COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors

Post-Acute Sequelae of SARS-COVID-2 Syndrome: Just the Beginning

Viral diseases are some of the most common infections affecting humans. Despite the unpleasant symptoms, most people return to their normal lives without residual symptoms. Following the acute infectious phase of some viruses, however, in some individuals symptoms may linger to the extent they are unable to return to a normal lifestyle. Following coronavirus disease 2019 infection, significant numbers of patients continued to have symptoms that persisted for months after hospital discharge. Symptoms spanned many organ systems and were prominent in the pulmonary and cardiovascular systems. The exact mechanism is not clear. This group of patients represents a new challenge to our health care systems. An organized, multi-disciplinary approach and further research are warranted to be ready to deliver better care to these patients.

Risk factors associated with the severity of COVID-19 in a region of the Brazilian Amazon

The Brazilian Northern region registered a high incidence of COVID-19 cases, particularly in the state of Pará. The present study investigated the risk factors associated with the severity of COVID-19 in a Brazilian Amazon region of 100,819 cases. An epidemiological, cross-sectional, analytical and demographic study, analyzing data on confirmed cases for COVID-19 available at the Brazilian Ministry of Health's surveillance platform, was conducted. Variables such as, municipalities of residence, age, gender, signs and symptoms, comorbidities were included and associated with COVID-19 cases and outcomes. The spatial distribution was performed using the ArcGIS program. A total of 100,819 cases were evaluated. Overall, patients had the mean age of 42.3 years, were female (51.2%) and with lethality reaching 4.79% of cases. Main symptoms included fever (66.5%), cough (61.9%) and sore throat (39.8%). Regarding comorbidities, most of the patients presented cardiovascular disease (5.1%) and diabetes (4.2%). Neurological disease increased risk of death by nearly 15 times, followed by obesity (5.16 times) and immunodeficiency (5.09 time). The municipalities with the highest incidence rate were Parauapebas, Canaã dos Carajás and Jacareacanga. Similarity between the Lower Amazon, Marajó and Southwest mesoregions of Pará state were observed concerning the highest morbidity rates. The obtained data demonstrated that the majority of cases occurred among young adults, females, with the classic influenza symptoms and chronic diseases. Finally, data suggest that the highest incidences were no longer in the metropolitan region of the state. The higher lethality rate than in Brazil may be associated with the greater impacts of the disease in this Amazonian population, or factors associated with fragile epidemiological surveillance in the notification of cases of cure.

Exploring the scope of homoeopathy in combating the unfortunate consequences of post-COVID-19 survivors based on non-COVID conditions: a narrative review

OBJECTIVES

The long-term consequences of COVID-19 survivors care and post-coronavirus infection are not yet well understood. The review aims to see whether homoeopathy can help COVID-19 survivors recover from its consequences and improve their quality of life.

CONTENT

A systematic search of published articles for post-COVID sequelae and the impact of Homoeopathy were conducted. For the literature search, the major electronic bio-medical database PubMed/MEDLINE was used. In addition, supplementary searches were conducted through the references of those published articles.

SUMMARY

A total of 113 records were identified of which 61 studies included for this review. Homoeopathy is effective in the treatment of mental disorders including anxiety and depressive disorder (ADD), some research studies have found, although systematic reviews disagree. Likewise, some medical societies denounce homoeopathy for pain management; other literature shows that it can be used to treat pain effectively. Homoeopathy can aid in the treatment of cardiovascular diseases, as Crataegus, a homoeopathic medication, was found to be just as effective as a standard angiotensin-converting enzyme (ACE) inhibitor and diuretic treatment for minor cardiac insufficiency. The outcomes for Chronic Fatigue Syndrome (CFS), Influenza, and Acute Respiratory Tract Infections (ARTIs) are also promising.

OUTLOOK

Based on the results of homoeopathy in non-COVID conditions, it can be thought of in the management of post-COVID-19 outcomes. Consequently, we propose that while investigating post-COVID-19 patient rehabilitation, homoeopathic management may be included as part of the follow-up route and as much data as possible in the context of homoeopathy should be collected, so that in future, the role of homoeopathy in dealing with it can be better demonstrated.

Comprehensive evaluation of COVID-19 patient short- and long-term outcomes: Disparities in healthcare utilization and post-hospitalization outcomes

BACKGROUND

Understanding risk factors for short- and long-term COVID-19 outcomes have implications for current guidelines and practice. We study whether early identified risk factors for COVID-19 persist one year later and through varying disease progression trajectories.

METHODS

This was a retrospective study of 6,731 COVID-19 patients presenting to Michigan Medicine between March 10, 2020 and March 10, 2021. We describe disease progression trajectories from diagnosis to potential hospital admission, discharge, readmission, or death. Outcomes pertained to all patients: rate of medical encounters, hospitalization-free survival, and overall survival, and hospitalized patients: discharge versus in-hospital death and readmission. Risk factors included patient age, sex, race, body mass index, and 29 comorbidity conditions.

RESULTS

Younger, non-Black patients utilized healthcare resources at higher rates, while older, male, and Black patients had higher rates of hospitalization and mortality. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss anemia were risk factors for these outcomes. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss were associated with lower discharge and higher inpatient mortality rates.

CONCLUSIONS

This study found differences in healthcare utilization and adverse COVID-19 outcomes, as well as differing risk factors for short- and long-term outcomes throughout disease progression. These findings may inform providers in emergency departments or critical care settings of treatment priorities, empower healthcare stakeholders with effective disease management strategies, and aid health policy makers in optimizing allocations of medical resources.

Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments

Long COVID or post-COVID-19 syndrome first gained widespread recognition among social support groups and later in scientific and medical communities. This illness is poorly understood as it affects COVID-19 survivors at all levels of disease severity, even younger adults, children, and those not hospitalized. While the precise definition of long COVID may be lacking, the most common symptoms reported in many studies are fatigue and dyspnoea that last for months after acute COVID-19. Other persistent symptoms may include cognitive and mental impairments, chest and joint pains, palpitations, myalgia, smell and taste dysfunctions, cough, headache, and gastrointestinal and cardiac issues. Presently, there is limited literature discussing the possible pathophysiology, risk factors, and treatments in long COVID, which the current review aims to address. In brief, long COVID may be driven by long-term tissue damage (e.g. lung, brain, and heart) and pathological inflammation (e.g. from viral persistence, immune dysregulation, and autoimmunity). The associated risk factors may include female sex, more than five early symptoms, early dyspnoea, prior psychiatric disorders, and specific biomarkers (e.g. D-dimer, CRP, and lymphocyte count), although more research is required to substantiate such risk factors. While preliminary evidence suggests that personalized rehabilitation training may help certain long COVID cases, therapeutic drugs repurposed from other similar conditions, such as myalgic encephalomyelitis or chronic fatigue syndrome, postural orthostatic tachycardia syndrome, and mast cell activation syndrome, also hold potential. In sum, this review hopes to provide the current understanding of what is known about long COVID.

Hidden danger of COVID-19 outbreak: evaluation of subclinical myocardial dysfunction in patients with mild symptoms

The COVID-19 infection, which is caused by the novel coronavirus SARS-CoV-2, has rapidly emerged as a global public health issue. Cardiac complications secondary to this infection are common and associated with mortality. This study aimed to evaluate whether subclinical myocardial dysfunction exists in non-hospitalized mildly symptomatic COVID-19 patients using left ventricular global longitudinal strain (LVGLS). In this cross-sectional, single-center study, data were collected from non-hospitalized mildly symptomatic COVID-19 patients between January 01 and February 01, 2021. Fifty (26 male, 24 female) COVID-19 patients and 50 age- and sex-matched healthy volunteers were included in the study. Apical four-, three-, and two-chamber images were analyzed longitudinally by conventional methods and speckle tracking echocardiography (STE) for left ventricle functions. The mean age of the COVID-19 patients was 39.5 ± 8.96, and 52% of them were male. The most prevalent presenting symptoms were fever [in 34 (68%)], asthenia [in 30 (60%)], loss of appetite [in 21 (42%)], myalgia [in 20 (40%)], and cough [in 13 (26%)]. Plasma levels of C-reactive protein (CRP) were significantly higher in the COVID-19 patients than in the controls (10.84 ± 12.44 vs. 4.50 ± 2.81, p < 0.001). There was no significant difference between the groups in terms of standard echocardiography and Doppler parameters (p > 0.05). Left ventricular longitudinal strain and strain velocity parameters were significantly decreased in COVID-19 patients compared to healthy individuals. LV-GLS values (- 21.72 ± 3.85% vs. - 23.11 ± 4.16%; p = 0.003) were significantly lower in COVID-19 patients compared with the healthy controls. Mildly symptomatic COVID-19 patients also have subclinical myocardial dysfunction similar to hospitalized patients. STE has the potential for detecting subclinical LV systolic dysfunction, and can provide useful information regarding cardiac status in mildly symptomatic COVID-19 population.

Application of machine learning in CT images and X-rays of COVID-19 pneumonia

ABSTRACT

Coronavirus disease (COVID-19) has spread worldwide. X-ray and computed tomography (CT) are 2 technologies widely used in image acquisition, segmentation, diagnosis, and evaluation. Artificial intelligence can accurately segment infected parts in X-ray and CT images, assist doctors in improving diagnosis efficiency, and facilitate the subsequent assessment of the severity of the patient infection. The medical assistant platform based on machine learning can help radiologists make clinical decisions and helper in screening, diagnosis, and treatment. By providing scientific methods for image recognition, segmentation, and evaluation, we summarized the latest developments in the application of artificial intelligence in COVID-19 lung imaging, and provided guidance and inspiration to researchers and doctors who are fighting the COVID-19 virus.

Post-akutes COVID-19 (“long-COVID”): Andauernde Symptome, mögliche Ursachen und symptomgeleitetes post-akut COVID-19 Management zur Wiedererlangung der körperlichen Leistungsfähigkeit (Scoping Review)

Das schwere akute respiratorische Syndrom Coronavirus 2 (SARS-CoV-2) ist der Erreger der pandemischen Erkrankung COVID-19, für die nach mehr als einem Jahr erkennbar ist, dass nach einer überstandenen akuten Erkrankung andauernde Symptome existieren können. Als post-akutes COVID-19 werden das Anhalten klinischer Symptome und/oder das Auftreten langfristiger Komplikationen über 4 Wochen nach der akut symptomatischen Krankheitsphase hinaus definiert. Aussagen über die Prävalenz sind vorläufig und abhängig vom Betrachtungszeitraum und untersuchter Bevölkerungsgruppe. In der Allgemeinbevölkerung wird das Auftreten derzeit mit einem Anteil von 15-30% der Infizierten angegeben. Die angegebenen Symptome lassen sich einer Vielzahl von Organsystemen zuordnen und weisen, was Anzahl, Dauer und Schweregrad anbelangt, teilweise große, interindividuelle Unterschiede auf. Die Ursachen für die subakute und chronische Manifestation der Symptome sind noch ungeklärt und verschiedene Mechanismen, wie funktionelle Einschränkungen multipler Organsysteme durch Gewebeschädigung sowie eine postivirale Autoimmunität werden diskutiert. Cluster aus möglichen individuellen Risikofaktoren, wie Alter und Geschlecht, kombiniert mit den Symptomen in der Akutphase zeigen sich am vielversprechendsten, um die Entwicklung von post-akutem COVID-19 zu prognostizieren. Ziel des Scoping Reviews ist es, andauernde Symptome und mögliche Ursachen für post-akutes COVID-19 (”long-COVID“) zusammenzufassen und wesentliche Aspekte für ein post-akutes COVID-19-Management zur Wiedererlangung der körperlichen Leistungsfähigkeit evidenzbasiert einzuordnen.

Residual Lung Injury in Patients Recovering From COVID-19 Critical Illness: A Prospective Longitudinal Point-of-Care Lung Ultrasound Study

Scarce data exist regarding the natural history of lung lesions detected on ultrasound in those who survive severe COVID-19 pneumonia.

OBJECTIVE

We performed a prospective analysis of point-of-care ultrasound (POCUS) findings in critically ill COVID-19 patients during and after hospitalization.

METHODS

We enrolled 171 COVID-19 intensive care unit patients. POCUS of the lungs was performed with phased array (2-4 MHz), convex (2-6 MHz) and linear (10-15 MHz) transducers, scanning 12 lung areas. Chest computed tomography angiography was performed to exclude suspected pulmonary embolism. Survivors were clinically and sonographically evaluated during a 4 month period for evidence of residual lung injury. Chest computed tomography angiography and echocardiography were used to exclude pulmonary hypertension (PH) and chest high-resolution-computed-tomography to exclude interstitial lung disease (ILD) in symptomatic survivors.

RESULTS

Cox regression analysis showed that lymphocytopenia (hazard ratio [HR]: 0.88, 95% confidence intervals [CI]: 0.68-0.96, p = .048), increased lactate (HR: 1.17, 95% CI: 0.94-1.46, p = 0.049), and D-dimers (HR: 1.21, 95% CI: 1.03-1.44, p = .03) were mortality predictors. Non-survivors had increased incidence of pulmonary abnormalities (B-lines, pleural line irregularities, and consolidations) compared to survivors (p < .05). During follow-up, POCUS with clinical and laboratory parameters integrated in the semi-quantitative Riyadh-Residual-Lung-Injury scale had sensitivity of 0.82 (95% CI: 0.76-0.89) and specificity of 0.91 (95% CI: 0.94-0.95) in predicting ILD. The prevalence of PH and ILD (non-specific-interstitial-pneumonia) was 7% and 11.8%, respectively.

CONCLUSION

POCUS showed ability to monitor the evolution of severe COVID-19 pneumonia after hospital discharge, supporting its integration in clinical predictive models of residual lung injury.

Risk profiles for negative and positive COVID-19 hospitalized patients

COVID-19 is a viral infection that affects people differently, where the majority of cases develop mild symptoms, some people require hospitalization, and unfortunately, a small number of patients perish. Hence, identifying risk factors is critical for physicians to make treatment decisions. The purpose of this article is to determine whether unsupervised analysis of risk factors in positive and negative COVID-19 subjects can aid in the identification of a set of reliable and clinically relevant risk profiles. Positive and negative patients hospitalized were randomly selected from the Mexican Open Registry between March and May 2020. Thirteen risk factors, three distinct outcomes, and COVID-19 test results were used to categorize registry patients. As a result, the dataset was reported via 6144 different risk profiles for each age group. The unsupervised learning method is proposed in this study to discover the most prevalent risk profiles. The data was partitioned into discovery (70%) and validation (30%) sets. The discovery set was analyzed using the partition around medoids (PAM) method, and the stable set of risk profiles was estimated using robust consensus clustering. The PAM models' reliability was validated by predicting the risk profile of subjects from the validation set and patients admitted in November 2020. In the validation set, the clinical relevance of the risk profiles was evaluated by determining the prevalence of three patient outcomes: pneumonia diagnosis, ICU admission, or death. Six positive and five negative COVID-19 risk profiles were identified, with significant statistical differences between them. As a result, PAM clustering with consensus mapping is a viable method for discovering unsupervised risk profiles in subjects with severe respiratory health problems.

Myocarditis With COVID-19 mRNA Vaccines

Myocarditis has been recognized as a rare complication of coronavirus disease 2019 (COVID-19) mRNA vaccinations, especially in young adult and adolescent males. According to the US Centers for Disease Control and Prevention, myocarditis/pericarditis rates are ≈12.6 cases per million doses of second-dose mRNA vaccine among individuals 12 to 39 years of age. In reported cases, patients with myocarditis invariably presented with chest pain, usually 2 to 3 days after a second dose of mRNA vaccination, and had elevated cardiac troponin levels. ECG was abnormal with ST elevations in most, and cardiac MRI was suggestive of myocarditis in all tested patients. There was no evidence of acute COVID-19 or other viral infections. In 1 case, a cardiomyopathy gene panel was negative, but autoantibody levels against certain self-antigens and frequency of natural killer cells were increased. Although the mechanisms for development of myocarditis are not clear, molecular mimicry between the spike protein of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and self-antigens, trigger of preexisting dysregulated immune pathways in certain individuals, immune response to mRNA, and activation of immunologic pathways, and dysregulated cytokine expression have been proposed. The reasons for male predominance in myocarditis cases are unknown, but possible explanations relate to sex hormone differences in immune response and myocarditis, and also underdiagnosis of cardiac disease in women. Almost all patients had resolution of symptoms and signs and improvement in diagnostic markers and imaging with or without treatment. Despite rare cases of myocarditis, the benefit-risk assessment for COVID-19 vaccination shows a favorable balance for all age and sex groups; therefore, COVID-19 vaccination is recommended for everyone ≥12 years of age.

Long COVID-19 Syndrome: A Comprehensive Review of Its Effect on Various Organ Systems and Recommendation on Rehabilitation Plans

The majority of people infected with SARS-CoV-2 fully recovered within a few weeks. However, a considerable number of patients of different ages still suffer from long-lasting problems similar to the multi-organ damage in its acute phase of infection, or experience symptoms continuously for a longer term after the recovery. The severity of the primary infection seems not to be associated with the possibility and severity of long-term symptoms. Various unresolved symptoms have been reported in COVID-19 survivors months after hospital discharge. Long COVID-19 Syndrome refers to survivors 4 months after initial symptoms onset. It is important to understand the systemic effects of Long COVID-19 Syndrome, its presentations, and the need for rehabilitations to restore functional recovery in survivors. Government, healthcare workers, and survivor groups should collaborate to establish a self-sustaining system to facilitate follow-up and rehabilitations, with prioritization of resources to more severely Long COVID-19 Syndrome survivors. This review looks into the systemic effects of Long COVID-19 Syndrome in various aspects: respiratory, cardiovascular, hematological, renal, gastrointestinal, neurological, and metabolic effects of Long COVID-19 Syndromes. Recommendations for follow-up and rehabilitations details have been explored to cope with the tremendous Long COVID-19 Syndrome patients.

Bufei huoxue capsules in the management of convalescent COVID-19 infection: study protocol for a multicenter, double-blind, and randomized controlled trial

Up to 30 May 2021, the cumulative number of patients diagnosed with corona virus disease-19 (COVID-19) globally has exceeded 170 million, with more than 152 million patients recovered from COVID-19. However, the long-term effect of the virus infection on the human body’s function is unknown for convalescent patients. It was reported that about 63% of COVID-19 patients had observable lung damage on CT scans after being released from the hospital. Bufei Huoxue (BFHX) capsules, including three active ingredients of traditional Chinese herbal medicine, has been used clinically to prevent and treat pulmonary heart diseases with Qi deficiency and blood stasis syndrome. Some small-scale clinical trials have found that BFHX can improve lung ventilation function, reduce blood viscosity, and improve cardiopulmonary function. However, the efficacy and safety of BFHX in the treatment of the recovery phase of COVID-19 are unknown. This study is a multicenter, double-blinded, randomized, controlled trial. Subjects with convalescent COVID-19 were randomized (1:1) into either a BFHX or control group and observed for three months concomitant with receiving routine treatment. The primary efficacy indicators are the evaluation results and changes of the St. George’s Respiratory Questionnaire score, Fatigue Assessment Inventory, and 6-min walk distance. Based on the intention-to-treat principle, all randomly assigned participants will be included in the statistical analysis. The last visit’s outcomes will be used as the final outcomes for participants who prematurely withdraw from the trial. Per protocol set will pick up from the full analysis set for analysis. Efficacy analysis will be performed on the intention-to-treat datasets and per-protocol datasets. This study and its protocol were approved by the Ethics Committee of our University. Prior to participation, all subjects provided written informed consent. Results will be disseminated at medical conferences and in journal publications. We aimed to determine the efficacy and safety of BFHX for the treatment of the convalescent COVID-19 patients.

Trial registration number: ChiCTR2000032573

Characterizing long COVID in an international cohort: 7 months of symptoms and their impact

BACKGROUND

A significant number of patients with COVID-19 experience prolonged symptoms, known as Long COVID. Few systematic studies have investigated this population, particularly in outpatient settings. Hence, relatively little is known about symptom makeup and severity, expected clinical course, impact on daily functioning, and return to baseline health.

METHODS

We conducted an online survey of people with suspected and confirmed COVID-19, distributed via COVID-19 support groups (e.g. Body Politic, Long COVID Support Group, Long Haul COVID Fighters) and social media (e.g. Twitter, Facebook). Data were collected from September 6, 2020 to November 25, 2020. We analyzed responses from 3762 participants with confirmed (diagnostic/antibody positive; 1020) or suspected (diagnostic/antibody negative or untested; 2742) COVID-19, from 56 countries, with illness lasting over 28 days and onset prior to June 2020. We estimated the prevalence of 203 symptoms in 10 organ systems and traced 66 symptoms over seven months. We measured the impact on life, work, and return to baseline health.

FINDINGS

For the majority of respondents (>91%), the time to recovery exceeded 35 weeks. During their illness, participants experienced an average of 55.9+/- 25.5 (mean+/-STD) symptoms, across an average of 9.1 organ systems. The most frequent symptoms after month 6 were fatigue, post-exertional malaise, and cognitive dysfunction. Symptoms varied in their prevalence over time, and we identified three symptom clusters, each with a characteristic temporal profile. 85.9% of participants (95% CI, 84.8% to 87.0%) experienced relapses, primarily triggered by exercise, physical or mental activity, and stress. 86.7% (85.6% to 92.5%) of unrecovered respondents were experiencing fatigue at the time of survey, compared to 44.7% (38.5% to 50.5%) of recovered respondents. 1700 respondents (45.2%) required a reduced work schedule compared to pre-illness, and an additional 839 (22.3%) were not working at the time of survey due to illness. Cognitive dysfunction or memory issues were common across all age groups (~88%). Except for loss of smell and taste, the prevalence and trajectory of all symptoms were similar between groups with confirmed and suspected COVID-19.

INTERPRETATION

Patients with Long COVID report prolonged, multisystem involvement and significant disability. By seven months, many patients have not yet recovered (mainly from systemic and neurological/cognitive symptoms), have not returned to previous levels of work, and continue to experience significant symptom burden.

FUNDING

All authors contributed to this work in a voluntary capacity. The cost of survey hosting (on Qualtrics) and publication fee was covered by AA's research grant (Wellcome Trust/Gatsby Charity via Sainsbury Wellcome center, UCL).

Host factors facilitating SARS-CoV-2 virus infection and replication in the lungs

SARS-CoV-2 is the virus causing the major pandemic facing the world today. Although, SARS-CoV-2 primarily causes lung infection, a variety of symptoms have proven a systemic impact on the body. SARS-CoV-2 has spread in the community quickly infecting humans from all age, ethnicities and gender. However, fatal outcomes have been linked to specific host factors and co-morbidities such as age, hypertension, immuno-deficiencies, chronic lung diseases or metabolic disorders. A major shift in the microbiome of patients suffering of the coronavirus disease 2019 (COVID-19) have also been observed and is linked to a worst outcome of the disease. As many co-morbidities are already known to be associated with a dysbiosis of the microbiome such as hypertension, diabetes and metabolic disorders. Host factors and microbiome changes are believed to be involved as a network in the acquisition of the infection and the development of the diseases. We will review in detail in this manuscript, the immune response toward SARS-CoV-2 infection as well as the host factors involved in the facilitation and worsening of the infection. We will also address the impact of COVID-19 on the host's microbiome and secondary infection which also worsen the disease.

Global burden of acute myocardial injury associated with COVID-19: A systematic review, meta-analysis, and meta-regression

Background

The body of evidence showed that there is a strong correlation between acute myocardial Injury and COVID-19 infection. However, the link between acute myocardial infection and COVID-19, the prevalence, reliability of diagnostic modalities, independent predictors, and clinical outcomes are still uncertain and a topic of debate. The current study was designed to determine the prevalence, determinants, and outcomes of acute myocardial injury based on a systematic review and meta-analysis the global published peer-reviewed works of literature.

Methods

A comprehensive search was conducted in PubMed/Medline; Science direct, CINHAL, and LILACS from December 2019 to May 2021. All observational studies reporting the prevalence of AMI were included while case reports and reviews were excluded. The data were extracted with two independent authors in a customized format. The methodological quality of included studies was evaluated using the Newcastle-Ottawa appraisal tool.

Results

A total of 397 articles were identified from different databases. Thirty-seven Articles with 21, 204 participants were included while seven studies were excluded. The meta-analysis revealed that the pooled prevalence of myocardial injury during the COVID-19 pandemic was 22.33 % (95 % CI: 17.86 to 26.81, 37).

Conclusion

Our meta-analysis showed that mortality among patients with an acute myocardial injury during COVID-19 was more than four times more likely as compared to those without AMI. This necessitates a mitigating strategy to prevent and manage before its clinical outcomes getting worse.

∙

The meta-analysis revealed that more than one-fifth of patients with COVID-19 sustained AMI

∙The incidence of mortality among patients with AMI during COVID-19 pandemic was four times more likely as compared those without AMI

∙Prevalence of AMI was three times more likely in patients with history of Coronary artery disease

∙Smoking and hypertension were the independent predictors of acute myocardial Injury

The Impact of the COVID-19 Pandemic on Dementia Risk: Potential Pathways to Cognitive Decline

BACKGROUND

Coronavirus disease 2019 (COVID-19), the far-reaching pandemic, has infected approximately 185 million of the world's population to date. After infection, certain groups, including older adults, men, and people of color, are more likely to have adverse medical outcomes. COVID-19 can affect multiple organ systems, even among asymptomatic/mild severity individuals, with progressively worse damage for those with higher severity infections.

SUMMARY

The COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily attaches to cells through the angiotensin-converting enzyme 2 (ACE2) receptor, a universal receptor present in most major organ systems. As SARS-CoV-2 binds to the ACE2 receptor, its bioavailability becomes limited, thus disrupting homeostatic organ function and inducing an injury cascade. Organ damage can then arise from multiple sources including direct cellular infection, overactive detrimental systemic immune response, and ischemia/hypoxia through thromboembolisms or disruption of perfusion. In the brain, SARS-CoV-2 has neuroinvasive and neurotropic characteristics with acute and chronic neurovirulent potential. In the cardiovascular system, COVID-19 can induce myocardial and systemic vascular damage along with thrombosis. Other organ systems such as the lungs, kidney, and liver are all at risk for infection damage. Key Messages: Our hypothesis is that each injury consequence has the independent potential to contribute to long-term cognitive deficits with the possibility of progressing to or worsening pre-existing dementia. Already, reports from recovered COVID-19 patients indicate that cognitive alterations and long-term symptoms are prevalent. This critical review highlights the injury pathways possible through SARS-CoV-2 infection that have the potential to increase and contribute to cognitive impairment and dementia.

Survival from Maternal Cardiac Arrest Complicating Coronavirus Disease 2019

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has been linked to significant cardiovascular complications such as cardiac arrest, which are associated with a poor prognosis in adults. Little is known about the cardiac complications, specifically cardiac arrest, of COVID-19 during pregnancy and postpartum periods.

CASE

We present a case of survival and full neurological recovery after maternal cardiac arrest associated with COVID-19 in a postpartum female. Her postpartum course was also associated with seizures attributed to posterior reversible encephalopathy syndrome. After 19 days in the hospital, she was discharged home neurologically intact.

CONCLUSION

More information is needed to determine the range of short- and long-term cardiac complications that may be associated with COVID-19 during pregnancy and postpartum. Additionally, pregnant patients with COVID-19 may be more likely to survive cardiac arrest compared to the general population.

COVID-19 and the clinical course of rheumatic manifestations

The manifestations of COVID-19 have been evolving over time. Various post-COVID-19 syndromes are being recognised. Various viruses have been implicated in the pathogenesis of autoimmune diseases, and we expect a similar outcome with the severe acute respiratory syndrome-associated coronavirus-2 (SARS-CoV-2). The SARS-CoV-2 virus penetrates various tissues and organs and has a predisposition to lead to endotheliitis that may cause vascular manifestations including thrombosis. SARS-CoV-2 has been shown to activate Toll-like receptors and the complement system. It perpetuates NETosis and leads to autoantibody formation. These predispose to systemic autoimmunity. Both reactive arthritis and connective tissue disorders such as lupus and inflammatory myositis have been reported after COVID-19. Other reported autoimmune disorders include haemolytic anaemia, immune thrombocytopenia, cutaneous vasculitis, and Guillain Barré-like acute demyelinating disorders. The multi-system inflammatory syndrome in children and its adult counterpart are another post-COVID-19 entity that presents as an admixture of Kawasaki disease and staphylococcal toxic shock syndrome. Patients with preexisting rheumatic diseases may flare during the SARS-CoV-2 infection. They may develop novel autoimmune features also. The immune-suppressants used during the acute COVID-19 illness may confound the outcomes whereas comorbidities present in patients with rheumatic diseases may mask them. There is an urgent need to follow-up patients recovering from COVID and monitor autoantibody production in the context of rheumatic manifestations. Key Points • COVID-19 is associated with both innate and acquired immune reactions and production of various autoantibodies. • Various immune-mediated manifestations such as arthritis, myositis, haemolytic anaemia, thrombocytopenia, and acute demyelination may develop after COVID-19. • Longitudinal cohort data are warranted to describe, predict, and test prevent various rheumatic manifestations in post-COVID-19 subjects.

Diagnosis, treatment and predictors of prognosis of myocarditis. A narrative review

Although it has been recognized for almost two centuries, myocarditis is still a challenging diagnosis due to the wide heterogeneity of its clinical manifestations and evolution. Moreover, the diagnostic gold standard, endomyocardial biopsy (EMB), is infrequently used, making hard to determine the exact incidence of myocarditis. Clinical presentation includes a wide range of symptoms, ranging from asymptomatic or subclinical disease with mild dyspnea and chest pain to sudden death, due to cardiogenic shock or malignant ventricular arrhythmias. Equally, the evolution of myocarditis largely varies: albeit short-term prognosis is usually good, with complete or partial recovery, dilated cardiomyopathy with chronic heart failure is the major long-term consequence of myocarditis, developing often several years after the acute onset. This narrative review aims to summarize the current knowledge about myocarditis, with a particular attention to predictors of short- and long-term prognosis, in order to provide a rational and practical approach to the diagnosis, evaluation and treatment of suspected myocarditis.

Cardio-Pulmonary Sequelae in Recovered COVID-19 Patients: Considerations for Primary Care

Background:

Current literature lacks characterization of the post-recovery sequelae among COVID-19 patients. This review characterizes the course of clinical, laboratory, radiological findings during the primary infection period, and the complications post-recovery. Primary care findings are presented for long-COVID care.

Methods:

Adhering to PRISMA guidelines, 4 databases were searched (PubMed, Embase, CINAHL Plus, Scopus) through December 5, 2020, using the keywords “COVID-19 and/or recovered and/or cardiovascular and/or long-term and/or sequelae and/or sub-acute and/or complication.” We included published peer-reviewed case reports, case series, and cross-sectional studies providing the clinical course of COVID-19 infection, and cardiopulmonary complications of patients who recovered from COVID-19, while making healthcare considerations for primary care workers.

Results:

We identified 29 studies across 9 countries including 37.9% Chinese and 24.1% U.S. studies, comprising 655 patients (Mean Age = 45) with various ethnical backgrounds including Asian and European. Based on the WHO COVID-19 severity classification scale, initial disease severity was mild for 377 patients and severe for 52 patients. Treatments during primary infection included corticosteroids, oxygen support, and antivirals. The mean value (in days) for complication onset after acute recovery was 28 days. Complete blood counts and RT-PCR tests were the most common laboratory results described. In 22 of the studies, patients showed signs of clinical improvement and were prescribed medications such as anticoagulants or corticosteroids.

Conclusion:

Post-recovery infectious complications are common in long-COVID-19 patients ranging from mild infections to life-threatening conditions. International thoracic and cardiovascular societies need to develop guidelines for patients recovering from COVID-19 pneumonia, while focused patient care by the primary care physician is crucial to curb preventable adverse events. Recommendations for real-time and lab-quality diagnostic tests are warranted to establish point-of-care testing, detect early complications, and provide timely treatment.

The Role of the Automated Implantable Cardioverter Defibrillator (AICD) for Secondary Prevention in the COVID-19 Era

Life-threatening arrhythmias have been variably reported among patients hospitalized for COVID-19 infection. Sudden cardiac arrest (SCA) in COVID-19 patients is an alarming concern for clinicians. Multiple factors play an important role in the development of SCA in patients with severe systemic illness. We describe a case of COVID-19 in a New York City hospital in Spring 2020 that rapidly developed SCA and, before discharge, received a single lead transvenous implantable cardioverter defibrillator for secondary prevention. This case highlights the use of an automated implantable cardioverter-defibrillator as a secondary preventive measure irrespective of left ventricular function as a means of preventing recurrence of SCA as a sequela of COVID-19.

Recovery of a critically ill patient with COVID-19 myocarditis

Myocarditis is a concerning potential consequence of COVID-19 infection, attributed to ventricular dysfunction, cardiac fibrosis, ventricular arrhythmias, cardiogenic shock, and sudden cardiac death. Recently, the Israeli Health Ministry announced that a small number of cases of myocarditis may be linked to second dose of Pfizer’s BioNTech-partnered COVID-19 vaccine. The long-term impact of COVID-19 myocarditis and coronary microthrombosis which has also been described and the best therapies for these complications remain unknown. Indeed, monomorphic ventricular tachycardia and regular ventricular arrhythmias have previously been found to be more common in those recovered from myocarditis than in acute myocarditis itself. Follow-up assessment of cardiac function has been suggested for this cohort to detect and possibly prevent further cardiac events in the rehabilitation phase. Functional capacity has been shown to be a better determinant of long-term morbidity than diagnostic testing alone, but integrated approach is likely the way forward in clinical follow-up. Assessment of residual complications in the post-COVID-19 recovery phase may identify the population burden of long-term cardiac disease as a direct consequence of COVID-19.

Demographic, multi-morbidity and genetic impact on myocardial involvement and its recovery from COVID-19: protocol design of COVID-HEART-a UK, multicentre, observational study

BACKGROUND

Although coronavirus disease 2019 (COVID-19) is primarily a respiratory illness, myocardial injury is increasingly reported and associated with adverse outcomes. However, the pathophysiology, extent of myocardial injury and clinical significance remains unclear.

METHODS

COVID-HEART is a UK, multicentre, prospective, observational, longitudinal cohort study of patients with confirmed COVID-19 and elevated troponin (sex-specific > 99th centile). Baseline assessment will be whilst recovering in-hospital or recently discharged, and include cardiovascular magnetic resonance (CMR) imaging, quality of life (QoL) assessments, electrocardiogram (ECG), serum biomarkers and genetics. Assessment at 6-months includes repeat CMR, QoL assessments and 6-min walk test (6MWT). The CMR protocol includes cine imaging, T1/T2 mapping, aortic distensibility, late gadolinium enhancement (LGE), and adenosine stress myocardial perfusion imaging in selected patients. The main objectives of the study are to: (1) characterise the extent and nature of myocardial involvement in COVID-19 patients with an elevated troponin, (2) assess how cardiac involvement and clinical outcome associate with recognised risk factors for mortality (age, sex, ethnicity and comorbidities) and genetic factors, (3) evaluate if differences in myocardial recovery at 6 months are dependent on demographics, genetics and comorbidities, (4) understand the impact of recovery status at 6 months on patient-reported QoL and functional capacity.

DISCUSSION

COVID-HEART will provide detailed characterisation of cardiac involvement, and its repair and recovery in relation to comorbidity, genetics, patient-reported QoL measures and functional capacity.

CLINICAL TRIAL REGISTRATION

ISRCTN 58667920. Registered 04 August 2020.

Changes in blood levels of IL1 family cytokines in patients with essential hypertension after having COVID-19

Pathogenetic progression mechanisms in the SARS-CoV-2–essential hypertension (EAH) system are more complex than interaction at the level of angiotensinconverting enzyme 2 (ACE2). The study was aimed to assess the dynamic changes of the IL1 members (IL1β, IL1α, IL1ra, IL18, IL18BP, IL37) blood levels in patients with EAH 10, 30, and 180 days after having COVID-19 in order to define cytokine-mediated mechanisms of EAH progression during the period following infection. The study involved four groups of patients: with a history of EAH and COVID-19 (pneumonia/no pneumonia), with a history of COVID-19 (pneumonia/no pneumonia) and no EAH. Cytokine levels were determined by enzyme immunoassay. The study results demonstrate the prolonged proinflammatory immune response during the period following infection in patients with EAH (retaining higher levels of IL1β, IL1α, and IL18 on days 10, 30, and 180 after recovery (р < 0.001) compared to levels measured prior to SARS-CoV-2 infection). In the group with no EAH, the balance of assayed cytokines was restored on day 30 of follow-up. The two-fold increase of blood IL18 levels in patients, having a history of EAH and COVID-19 and showing no increase in the IL18ВР levels after 30 days of follow up compared to the values measured prior to infection, is associated with cardiovascular complications occurring during the first six months of follow-up. This makes it possible to hypothesize the importance of these immunoregulatory peptides for the pathogenesis of complications and enhances the relevance of further scientific research.

Sequelae, persistent symptomatology and outcomes after COVID-19 hospitalization: the ANCOHVID multicentre 6-month follow-up study

BACKGROUND

Long-term effects of COVID-19, also called Long COVID, affect more than 10% of patients. The most severe cases (i.e. those requiring hospitalization) present a higher frequency of sequelae, but detailed information on these effects is still lacking. The objective of this study is to identify and quantify the frequency and outcomes associated with the presence of sequelae or persistent symptomatology (SPS) during the 6 months after discharge for COVID-19.

METHODS

Retrospective observational 6-month follow-up study conducted in four hospitals of Spain. A cohort of all 969 patients who were hospitalized with PCR-confirmed SARS-CoV-2 from March 1 to April 15, 2020, was included. We collected all the SPS during the 6 months after discharge reported by patients during follow-up from primary care records. Cluster analyses were performed to validate the measures. The main outcome measures were return to the Emergency Services, hospital readmission and post-discharge death. Surviving patients' outcomes were collected through clinical histories and primary care reports. Multiple logistic regression models were applied.

RESULTS

The 797 (82.2%) patients who survived constituted the sample followed, while the rest died from COVID-19. The mean age was 63.0 years, 53.7% of them were men and 509 (63.9%) reported some sequelae during the first 6 months after discharge. These sequelae were very diverse, but the most frequent were respiratory (42.0%), systemic (36.1%), neurological (20.8%), mental health (12.2%) and infectious (7.9%) SPS, with some differences by sex. Women presented higher frequencies of headache and mental health SPS, among others. A total of 160 (20.1%) patients returned to the Emergency Services, 35 (4.4%) required hospital readmission and 8 (1.0%) died during follow-up. The main factors independently associated with the return to Emergency Services were persistent fever, dermatological SPS, arrythmia or palpitations, thoracic pain and pneumonia.

CONCLUSIONS

COVID-19 cases requiring hospitalization during the first wave of the pandemic developed a significant range of mid- to long-term SPS. A detailed list of symptoms and outcomes is provided in this multicentre study. Identification of possible factors associated with these SPS could be useful to optimize preventive follow-up strategies in primary care for the coming months of the pandemic.

New Brazilian variant of the SARS-CoV-2 (P1/Gamma) of COVID-19 in Alagoas state

Since the beginning of 2020, health authorities have been monitoring the cases of Coronavirus Disease 2019 (COVID-19), which has grown every day in Brazil and around the world, becoming pandemic. The new coronavirus, also called SARS-CoV-2 by scientists spreads rapidly, causing fear, deaths, and threats for the economy of several countries. This work aimed to describe the clinical characterization of the first cases of a new Brazilian variant of SARS-CoV-2 (P1) in the State of Alagoas, which occurred on February 16th, 2021. Two cases are described: first, a person infected in Amazonas State, where the new variant P1 was first described, who migrated to Alagoas State, and second, a case of probable community transmission within Alagoas, since the patient had no history of recent travel. In both confirmed cases the symptoms were mild. Further studies are necessary to better understand the clinical behavior of P1 SARS-CoV-2 variant and also the associated sequelae in the context of COVID-19.

Post-COVID Syndrome: An Insight on Its Pathogenesis

Post-COVID syndrome is increasingly recognized as a new clinical entity in the context of SARS-CoV-2 infection. Symptoms persisting for more than three weeks after the diagnosis of COVID-19 characterize the post-COVID syndrome. Its incidence ranges from 10% to 35%, however, rates as high as 85% have been reported among patients with a history of hospitalization. Currently, there is no consensus on the classification of post-COVID syndrome. We reviewed the published information on post-COVID syndrome, putting emphasis on its pathogenesis. The pathogenesis of post-COVID syndrome is multi-factorial and more than one mechanism may be implicated in several clinical manifestations. Prolonged inflammation has a key role in its pathogenesis and may account for some neurological complications, cognitive dysfunction, and several other symptoms. A multisystem inflammatory syndrome in adults (MIS-A) of all ages has been also described recently, similarly to multisystem inflammatory syndrome in children (MIS-C). The post-infectious inflammatory pathogenetic mechanism of MIS-A is supported by the fact that its diagnosis is established through serology in up to one third of cases. Other pathogenetic mechanisms that are implicated in post-COVID syndrome include immune-mediated vascular dysfunction, thromboembolism, and nervous system dysfunction. Although the current data are indicating that the overwhelming majority of patients with post-COVID syndrome have a good prognosis, registries to actively follow them are needed in order to define the full clinical spectrum and its long-term outcome. A consensus-based classification of post-COVID syndrome is essential to guide clinical, diagnostic, and therapeutic management. Further research is also imperative to elucidate the pathogenesis of post-COVID syndrome.

Biomaterial-based immunoengineering to fight COVID-19 and infectious diseases

Infection by SARS-CoV-2 virus often induces the dysregulation of immune responses, tissue damage, and blood clotting. Engineered biomaterials from the nano- to the macroscale can provide targeted drug delivery, controlled drug release, local immunomodulation, enhanced immunity, and other desirable functions to coordinate appropriate immune responses and to repair tissues. Based on the understanding of COVID-19 disease progression and immune responses to SARS-CoV-2, we discuss possible immunotherapeutic strategies and highlight biomaterial approaches from the perspectives of preventive immunization, therapeutic immunomodulation, and tissue healing and regeneration. Successful development of biomaterial platforms for immunization and immunomodulation will not only benefit COVID-19 patients, but also have broad applications for a variety of infectious diseases.

Quality-Adjusted Life-Year Losses Averted With Every COVID-19 Infection Prevented in the United States

OBJECTIVE

To estimate the overall quality-adjusted life-years (QALYs) gained by averting 1 coronavirus disease 2019 (COVID-19) infection over the duration of the pandemic.

METHODS

A cohort-based probabilistic simulation model, informed by the latest epidemiological estimates on COVID-19 in the United States provided by the Centers for Disease Control and Prevention and literature review. Heterogeneity of parameter values across age group was accounted for. The main outcome studied was QALYs for the infected patient, patient's family members, and the contagion effect of the infected patient over the duration of the pandemic.

RESULTS

Averting a COVID-19 infection in a representative US resident will generate an additional 0.061 (0.016-0.129) QALYs (for the patient: 0.055, 95% confidence interval [CI] 0.014-0.115; for the patient's family members: 0.006, 95% CI 0.002-0.015). Accounting for the contagion effect of this infection, and assuming that an effective vaccine will be available in 3 months, the total QALYs gains from averting 1 single infection is 1.51 (95% CI 0.28-4.37) accrued to patients and their family members affected by the index infection and its sequelae. These results were robust to most parameter values and were most influenced by effective reproduction number, probability of death outside the hospital, the time-varying hazard rates of hospitalization, and death in critical care.

CONCLUSION

Our findings suggest that the health benefits of averting 1 COVID-19 infection in the United States are substantial. Efforts to curb infections must weigh the costs against these benefits.

Returning to a Normal Life via COVID-19 Vaccines in the United States: A Large-scale Agent-Based Simulation Study

BACKGROUND

In 2020, COVID-19 has claimed more than 300,000 deaths in the United States alone. Although nonpharmaceutical interventions were implemented by federal and state governments in the United States, these efforts have failed to contain the virus. Following the Food and Drug Administration's approval of two COVID-19 vaccines, however, the hope for the return to normalcy has been renewed. This hope rests on an unprecedented nationwide vaccine campaign, which faces many logistical challenges and is also contingent on several factors whose values are currently unknown.

OBJECTIVE

We study the effectiveness of a nationwide vaccine campaign in response to different vaccine efficacies, the willingness of the population to be vaccinated, and the daily vaccine capacity under two different federal plans. To characterize the possible outcomes most accurately, we also account for the interactions between nonpharmaceutical interventions and vaccines through 6 scenarios that capture a range of possible impacts from nonpharmaceutical interventions.

METHODS

We used large-scale, cloud-based, agent-based simulations by implementing the vaccination campaign using COVASIM, an open-source agent-based model for COVID-19 that has been used in several peer-reviewed studies and accounts for individual heterogeneity and a multiplicity of contact networks. Several modifications to the parameters and simulation logic were made to better align the model with current evidence. We chose 6 nonpharmaceutical intervention scenarios and applied the vaccination intervention following both the plan proposed by Operation Warp Speed (former Trump administration) and the plan of one million vaccines per day, proposed by the Biden administration. We accounted for unknowns in vaccine efficacies and levels of population compliance by varying both parameters. For each experiment, the cumulative infection growth was fitted to a logistic growth model, and the carrying capacities and the growth rates were recorded.

RESULTS

For both vaccination plans and all nonpharmaceutical intervention scenarios, the presence of the vaccine intervention considerably lowers the total number of infections when life returns to normal, even when the population compliance to vaccines is as low as 20%. We noted an unintended consequence; given the vaccine availability estimates under both federal plans and the focus on vaccinating individuals by age categories, a significant reduction in nonpharmaceutical interventions results in a counterintuitive situation in which higher vaccine compliance then leads to more total infections.

CONCLUSIONS

Although potent, vaccines alone cannot effectively end the pandemic given the current availability estimates and the adopted vaccination strategy. Nonpharmaceutical interventions need to continue and be enforced to ensure high compliance so that the rate of immunity established by vaccination outpaces that induced by infections.

Coronavirus disease 2019 severity in obesity: Metabolic dysfunction-associated fatty liver disease in the spotlight

The coronavirus disease 2019 (COVID-19) outbreak has drawn the scientific community's attention to pre-existing metabolic conditions that could aggravate the infection, causing extended viral shedding, prolonged hospitalization, and high death rates. Metabolic dysfunction-associated fatty liver disease (MAFLD) emerges as a surrogate for COVID-19 severity due to the constellation of metabolic alterations it entails. This review outlines the impact MAFLD exerts on COVID-19 severity in obese subjects, besides the possible mechanistic links to the poor outcomes. The data collected showed that MAFLD patients had poorer COVID-19 outcomes than non-MAFLD obese subjects. MAFLD is generally accompanied by impaired glycemic control and systemic arterial hypertension, both of which can decompensate during the COVID-19 clinical course. Also, MAFLD subjects had higher plasma inflammatory marker concentrations than non-MAFLD subjects, which might be related to an intensified cytokine storm syndrome frequently associated with the need for mechanical ventilation and death. In conclusion, MAFLD represents a higher risk than obesity for COVID-19 severity, resulting in poor outcomes and even progression to non-alcoholic steatohepatitis. Hepatologists should include MAFLD subjects in the high-risk group, intensify preventive measurements, and prioritize their vaccination.

Retrospective and prospective monitoring in post COVID-19 complications and an approach for vigilance in Post-recovery period

COVID-19 is a Severe acute respiratory syndrome (SARS-CoV-2). It threatened the whole world and considered as pandemic recently, emergencies and quarantine has been declared all over the world. Many published reviews and research articles, discussed analysis, symptoms, diagnosis, and possible ways of treatments. However, nowadays, more focus is inclined on recovered patients and the possible events faced by these patients in postrecovery period. Specialists, medical care workers are looking for unmistakable approaches to defend their life later on. It is important to have a full background on their physical and psychological status after their recovery with certain guidelines to follow-up. There is more concern, care for family and society as they might suffer from stress, depression, and stigmatization from society. Awareness programs and counseling should be recommended to bring the recovered patients to their normalcy. Surveys and cohort studies will be helpful for prognosis of the disease as well as to be ready to face the second stage of COVID-19. This article will focus on recovered COVID-19 patients, their complications, precautionary methods, and post care.

Getting to the Heart of the Matter: Myocardial Injury, Coagulopathy, and Other Potential Cardiovascular Implications of COVID-19

COVID-19 was primarily identified as a respiratory illness, but reports of patients presenting initially with cardiovascular complaints are rapidly emerging. Many patients also develop cardiovascular complications during and after COVID-19 infection. Underlying cardiovascular disease increases the severity of COVID-19 infection; however, it is unclear if COVID-19 increases the risk of or causes cardiovascular complications in patients without preexisting cardiovascular disease. The review is aimed at informing the primary care physicians of the potential cardiovascular complications, especially in patients without underlying cardiovascular disease. A comprehensive literature review was performed on cardiac and vascular complications of COVID-19. The primary cardiac and vascular complications include myocarditis, acute coronary syndrome, myocardial injury, arrhythmia, heart failure, shock, multisystem inflammatory syndrome, venous and arterial thrombotic events, stroke, and coagulopathy. A detailed analysis of the pathogenesis revealed six possible mechanisms: direct cardiac damage, hypoxia-induced injury, inflammation, a dysfunctional endothelial response, coagulopathy, and the catecholamine stress response. Autopsy reports from studies show cardiomegaly, hypertrophy, ventricular dilation, infarction, and fibrosis. A wide range of cardiac and vascular complications should be considered when treating patients with confirmed or suspected COVID-19 infection. Elevated troponin and natriuretic peptides indicate an early cardiac involvement in COVID-19. Continuous monitoring of coagulation by measuring serum D-dimer can potentially prevent vascular complications. A long-term screening protocol to follow-up the patients in the primary care settings is needed to follow-up with the patients who recovered from COVID cardiovascular complications.

Imaging in COVID-19-related myocardial injury

Severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), previously named "2019 novel coronavirus" (2019-nCoV) is an emerging disease and a major public health issue. At the moment, little is known, except that its spread is on a steady upward trend. That is the reason why it was declared pandemic since March 11th, 2020. Respiratory symptoms dominate the clinical manifestations of the virus, but in a few patients also other organs are involved, such as their heart. This review article provides an overview of the existing literature regarding imaging of heart injury during COVID-19 acute infection and follow-up.

Attributes and predictors of long COVID

Reports of long-lasting coronavirus disease 2019 (COVID-19) symptoms, the so-called 'long COVID', are rising but little is known about prevalence, risk factors or whether it is possible to predict a protracted course early in the disease. We analyzed data from 4,182 incident cases of COVID-19 in which individuals self-reported their symptoms prospectively in the COVID Symptom Study app¹. A total of 558 (13.3%) participants reported symptoms lasting ≥28 days, 189 (4.5%) for ≥8 weeks and 95 (2.3%) for ≥12 weeks. Long COVID was characterized by symptoms of fatigue, headache, dyspnea and anosmia and was more likely with increasing age and body mass index and female sex. Experiencing more than five symptoms during the first week of illness was associated with long COVID (odds ratio = 3.53 (2.76-4.50)). A simple model to distinguish between short COVID and long COVID at 7 days (total sample size, n = 2,149) showed an area under the curve of the receiver operating characteristic curve of 76%, with replication in an independent sample of 2,472 individuals who were positive for severe acute respiratory syndrome coronavirus 2. This model could be used to identify individuals at risk of long COVID for trials of prevention or treatment and to plan education and rehabilitation services.

Health Care Access Among Essential Critical Infrastructure Workers, 31 States, 2017-2018

OBJECTIVES

Essential workers in the United States need access to health care services for preventive care and for diagnosis and treatment of illnesses (coronavirus disease 2019 [COVID-19] or other infectious or chronic diseases) to remain healthy and continue working during a pandemic. This study evaluated access to health care services among selected essential workers.

METHODS

We used the most recent data from the Behavioral Risk Factor Surveillance System, 2017-2018, to estimate the prevalence of 4 measures of health care access (having health insurance, being able to afford to see a doctor when needed, having a personal health care provider, and having a routine checkup in the past year) by broad and detailed occupation group among 189 208 adults aged 18-64.

RESULTS

Of all occupations studied, workers in farming, fishing, and forestry occupations were most likely to have no health insurance (46.4%). Personal care aides were most likely to have been unable to see a doctor when needed because of cost (29.3%). Construction laborers were most likely to lack a personal health care provider (51.1%) and to have not had a routine physical checkup in the past year (50.6%). Compared with workers in general, workers in 3 broad occupation groups-food preparation and serving; building and grounds cleaning and maintenance; and construction trades-had significantly lower levels of health care access for all 4 measures.

CONCLUSION

Lack of health insurance and underinsurance were common among subsets of essential workers. Limited access to health care might decrease essential workers' access to medical testing and needed care and hinder their ability to address underlying conditions, thereby increasing their risk of severe outcomes from some infectious diseases, such as COVID-19. Improving access to health care for all workers, including essential workers, is critical to ensure workers' health and workforce stability.

A novel multi-omics-based highly accurate prediction of symptoms, comorbid conditions, and possible long-term complications of COVID-19

Comprehensive clinical pictures, comorbid conditions, and long-term complications of COVID-19 are still unknown. Recently, using a multi-omics-based strategy, we predicted potential drugs for COVID-19 with ∼70% accuracy. Herein, using a novel multi-omics-based bioinformatic approach and three ways of analysis, we identified the symptoms, comorbid conditions, and short-, mid-, and possible long-term complications of COVID-19 with >90% precision including 27 parent, 170 child, and 403 specific conditions. Among the specific conditions, 36 viral, 53 short-term, 62 short-mid-long-term, 194 mid-long-term, and 57 congenital conditions are identified. At a threshold "count of occurrence" of 4, we found that 83-100% (average 92.67%) of enriched conditions are associated with COVID-19. Except for dry cough and loss of taste, all the other COVID-19-associated mild and severe symptoms are enriched. CVDs, and pulmonary, metabolic, musculoskeletal, neuropsychiatric, kidney, liver, and immune system disorders are top comorbid conditions. Specific diseases like myocardial infarction, hypertension, COPD, lung injury, diabetes, cirrhosis, mood disorders, dementia, macular degeneration, chronic kidney disease, lupus, arthritis, etc. along with several other NCDs were found to be top candidates. Interestingly, many cancers and congenital disorders associated with COVID-19 severity are also identified. Arthritis, gliomas, diabetes, psychiatric disorders, and CVDs having a bidirectional relationship with COVID-19 are also identified as top conditions. Based on our accuracy (>90%), the long-term presence of SARS-CoV-2 RNA in human, and our "genetic remittance" assumption, we hypothesize that all the identified top-ranked conditions could be potential long-term consequences in COVID-19 survivors, warranting long-term observational studies.

COVID-19 Antibody Tests: A Valuable Public Health Tool with Limited Relevance to Individuals

Antibody tests for detecting past infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have many uses for public health decision making, but demand has largely come from individual consumers. This review focuses on the individual relevance of antibody tests: their accuracy in detecting prior infection, what past SARS-CoV-2 infection can currently infer about future immunity or possible medical sequelae, and the potential future importance of antibody tests for vaccine selection and medical screening. Given uncertainty about the antibody tests (quality, accuracy level, positive predictive value) and what those tests might indicate immunologically (durability of antibodies and necessity for protection from reinfection), seropositive test results should not be used to inform individual decision making, and antibody testing should remain a tool of public health at this time.

Implications of SARS-CoV-2-Associated Myocarditis in the Medical Evaluation of Athletes

CONTEXT

Myocarditis is a known cause of death in athletes. As we consider clearance of athletes to participate in sports during the COVID-19 pandemic, we offer a brief review of the myocardial effects of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) through the lens of what is known about myocarditis and exercise. All athletes should be queried about any recent illness suspicious for COVID-19 prior to sports participation.

EVIDENCE ACQUISITION

The PubMed database was evaluated through 2020, with the following keywords: myocarditis, COVID-19, SARS-CoV-2, cardiac, and athletes. Selected articles identified through the primary search, along with position statements from around the world, and the relevant references from those articles, were reviewed for pertinent clinical information regarding the identification, evaluation, risk stratification, and management of myocarditis in patients, including athletes, with and without SARS-CoV-2.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Since myocarditis can present with a variety of symptoms, and can be asymptomatic, the sports medicine physician needs to have a heightened awareness of athletes who may have had COVID-19 and be at risk for myocarditis and should have a low threshold to obtain further cardiovascular testing. Symptomatic athletes with SARS-CoV-2 may require cardiac evaluation including an electrocardiogram and possibly an echocardiogram. Athletes with cardiomyopathy may benefit from cardiac magnetic resonance imaging in the recovery phase and, rarely, endocardial biopsy.

CONCLUSION

Myocarditis is a known cause of sudden cardiac death in athletes. The currently reported rates of cardiac involvement of COVID-19 makes myocarditis a risk, and physicians who clear athletes for participation in sport as well as sideline personnel should be versed with the diagnosis, management, and clearance of athletes with suspected myocarditis. Given the potentially increased risk of arrhythmias, sideline personnel should practice their emergency action plans and be comfortable using an automated external defibrillator.

Assessing the feasibility and effectiveness of household-pooled universal testing to control COVID-19 epidemics

Outbreaks of SARS-CoV-2 are threatening the health care systems of several countries around the world. The initial control of SARS-CoV-2 epidemics relied on non-pharmaceutical interventions, such as social distancing, teleworking, mouth masks and contact tracing. However, as pre-symptomatic transmission remains an important driver of the epidemic, contact tracing efforts struggle to fully control SARS-CoV-2 epidemics. Therefore, in this work, we investigate to what extent the use of universal testing, i.e., an approach in which we screen the entire population, can be utilized to mitigate this epidemic. To this end, we rely on PCR test pooling of individuals that belong to the same households, to allow for a universal testing procedure that is feasible with the limited testing capacity. We evaluate two isolation strategies: on the one hand pool isolation, where we isolate all individuals that belong to a positive PCR test pool, and on the other hand individual isolation, where we determine which of the individuals that belong to the positive PCR pool are positive, through an additional testing step. We evaluate this universal testing approach in the STRIDE individual-based epidemiological model in the context of the Belgian COVID-19 epidemic. As the organisation of universal testing will be challenging, we discuss the different aspects related to sample extraction and PCR testing, to demonstrate the feasibility of universal testing when a decentralized testing approach is used. We show through simulation, that weekly universal testing is able to control the epidemic, even when many of the contact reductions are relieved. Finally, our model shows that the use of universal testing in combination with stringent contact reductions could be considered as a strategy to eradicate the virus.

COVID-19 sequelae in adults aged less than 50 years: A systematic review

BACKGROUND

There is emerging evidence of long-term sequelae in a considerable proportion of COVID-19 patients after recovery and the spectrum and severity of such sequelae should be systematically reviewed. This review aims to evaluate the available evidence of all intermediate and long-term COVID-19 sequelae affecting formerly healthy adults.

METHODS

A systematic literature search of Embase, WHO, Scopus, Pubmed, Litcovid, bioRxiv and medRxiv was conducted with a cutoff date of the 17th September 2020 according to PRISMA guidelines and registered in PROSPERO (CRD42020208725). Search terms included "COVID-19", "coronavirus disease 2019", "SARS-CoV-2", "sequelae" and "consequence*". Publications on adult participants, with a confirmed SARS-CoV-2 infection were included. Elderly (>50 years old) and children (<18 years old) were excluded. Bias assessment was performed using a modified Newcastle-Ottawa Scale.

RESULTS

A total of 31 papers were included. Study types included prospective and retrospective cohort studies, cross-sectional studies and case reports. Sequelae persistence since infection spanned 14 days to three months. Sequelae included persistent fatigue (39-73% of assessed persons), breathlessness (39-74%), decrease in quality of life (44-69%), impaired pulmonary function, abnormal CT findings including pulmonary fibrosis (39-83%), evidence of peri-/perimyo-/myocarditis (3-26%), changes in microstructural and functional brain integrity with persistent neurological symptoms (55%), increased incidence of psychiatric diagnoses (5.8% versus 2.5-3.4% in controls), incomplete recovery of olfactory and gustatory dysfunction (33-36% of evaluated persons).

CONCLUSIONS

A variety of organ systems are affected by COVID-19 in the intermediate and longer-term after recovery. Main sequelae include post-infectious fatigue, persistent reduced lung function and carditis. Careful follow-up post COVID 19 is indicated to assess and mitigate possible organ damage and preserve life quality.

Myocardial fibrosis after COVID-19 infection and severe sinus arrest episodes in an asymptomatic patient with mild sleep apnea syndrome: A case report and review of the literature

COVID-19 infection is a new disease mainly affecting the respiratory system but is also accompanied by many extra-pulmonary manifestations. A case of a 47-year old male with unique myocardial fibrosis after COVID-19 infection involving the left ventricular wall, intraventricular septum and almost complete damage of interatrial septum, in combination with asymptomatic severe sinus arrest episodes related to mild obstructive sleep apnea syndrome is described here.

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Myocardial fibrosis may be a consequence of COVID-19 infection.

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Almost complete fibrosis of interatrial septum is a unique complication of COVID-19.

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Cardiac MRI is very useful in detecting myocardial complications.

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Severe sinus arrest episodes are very unusual in patients with mild OSA syndrome.

Post-COVID Recovery Assessment Clinics: A Real Need of Time

COVID-19 is an infectious respiratory and vascular disease caused by SARS-CoV-2. This virus was first identified in Wuhan, China and caused an ongoing pandemic. The World Health Organization (WHO) declared the outbreak a public health emergency of international concern in January 2020 and a pandemic in March 2020. Reports suggest that patients experience persistent deficits in pulmonary and cognitive functioning, as well as multifaceted health issues and worsened quality of life. From records in Italy and France, COVID-19 survivors experience the return of symptoms. COVID-19 survivors need specialist investigation once they have been discharged from hospital. No proper guidelines are recommending that COVID-19 survivors should be under assessment. We intended to provide a model to assist local healthcare systems to establish post-COVID recovery assessment clinic(s) for CVOID-19 survivors. Our model will enable COVID-19 patients' access to multi-professional advice, so that they are put onto the right clinical pathway to treat their symptoms. Furthermore, the findings of different specialties in post-COVID recovery assessment clinic(s) may help doctors determine the best discharge plan for COVID-19 patients.

COVID-19 herd immunity in the absence of a vaccine: an irresponsible approach

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread rapidly throughout the human population, the concept of “herd immunity” has attracted the attention of both decision-makers and the general public. In the absence of a vaccine, this entails that a large proportion of the population will be infected to develop immunity that would limit the severity and/or extent of subsequent outbreaks. We argue that adopting such an approach should be avoided for several reasons. There are significant uncertainties about whether achieving herd immunity is possible. If possible, achieving herd immunity would impose a large burden on society. There are gaps in protection, making it difficult to shield the vulnerable. It would defeat the purpose of avoiding harm caused by the virus. Lastly, dozens of countries are showing that containment is possible.

COVID-19, hydroxychloroquine and sudden cardiac death: implications for clinical practice in patients with rheumatic diseases

Sudden cardiac death is commonly seen due to arrhythmias, which is a common cardiac manifestation seen in COVID-19 patients, especially those with underlying cardiovascular disease (CVD). Administration of hydroxychloroquine (HCQ) as a potential treatment option during SARS-CoV-2, initially gained popularity, but later, its safe usage became questionable due to its cardiovascular safety, largely stemming from instances of cardiac arrhythmias in COVID-19. Moreover, in the setting of rheumatic diseases, in which patients are usually on HCQ for their primary disease, there is a need to scale the merits and demerits of HCQ usage for the treatment of COVID-19. In this narrative review, we aim to address the association between usage of HCQ and sudden cardiac death in COVID-19 patients. MEDLINE, EMBASE, ClinicalTrials.gov and SCOPUS databases were used to review articles in English ranging from case reports, case series, letter to editors, systematic reviews, narrative reviews, observational studies and randomized control trials. HCQ is a potential cause of sudden cardiac death in COVID-19 patients. As opposed to the reduction in CVD with HCQ in treatment of systemic lupus erythematous, rheumatoid arthritis, and other rheumatic diseases, safe usage of HCQ in COVID-19 patients is unclear; whereby, it is observed to result in QTc prolongation and Torsades de pointes even in patients with no underlying cardiovascular comorbidity. This is occasionally associated with sudden cardiac death or cardiac arrest; hence, its clinical efficacy needs further investigation by large-scale clinical trials.