients with COVID-19-related fatigue showed increased sleep duration. As sleep characteristics play a crucial role in mental and physical wellbeing, the association of sleep, physical activity, and fatigue should be evaluated in further studies.

Fatigue and cognitive dysfunction in previously hospitalized patients with COVID-19: A 1-year follow-up

PURPOSE

The aim was to longitudinally explore changes in fatigue- and cognition-related symptoms during the first year after hospital treatment for COVID-19.

METHOD

Patients hospitalized for COVID-19 in Gothenburg, Sweden, were consecutively included from 01-07-2020 to 28-02-2021. Patients were assessed at the hospital (acute) and at 3 and 12 months after hospital discharge. Cognition was assessed with the Montreal Cognitive Assessment (MoCA), the Trail Making Test B (TMTB), and the Cognitive Failure Questionnaire (CFQ). Fatigue was assessed using the Multidimensional Fatigue Inventory-20 (MFI-20) and the Mental Fatigue Scale (MFS). Data was analyzed with demographics and changes over time calculated with univariable mixed-effects models.

RESULT

In total, 122 participants were included. Analyzes of Z-scores for MoCA indicated improvement over the year, however the results were 1 SD below norm at all assessments. Alertness (TMTB scores) improved significantly from the acute assessment to the 12- month follow-up (p = <0.001, 95% CI 34.67-69.67). CFQ scores indicated cognitive impairment, and the sum scores for MFI reflected a relatively high degree of fatigue at follow-up.

CONCLUSION

In the first year after hospitalization for COVID-19, most patients experienced fatigue and cognitive impairment. Alertness improved, but improvements in other domains were limited.

Neuroinflammation in Post COVID-19 Sequelae: Neuroinvasion and Neuroimmune Crosstalk

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019 triggered a swift global spread, leading to a devastating pandemic. Alarmingly, approximately one in four individuals diagnosed with coronavirus disease 2019 (COVID-19) experience varying degrees of cognitive impairment, raising concerns about a potential increase in neurological sequelae cases. Neuroinflammation seems to be the key pathophysiological hallmark linking mild respiratory COVID-19 to cognitive impairment, fatigue, and neurological sequelae in COVID-19 patients, highlighting the interaction between the nervous and immune systems following SARS-CoV-2 infection. Several hypotheses have been proposed to explain how the virus disrupts physiological pathways to trigger inflammation within the CNS, potentially leading to neuronal damage. These include neuroinvasion, systemic inflammation, disruption of the lung and gut-brain axes, and reactivation of latent viruses. This review explores the potential origins of neuroinflammation and the underlying neuroimmune cross-talk, highlighting important unanswered questions in the field. Addressing these fundamental issues could enhance our understanding of the virus's impact on the CNS and inform strategies to mitigate its detrimental effects.

Immune activation and immune-associated neurotoxicity in Long-COVID: A systematic review and meta-analysis of 103 studies comprising 58 cytokines/chemokines/growth factors

BACKGROUND

Multiple studies have shown that Long COVID (LC) disease is associated with heightened immune activation, as evidenced by elevated levels of inflammatory mediators. However, there is no comprehensive meta-analysis focusing on activation of the immune inflammatory response system (IRS) and the compensatory immunoregulatory system (CIRS) along with other immune phenotypes in LC patients.

OBJECTIVES

This meta-analysis is designed to explore the IRS and CIRS profiles in LC patients, the individual cytokines, chemokines, growth factors, along with C-reactive protein (CRP) and immune-associated neurotoxicity.

METHODS

To gather relevant studies for our research, we conducted a thorough search using databases such as PubMed, Google Scholar, and SciFinder, covering all available literature up to July 5th, 2024.

RESULTS

The current meta-analysis encompassed 103 studies that examined multiple immune profiles, C-reactive protein, and 58 cytokines/chemokines/growth factors in 5502 LC patients versus 5962 normal controls (NC). LC patients showed significant increases in IRS/CIRS ratio (standardized mean difference (SMD: 0.156, confidence interval (CI): 0.062;0.250), IRS (SMD: 0.338, CI: 0.236;0.440), M1 macrophage (SMD: 0.371, CI: 0.263;0.480), T helper (Th)1 (SMD: 0.316, CI: 0.185;0.446), Th17 (SMD: 0.439, CI: 0.302;0.577) and immune-associated neurotoxicity (SMD: 0.384, CI: 0.271;0.497). In addition, CRP and 21 different cytokines displayed significantly elevated levels in LC patients compared to NC.

CONCLUSION

LC disease is characterized by IRS activation and increased immune-associated neurotoxicity.

Neurological long-COVID: Associations among fatigue, dysautonomia, depression, and subjective memory complaints

INTRODUCTION

Long-COVID is a multisystem disease characterized by a varied presentation of symptoms. According to most recent research, the most common symptom of long-COVID is fatigue, which up to this date lacks a universally accepted definition. This study aimed to investigate neurocognitive and physical manifestations of neurological long-COVID, particularly fatigue and its relation with autonomic disfunction, cognitive impairment (known as, brain fog), and depressive symptoms. Furthermore, the study provided insights into predictors of fatigue in long-COVID.

METHODS

The included patients (n=141) were referred to the neuro-long-COVID ambulatory service of Trieste from 30 September 2021-02 March 2022. Patients were given self-reporting questionnaires to screen for fatigue, autonomic dysfunction, cognitive impairment and depressive symptoms. The questionnaires adopted for these conditions to be assessed were Fatigue Severity Scale (FSS), COMPASS-31, Prospective-Retrospective Memory Questionnaire (PRMQ), and Beck Depression Inventory (BDI). Participants were divided into two groups, fatigued and non-fatigued patients, based on FSS scoring (scores > 4.67 indicate fatigued patients). The questionnaire scores of the two groups were then compared.

RESULTS

Fatigued patients had significantly higher scores in COMPASS (p<0.001, Cohen's d=1.077), BDI (p<0.001, Cohen's d=0.862), and PRMQ ( p<0.001, Cohen's d=1.159). Furthermore, the multivariate regression analysis showed that predictors of fatigue in long-COVID were symptomatological burden in acute infection (OR=1.38, 95 % CI 1.020-1.887, p=0.037) and in long-COVID (OR=1.78, 95 % CI 1.133-2.2824, p=0.013), COMPASS-31>16 (OR=3.44, 95 % CI 1240-9.560, p=0.018) and BDI>15 (OR=5.1, 95 % CI 1.715-15.164, p=0.003).

CONCLUSION

This study showed associations between fatigue, dysautonomia and depression, as well as with symptom burden in acute and long-COVID.

Immune response in vaccinated healthcare workers with frequent COVID-19 infections is characterised by blunted IFNγ and IL-2 responses to SARS-CoV-2 variants

Healthcare workers (HCWs) are at increased risk of SARS-CoV-2 infection. Despite widespread vaccination, some HCWs develop frequent symptomatic infection. We hypothesised that HCWs with frequent symptomatic COVID-19 have impaired T and B cell mediated immunity to SARS-CoV-2. Vaccinated HCWs with no prior COVID infection (n = 9), asymptomatic recent infection (n = 10), and frequent recent infection (n = 15) were recruited from a longitudinal HCW cohort study. Whole blood stimulation with SARS-CoV-2 variants (Wuhan, B.1.617, BA.2, BA.2.75, BA.4/5, XBB.1.5, BQ.1.1) was performed, with IFNγ and IL-2 responses, total IgG produced, and anti-Spike antibody neutralising capacity measured. Frequent infections had similar IFNγ and IL-2 responses to the never infected group, with significantly higher responses in the asymptomatic group. The frequent cohort had higher IgG responses to Delta and BA.4/5 and higher neutralising capacity against Omicron variants. An immune signature of blunted IL-2 and IFNγ in frequent infections may identify HCWs at increased risk of further infection.

SARS-CoV-2 propagation to the TPH2-positive neurons in the ventral tegmental area induces cell death via GSK3β-dependent accumulation of phosphorylated tau

COVID-19, an infectious disease caused by SARS-CoV-2, was declared a pandemic by the WHO in 2020. Psychiatric symptoms including sleep disturbance, memory impairment, and depression are associated with SARS-CoV-2 infection. These symptoms are causes long-term mental and physical distress in recovering patients; however, the underlying mechanism is unclear. In this study, we determined the effects of SARS-CoV-2 infection on brain tissue using k18hACE2 mice. Using brain tissue from 18hACE2 mice infected with SARS-CoV-2 through intranasal administration, SARS-CoV-2 spike protein and RNA were analyzed by immunohistochemical staining and in-situ hybridization. Immunohistochemical analysis revealed that Tryptophan hydroxylase 2 (TPH2)-positive cells and SARS-CoV-2 spike protein were co-localized in the ventral tegmental area of SARS-CoV-2-infected mice. We observed decreased TPH2 expression and increased accumulation of phosphorylated tau protein and Phospho-Histone H2A.X (γH2AX) expression in the ventral tegmental region. In addition, activation of glycogen synthase kinase 3β (GSK3β) was induced by SARS-CoV-2 infection. Overall, our results suggest that SARS-CoV-2 infection of TPH2-positive cells in the ventral tegmental area induces neuronal cell death through increased accumulation of phosphorylated tau. Attenuation of the GSK3β pathway and decreased serotonin synthesis through suppression of TPH2 expression may contribute to the development of neurological symptoms.

Effectiveness of Combined Pulmonary Rehabilitation and Progressive Muscle Relaxation in Treating Long-Term COVID-19 Symptoms: A Randomized Controlled Trial

Background: The aim of this study was to investigate the effects of pulmonary rehabilitation (PR) and additional progressive muscle relaxation (PMR) techniques in patients with long-term COVID-19 symptoms. Methods: We included 61 patients with long COVID-19 symptoms and randomly assigned them to two groups: PR only (group 1 with 30 subjects) and PR with PMR (group 2 with 31 subjects). The PR program consisted of gradual aerobic conditioning, strength training, and breathing exercises. Group 2 received additional 20 min daily sessions of progressive muscle relaxation techniques. Results: Following a 21-day intervention, it was observed that both groups had noteworthy improvements in lung function, exercise capacity, and sleep quality with statistical significance (p < 0.0001). Group 2 showed significant improvements in overall health (as measured by the General Health Questionnaire-12), patient health (as assessed by the Patient Health Questionnaire-9), general anxiety levels (as indicated by the Generalized Anxiety Disorders Scale-7), and sleep quality (as measured by the Pittsburgh Sleep Quality Index), with statistical significance (p < 0.0001), compared to group 1. Moreover, the statistical analysis demonstrated no significant difference in exercise capacity improvement between group 1 and group 2, as indicated by a p-value of 0.1711. Conclusions: The addition of progressive muscle relaxation to pulmonary rehabilitation significantly enhances mental health outcomes, particularly in reducing anxiety and improving sleep quality, for patients with long-term COVID-19 symptoms. These findings suggest that incorporating PMR into PR programs offers a valuable non-pharmacological approach to improving overall patient well-being during long-term COVID-19 recovery.

Prevalence, duration, and factors influencing post-COVID conditions among patients at several public hospitals, Alexandria governorate, Egypt 2022-2023

Background

Post-COVID conditions (PCC), characterized by persistent symptoms following acute infection, represent an emerging chronic illness that potentially affects millions of people worldwide. SARS-CoV-2 infection has resulted in a PCC incidence ranging from 10 to 30 % in non-hospitalized individuals to 50-70 % in hospitalized patients. Most PCC patients experience mild symptoms, while a minority report severe manifestations. We aimed to estimate the prevalence of PCC among COVID-19 patients who attended three public hospitals in Alexandria, Egypt between June 2022 and February 2023, and to investigate its risk factors.

Methods

All COVID-19-confirmed patients aged >18 years attended the selected hospitals, and their household contacts were contacted. Data were collected through telephone interviews using a questionnaire adapted from World Health Organization (WHO) and Penn Medicine tools, covering demographics, COVID-19 history, and PCC symptoms. PCC was defined as symptoms starting three months after the post-acute infection and lasting for at least two months beyond. Statistical analyses employed descriptive statistics, chi-square tests, and a logistic regression model, with a significance level of p < 0.05.

Results

A total of 1546 patients were enrolled. Their mean age was 39.7 ± 15.9 years, 46.0 % were males, and 13.9 % had comorbidities. Of them, 760 patients (49.2 %) reported PCC symptoms including, 52.6 % seen at outpatients, 26.7 % were admitted, and 0.5 % required admission to ICU. PCC symptoms included shortness of breath (94.2 %), mood changes (13.9 %), cough (13.0 %), and fatigue (8.8 %). PCC was associated with older age, hospitalization during acute COVID-19, comorbidities including asthma, hypertension, and diabetes, as well as treatment with different COVID-19 medications. Logistic regression shows that asthma, male gender, and treatment with medicines at the hospital remained significant in the model (ORs: 6.85, 0.36, and 0.88, p < 0.001).

Conclusion

This study sheds light on PCC's prevalence and influencing factors following infection in Alexandria, Egypt. Common PCC symptoms included difficulty in breathing, fatigue, and psychological manifestations. The findings emphasize the critical need for early intervention and targeted management strategies, especially for high-risk groups such as asthma patients, to alleviate the long-term health consequences of COVID-19. Study results could guide the prevention of PCC e.g., through vaccination, management of long-term sequelae of PCC e.g., rehabilitation, and psychological support initiatives.

Differences in brain structure and cognitive performance between patients with long-COVID and those with normal recovery

BACKGROUND

The pathophysiology of protracted symptoms after COVID-19 is unclear. This study aimed to determine if long-COVID is associated with differences in baseline characteristics, markers of white matter diffusivity in the brain, and lower scores on objective cognitive testing.

METHODS

Individuals who experienced COVID-19 symptoms for more than 60 days post-infection (long-COVID) (n = 56) were compared to individuals who recovered from COVID-19 within 60 days of infection (normal recovery) (n = 35). Information regarding physical and mental health, and COVID-19 illness was collected. The National Institute of Health Toolbox Cognition Battery was administered. Participants underwent magnetic resonance imaging (MRI) with diffusion tensor imaging (DTI). Tract-based spatial statistics were used to perform a whole-brain voxel-wise analysis on standard DTI metrics (fractional anisotropy, axial diffusivity, mean diffusivity, radial diffusivity), controlling for age and sex. NIH Toolbox Age-Adjusted Fluid Cognition Scores were used to compare long-COVID and normal recovery groups, covarying for Age-Adjusted Crystallized Cognition Scores and years of education. False discovery rate correction was applied for multiple comparisons.

RESULTS

There were no significant differences in age, sex, or history of neurovascular risk factors between the groups. The long-COVID group had significantly (p < 0.05) lower mean diffusivity than the normal recovery group across multiple white matter regions, including the internal capsule, anterior and superior corona radiata, corpus callosum, superior fronto-occiptal fasciculus, and posterior thalamic radiation. However, the effect sizes of these differences were small (all β<|0.3|) and no significant differences were found for the other DTI metrics. Fluid cognition composite scores did not differ significantly between the long-COVID and normal recovery groups (p > 0.05).

CONCLUSIONS

Differences in diffusivity between long-COVID and normal recovery groups were found on only one DTI metric. This could represent subtle areas of pathology such as gliosis or edema, but the small effect sizes and non-specific nature of the diffusion indices make pathological inference difficult. Although long-COVID patients reported many neuropsychiatric symptoms, significant differences in objective cognitive performance were not found.

Effects of an 8-week high-dose vitamin D supplementation on fatigue and neuropsychiatric manifestations in post-COVID syndrome: A randomized controlled trial

AIM

This study evaluated the effectiveness of high-dose vitamin D supplementation in alleviating fatigue and neuropsychiatric symptoms in post-COVID syndrome.

METHODS

In an 8-week, double-blind, randomized, placebo-controlled trial, 80 patients with post-COVID fatigue or neuropsychiatric symptoms were enrolled. Participants were randomly assigned to receive either 60,000 IU of vitamin D weekly (n = 40) or a placebo (n = 40) for 8 weeks. Clinical outcomes were assessed using the 11-item Chalder Fatigue Scale (CFQ-11); 21-item Depression, Anxiety, and Stress Scale (DASS-21); Pittsburgh Sleep Quality Index (PSQI); Addenbrooke's Cognitive Examination III (ACE); and Trail Making Test A and B (TMT-A and TMT-B). Baseline and 8-week measurements of inflammatory markers, including interleukin 6 (IL-6) and C-reactive protein (CRP), were also collected.

RESULTS

Significant improvements were found in the vitamin D group for CFQ (coefficient -3.5, P = 0.024), DASS-anxiety (-2.0, P = 0.011), and ACE (2.1, P = 0.012). No significant differences were observed in PSQI, DASS-depression, TMT, IL-6, or CRP levels. The incidence of adverse events was comparable between groups, with no serious adverse events reported.

CONCLUSION

High-dose vitamin D supplementation may benefit patients with post-COVID syndrome by reducing fatigue, alleviating anxiety, and improving cognitive symptoms, with minimal side effects.

Post-COVID fatigue: Reduced quality-of-life associated with clinically relevant fatigue in mild disease courses

Fatigue is a pervasive symptom experienced by many individuals after COVID-19. Despite its widespread occurrence, fatigue remains a poorly understood and complex phenomenon. Our aim is to evaluate the subjective experience of mental fatigue after COVID-19 and to assess its significance for daily life functioning. In this online questionnaire study (N = 220), the Fatigue Severity Scale (FSS), World Health Organization Quality-of-Life assessment (WHOQoL) and a subjective severity rating of the COVID-19 disease progression were used. For our statistical analyses we utilized independent samples t-tests, one-way ANOVA with post-hoc analyses, and a multiple regression. As expected our findings revealed the COVID group reported significantly higher levels of subjective fatigue compared to the control group. Moreover, there was a significant difference between experienced fatigue across the four severity groups. Participants who had a milder course of disease also experienced severe subjective fatigue. Subjective fatigue explained 40% variance in quality-of-life. In conclusion, severe subjective fatigue appears to be associated with increased self-reported COVID-19 symptom severity and lower quality-of-life but is already observable in milder cases. This underscores, firstly, the importance of considering also less severe cases and, secondly, the need to develop rehabilitation and psychological interventions for fatigue.

Somatosensory processing in long COVID fatigue and its relations with physiological and psychological factors

Fatigue is prevalent amongst people with long COVID, but is poorly understood. The sensory attenuation framework proposes that impairments in sensory processing lead to heightened perception of effort, driving fatigue. This study aims to investigate the role of somatosensory processing impairments in long COVID fatigue and quantify how sensory processing relates to other prominent symptoms of long COVID including autonomic dysfunction, mood and illness beliefs in driving the experience of fatigue. We will recruit 44 individuals with long COVID fatigue and 44 individuals with neither long COVID nor fatigue (controls). Our primary objective is to compare baseline somatosensory processing between individuals with long COVID fatigue and controls. Additionally, we will explore the associations between somatosensory processing, fatigability and the level of fatigue induced by cognitive and physical exertion. Due to the complex nature of fatigue, we will also investigate how long COVID, state fatigue, perceived effort, mood, illness beliefs, autonomic symptoms and autonomic nervous system function interact to predict trait fatigue. This comprehensive investigation aims to elucidate how sensory processing and other prominent symptoms interact to impact the experience of fatigue.

The roles of the kynurenine pathway in COVID-19 neuropathogenesis

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the highly contagious respiratory disease Corona Virus Disease 2019 (COVID-19) that may lead to various neurological and psychological disorders that can be acute, lasting days to weeks or months and possibly longer. The latter is known as long-COVID or more recently post-acute sequelae of COVID (PASC). During acute COVID-19 infection, a strong inflammatory response, known as the cytokine storm, occurs in some patients. The levels of interferon-γ (IFN-γ), interferon-β (IFN-β), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α) are particularly increased. These cytokines are known to activate the enzyme indoleamine 2,3-dioxygenase 1 (IDO-1), catalysing the first step of tryptophan (Trp) catabolism through the kynurenine pathway (KP) leading to the production of several neurotoxic and immunosuppressive metabolites. There is already data showing elevation in KP metabolites both acutely and in PASC, especially regarding cognitive impairment. Thus, it is likely that KP involvement is significant in SARS-CoV-2 pathogenesis especially neurologically.

Efficacy of Donepezil for Fatigue and Psychological Symptoms in Post-COVID-19 Condition: Study Protocol for a Multicenter Randomized, Placebo-controlled, Double-blind Trial

BACKGROUND

Approximately 30% of coronavirus disease 2019 COVID-19 patients develop fatigue and psychological symptoms. We previously demonstrated the efficacy of donepezil, an acetylcholinesterase inhibitor that is widely used to treat dementia, in basic research.

METHODS

This is a multicenter, double-blind, randomized, controlled, phase II clinical trial in which 120 patients with COVID-19 will be randomized in a 1:1 ratio to a donepezil or placebo group. Inclusion criteria are as follows: (1) Adult. (2) With COVID-19 infection who had an upper respiratory tract infection, fever, or cough in the acute phase. (3) With a global binary fatigue score ≥4 on the Chalder Fatigue Scale assessment (4) Within 52 weeks of the onset of COVID-19. (5) Patients who provide consent themselves. In the donepezil group, a low dose (3 mg/day) is administered for the first week and is increased to 5 mg/day for 2 weeks. The control group receives placebo for 3 weeks. The primary endpoint is a change in and the absolute value of the Chalder Fatigue Scale score after 3 weeks of treatment. Secondary endpoints are a change in and the absolute value of the Chalder Fatigue Scale score after 8 weeks of treatment, the other mental scores after 3 and 8 weeks of treatment, a symptom survey, adverse events, and medication compliance rate.

RESULTS

This study protocol is ongoing and the results will be analyzed in April 2024.

CONCLUSIONS

The off-label use of donepezil at the default dose for dementia has potential for the treatment of post-COVID-19 condition.

Care needs of patients with the post-COVID syndrome in Dutch general practice: an interview study among patients and general practitioners

BACKGROUND

The post-COVID syndrome (PCS) has a large impact on an individual's daily life. The wide variety of symptoms in PCS patients and the fact that it is still relatively new makes it difficult for general practitioners (GPs) to recognize, diagnose and treat patients with PCS, leading to difficulties in assessing and fulfilling healthcare needs. It is largely unknown what the experiences of Dutch patients and GPs are with PCS and, therefore, we gained insight into the different aspects of living with PCS and the associated healthcare needs.

METHODS

Semi-structured interviews were performed with 13 self-reported PCS patients (varying in sex, age, education, and health literacy) and 6 GPs (varying in gender, age, and type of practice) between January-July 2022. Patients and GPs were most likely unrelated (not in the same practices). The data have been analysed using the Thematic Analysis method.

RESULTS

Experiences appeared to vary between two types of PCS patients that emerged during the interviews: (1) individuals with good pre-existing health status (PEHS) who are severely affected by PCS and have difficulty recovering and (2) individuals with poorer PEHS whose health became even poorer after COVID-19 infection. The interviews with PCS patients and GPs revealed two main themes, in which the types of patients differed: (1) aspects of living with PCS; individuals with good PEHS mainly experience symptoms when overstimulated, while individuals with poorer PEHS generally feel exhausted continuously. (2) Healthcare experiences; GPs emphasized that individuals with good PEHS seem to benefit from support in distributing their energy by careful planning of daily activities, whereas individuals with poorer PEHS require support in activation. Patients and GPs emphasised the importance of taking patients seriously and acknowledging their symptoms. Finally, the patients interviewed indicated that some GPs doubted the existence of PCS, resulting in insufficient recognition.

CONCLUSION

Awareness of the differences in needs and experiences of the two types of PCS patients could contribute to more appropriate care. Acknowledgement of PCS by GPs as a real syndrome is important for patients and plays an important role in coping with or recovering from PCS. A multidisciplinary person-centred approach is important and can be coordinated by a GP.