Long COVID: Clinical characteristics, proposed pathogenesis and potential therapeutic targets

Health Care Personnel Workdays Lost and Direct Health Care Salary Costs Incurred due to COVID-19 Infection in the Age of Widespread Vaccine Availability

BACKGROUND

Vaccination against coronavirus disease 2019 (COVID-19) can mitigate the burden of health care worker (HCW) infection. We investigate the burden of HCW illness and its associated direct health care personnel costs in the setting of widespread vaccine availability and explore factors influencing these outcomes.

METHODS

This multicenter prospective study followed HCWs over an 8-month period from January to August 2023. Data recorded included incident COVID-19 infection, symptom burden, workdays missed, and vaccine history. Workdays lost due to illness were used to calculate direct health care personnel costs due to COVID-19 infection. Univariate analysis and multivariable regression investigated the factors associated with workdays lost and direct health care personnel.

RESULTS

In total, 1218 participants were enrolled and followed for 8 months, with 266 incidents of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 1191 workdays lost, and health care personnel costs of €397 974. Multivariable regression revealed that workdays lost were associated with incomplete primary COVID-19 vaccination course. Being unvaccinated, older age, and male were associated with increased health care personnel costs.

CONCLUSIONS

Health care workdays lost remain a significant issue and are associated with health care system burden despite vaccine availability. These can be mitigated via targeted implementation of vaccine programs. Seasonal variation in health care workdays lost should inform workforce planning to accommodate surge periods.

Combining Double-Dose and High-Dose Pulsed Dapsone Combination Therapy for Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome and Co-Infections, Including Bartonella: A Report of 3 Cases and a Literature Review

Three patients with relapsing and remitting borreliosis, babesiosis, and bartonellosis, despite extended anti-infective therapy, were prescribed double-dose dapsone combination therapy (DDDCT) for 8 weeks, followed by one or several two-week courses of pulsed high-dose dapsone combination therapy (HDDCT). We discuss these patients' cases to illustrate three important variables required for long-term remission. First, diagnosing and treating active co-infections, including Babesia and Bartonella were important. Babesia required rotations of multiple anti-malarial drug combinations and herbal therapies, and Bartonella required one or several 6-day HDDCT pulses to achieve clinical remission. Second, all prior oral, intramuscular (IM), and/or intravenous (IV) antibiotics used for chronic Lyme disease (CLD)/post-treatment Lyme disease syndrome (PTLDS), irrespective of the length of administration, were inferior in efficacy to short-term pulsed biofilm/persister drug combination therapy i.e., dapsone, rifampin, methylene blue, and pyrazinamide, which improved resistant fatigue, pain, headaches, insomnia, and neuropsychiatric symptoms. Lastly, addressing multiple factors on the 16-point multiple systemic infectious disease syndrome (MSIDS) model was important in achieving remission. In conclusion, DDDCT with one or several 6-7-day pulses of HDDCT, while addressing abnormalities on the 16-point MSIDS map, could represent a novel effective clinical and anti-infective strategy in CLD/PTLDS and associated co-infections including Bartonella.

Long-COVID-19 Impact in non-hospitalized patients: Sleep and quality of life 24 months after SARS-CoV-2 infection

Background and Aims

Sleep disruption and reduced quality of life are common long coronavirus disease (COVID) manifestations, affecting survivors irrespective of initial COVID-19 severity. Limited research investigates symptoms beyond 24 months post-infection. We aimed to address this gap by longitudinally studying sleep patterns and overall quality of life in non-hospitalized adults, 24 months after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.

Methods

This prospective observational study involved the enrolment of 337 adult non-hospitalized patients in a consecutive fashion. Individuals with past COVID-19 (from 15 April 2020 to 30 June 2021) were examined at two Government hospitals and completed a telephone interview between 1 May 2023 and 30 June 2023, located in Jharkhand, India. Participants were queried about their sleep patterns and quality of life, utilizing the DSM5 LEVEL 2 and EQ-ED-5L tool, respectively.

Results

Among 337 non-hospitalized participants, 212 completed the survey. Within this group (59.4% men, mean age 38), 36 (17.0%) experienced sleep impairment. All five dimensions of quality of life (QoL) were adversely affected in long COVID patients. Advanced age, high income, residing in rural or semi-urban areas, and having comorbidities were associated with a higher likelihood of decreased quality of life across various domains. Conversely, participants who were married, employed in healthcare or government positions, and vaccinated exhibited a reduced likelihood of experiencing lower quality of life.

Conclusion

Long COVID-19 affects sleep and quality of life, with various demographic and clinical factors influencing outcomes. This study provides insights into the extended consequences of long COVID-19 and aids healthcare systems in addressing the challenges posed by this condition.

Safety and Efficacy of Pulmonary Rehabilitation for Long COVID Patients Experiencing Long-Lasting Symptoms

Due to the high prevalence and persistence of long COVID, it is important to evaluate the safety and efficacy of pulmonary rehabilitation (PR) for patients who experience long-lasting symptoms more than six months after initial COVID-19 onset. Enrolled patients were admitted for a four-week in-patient-PR due to long COVID symptoms (n = 47). The safety of PR was confirmed by the absence of adverse events. Symptom-related outcomes were evaluated pre- and post-PR with significant score changes for: 6 min walking distance (61 [28 to 103] m), quality of life (mental Short Form-12: 10 [6 to 13], and physical: 9 [6 to 12]), Montreal Cognitive Assessment (1 [0 to 3]), fatigue (MFI-20: -19 [-28 to -8]), dyspnea (DYSPNEA-12: -7 [-9 to -2] and mMRC; -1 [-1 to 0]), Nijmegen questionnaire (-8 [-11 to -5]), anxiety and depression (HADS:-4 [-5 to -2] and -2 [-4 to -1], respectively) and posttraumatic stress disorder checklist scale (-8 [-12 to -4]). At the individual level, the percentage of symptomatic patients for each outcome decreased, with a high response rate, and the number of persistent symptoms per patient was reduced from six at PR initiation to three at the end of the program. Our results show that in-PR is safe and efficient at decreasing long-lasting symptoms experienced by long COVID patients at more than six months after initial disease onset.

Potential Beneficial Effects of Naringin and Naringenin on Long COVID-A Review of the Literature

Coronavirus disease 2019 (COVID-19) caused a severe epidemic due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Recent studies have found that patients do not completely recover from acute infections, but instead, suffer from a variety of post-acute sequelae of SARS-CoV-2 infection, known as long COVID. The effects of long COVID can be far-reaching, with a duration of up to six months and a range of symptoms such as cognitive dysfunction, immune dysregulation, microbiota dysbiosis, myalgic encephalomyelitis/chronic fatigue syndrome, myocarditis, pulmonary fibrosis, cough, diabetes, pain, reproductive dysfunction, and thrombus formation. However, recent studies have shown that naringenin and naringin have palliative effects on various COVID-19 sequelae. Flavonoids such as naringin and naringenin, commonly found in fruits and vegetables, have various positive effects, including reducing inflammation, preventing viral infections, and providing antioxidants. This article discusses the molecular mechanisms and clinical effects of naringin and naringenin on treating the above diseases. It proposes them as potential drugs for the treatment of long COVID, and it can be inferred that naringin and naringenin exhibit potential as extended long COVID medications, in the future likely serving as nutraceuticals or clinical supplements for the comprehensive alleviation of the various manifestations of COVID-19 complications.

Autoimmunity and long COVID in children

Numerous hypotheses regarding the pathogenetic mechanisms of long COVID have been proposed. Immune dysregulation and autoimmunity are among the leading hypotheses. In this article, we present two clinical cases of long COVID. The first case demonstrates the phenotype of long COVID with pain and musculoskeletal symptoms, which is often associated with autoimmunity and mimics systemic connective tissue diseases. In the second case, a high titer of antinuclear antibodies was observed after SARS-CoV-2 infection, but the clinical symptoms were limited to fever and headache. Only a comprehensive evaluation of clinical symptoms and thorough objective examination can confirm or exclude autoimmune diseases after a previous SARS-CoV-2 infection. A systematic search in the PubMed Medline database was carried out for studies focusing on immune dysregulation, autoimmunity, and its association with the clinical phenotype of long COVID. The question of the role of autoimmunity in the development of long COVID and the management approaches are discussed.

Gut Microbiota and Mitochondria: Health and Pathophysiological Aspects of Long COVID

The current understanding of long COVID (LC) is still limited. This review highlights key findings regarding the role of gut microbiota, mitochondria, and the main pathophysiological aspects of LC revealed by clinical studies, related to the complex interplay between infection, intestinal dysbiosis, dysfunctional mitochondria, and systemic inflammation generated in a vicious circle, reflecting the molecular and cellular processes from the "leaky gut" to the "leaky electron transport chain (ETC)" into a quantum leap. The heterogeneity of LC has hindered progress in deciphering all the pathophysiological mechanisms, and therefore, the approach must be multidisciplinary, with a special focus not only on symptomatic management but also on addressing the underlying health problems of the patients. It is imperative to further assess and validate the effects of COVID-19 and LC on the gut microbiome and their relationship to infections with other viral agents or pathogens. Further studies are needed to better understand LC and expand the interdisciplinary points of view that are required to accurately diagnose and effectively treat this heterogeneous condition. Given the ability of SARS-CoV-2 to induce autoimmunity in susceptible patients, they should be monitored for symptoms of autoimmune disease after contracting the viral infection. One question remains open, namely, whether the various vaccines developed to end the pandemic will also induce autoimmunity. Recent data highlighted in this review have revealed that the persistence of SARS-CoV-2 and dysfunctional mitochondria in organs such as the heart and, to a lesser extent, the kidneys, liver, and lymph nodes, long after the organism has been able to clear the virus from the lungs, could be an explanation for LC.

Quality of life, exercise capacity, cognition, and mental health of Chilean patients after COVID-19: an experience of a multidisciplinary rehabilitation program at a physical and rehabilitation medicine unit

Background

Post-COVID disabilities, encompassing physical, cognitive, and psychological aspects, constitute the primary health sequelae for survivors. While the rehabilitation needs post COVID-19 are now well understood, each country possesses unique characteristics in terms of populations, healthcare systems, social dynamics, and economic profiles, necessitating context-specific recommendations. This study aims to address two main objectives: (1) analyze the impact of an 8-week multidisciplinary rehabilitation program on the quality of life, functional capacity, cognition, and mental health adaptations in adults recovering from COVID-19 in northern Chile, and (2) propose a personalized model for predicting program dropouts and responses.

Methods

A total of 44 subjects were enrolled, forming two groups during the study: a treatment group (n = 32) and a dropout group (n = 12). The treatment group participated in the 8-week multidisciplinary rehabilitation program.

Results

The results indicate that (1) After 8 weeks, the quality of life of the patients in the treatment group exhibited significant improvements reflected in all aspects of the Short Form-36 Health Survey (SF36, p < 0.005) and the total score (p < 0.001), with a concurrent decrease in dysfunctionality (p < 0.001). (2) Significant improvements were also observed in various physical performance tests, including the: 6-minute walk test, 1-min sit-to-stand, dynamometry, Tinetti balance, and Berg score (p < 0.001). Moreover, physical therapy led to a reduction in neuropathic symptoms and pain, psychological therapy reduced anxiety and depression, and language therapy enhanced memory and speech (all p < 0.05). (3) Demographic and clinical history characteristics did not predict responses to rehabilitation. (4) A regression model for predicting changes in SF-36 total score, based on physical function, physical role, general health, and mental health, was established based on the data from study (p < 0.01, adjusted R2 = 0.893). (5) Classification models for predicting dropouts achieved 68% accuracy, with key predictors of treatment adherence including diabetes, hypertension, and dyslipidemia, Tinetti balance, physical role, and vitality of SF36, and performance on the 6-minute walk test and 1-minute sit-to-stand.

Conclusions

This study demonstrates significant enhancements in quality of life, improved functional performance, and reductions in mental and cognitive burdens within an 8-week rehabilitation program. Additionally, it is possible to identify patients at risk of dropping out using cost-effective, outpatient, and clinically applicable tests.

A prognostic model and pre-discharge predictors of post-COVID-19 syndrome after hospitalization for SARS-CoV-2 infection

Background

Post-COVID-19 syndrome (PCS) has been increasingly recognized as an emerging problem: 50% of patients report ongoing symptoms 1 year after acute infection, with most typical manifestations (fatigue, dyspnea, psychiatric and neurological symptoms) having potentially debilitating effect. Early identification of high-risk candidates for PCS development would facilitate the optimal use of resources directed to rehabilitation of COVID-19 convalescents.

Objective

To study the in-hospital clinical characteristics of COVID-19 survivors presenting with self-reported PCS at 3 months and to identify the early predictors of its development.

Methods

221 hospitalized COVID-19 patients underwent symptoms assessment, 6-min walk test, and echocardiography pre-discharge and at 1 month; presence of PCS was assessed 3 months after discharge. Unsupervised machine learning was used to build a SANN-based binary classification model of PCS development.

Results

PCS at 3 months has been detected in 75% patients. Higher symptoms level in the PCS group was not associated with worse physical functional recovery or significant echocardiographic changes. Despite identification of a set of pre-discharge predictors, inclusion of parameters obtained at 1 month proved necessary to obtain a high accuracy model of PCS development, with inputs list including age, sex, in-hospital levels of CRP, eGFR and need for oxygen supplementation, and level of post-exertional symptoms at 1 month after discharge (fatigue and dyspnea in 6MWT and MRC Dyspnea score).

Conclusion

Hospitalized COVID-19 survivors at 3 months were characterized by 75% prevalence of PCS, the development of which could be predicted with an 89% accuracy using the derived neural network-based classification model.

Healthcare Worker Characteristics Associated with SARS-CoV-2 Vaccine Uptake in Ireland; a Multicentre Cross-Sectional Study

The prevention of SARS-CoV-2 acquisition and transmission among healthcare workers is an ongoing challenge. Vaccination has been introduced to mitigate these risks. Vaccine uptake varies among healthcare workers in the absence of vaccine mandates. We investigated engagement with SARS-CoV-2 vaccination among healthcare workers and identified characteristics associated with lower vaccine uptake. This multi-site cross-sectional study recruited n = 1260 healthcare workers in both clinical and non-clinical roles over a three-month period from November 2022. Participants reported their engagement with the primary SARS-CoV-2 vaccination programme and subsequent booster programmes, as well as providing demographic, occupational and personal medical history information. Multivariable linear regression identified characteristics associated with vaccine uptake. Engagement with vaccination programmes was high, with 88% of participants receiving at least one booster dose after primary vaccination course. Younger age and female sex were associated with reduced vaccine uptake. Healthcare workers in non-clinical roles also had reduced vaccine uptake. These findings should inform vaccination strategies across healthcare settings and target populations with reduced vaccine uptake directly, in particular young, female, and non-clinical healthcare workers, both for SARS-CoV-2 and other healthcare-associated vaccine-preventable infections.

The pathophysiology of postacute sequelae of COVID-19 (PASC): Possible role for persistent inflammation

As the SARS-CoV-2-induced pandemic wanes, a substantial number of patients with acute Corona Virus-induced disease (COVID-19 continue to have symptoms for a prolonged time after initial infection. These patients are said to have postacute sequelae of COVID (PASC) or "long COVID". The underlying pathophysiology of this syndrome is poorly understood and likely quite heterogeneous. The role of persistent, possibly deviant inflammation as a major factor in comorbidity is suspected.

Objective

To review data that address the relative importance of inflammation in the pathophysiology spectrum of PASC and to address how this would impact diagnosis and approach to therapy in patients identified as having such inflammatory abnormalities.

Methods

A review of public databases, including PubMed, MeSH, NLM catalog, and clinical trial databases such as clinicaltrials.gov.

Results

The literature supports a prominent role for various forms and types of inflammation in the pathophysiologic spectrum of PASC. Such inflammation can be persistent ant CoV-2-specific responses, new onset autoimmune responses, or a loss of normal immunoregulation resulting in widespread, sustained inflammatory pathologies that can affect both broad constitutional symptoms (such as fatigue, neurocognitive dysfunction, and anxiety/depression) and organ-specific dysfunction and/or failure.

Conclusions

PASC is a significant clinical entity with similarities to and differences from other postviral syndromes. Significant research efforts are ongoing to better understand specific aberrant inflammatory pathways present in individual patients for the purpose of developing and implementing effective therapies and ultimately prophylaxis strategies to prevent the progression of COVID-19 as well as likely future viral illnesses and pandemics.