Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review

Generalized anxiety disorder in Brazilian undergraduate dental students during the COVID-19 pandemic: A cross-sectional study

OBJECTIVE

Explore the prevalence of generalized anxiety disorder (GAD) and associated factors in undergraduate dental students during the first wave of the COVID-19 pandemic in Brazil.

MATERIALS AND METHODS

Cross-sectional study. A semi-structured questionnaire addressing the variables of interest was shared with dental students between July 8 and 27 2020. The outcome was determined using the seven-item generalized anxiety disorder (GAD-7) scale. A 'positive' diagnosis was defined as a total of ≥10 points on the scale. Statistical analysis involved descriptive, bivariate and multivariate analyses, with the significance level set at 5%.

RESULTS

Among the 1050 students evaluated, 53.8% had a positive diagnosis for GAD. The multivariate analysis revealed that the prevalence of symptoms was higher among individuals who resided with more than three people, those enrolled at teaching institutions that suspended all clinical and laboratory activities, those who did not have an adequate home situation to maintain distance learning, those who had been diagnosed with COVID-19, those who felt anxious about having to see patients with a suspicion or diagnosis of COVID-19 and those who preferred to interrupt in-person academic activities until the population is vaccinated for the COVID-19 virus.

CONCLUSION

The prevalence of GAD was high. Aspects related to the composition and organization of the home, the suspension of academic activities, a history of COVID-19 contamination, feelings of anxiety in providing dental care to patients with symptoms/suspected of COVID-19 infection and the preference to interrupt in-person academic activities until the population is vaccinated for COVID-19 were factors predisposing the students to anxiety during the first wave of the pandemic.

Mortality-related risk factors of inpatients with diabetes and COVID-19: A multicenter retrospective study in Belgium

BACKGROUND AND AIMS

We describe mortality-related risk factors of inpatients with diabetes and coronavirus disease 2019 (COVID-19) in Belgium.

METHODS

We conducted a multicenter retrospective study from March to May, 2020, in 8 Belgian centers. Data on admission of patients with diabetes and COVID-19 were collected. Survivors were compared to non-survivors to identify prognostic risk factors for in-hospital death using multivariate analysis in both the total population and in the subgroup of patients admitted in the intensive care unit (ICU).

RESULTS

The study included 375 patients. The mortality rate was 26.4% (99/375) in the total population and 40% (27/67) in the ICU. Multivariate analysis identified older age (HR 1.05 [CI 1.03-1.07], P<0.0001) and male gender (HR 2.01 [1.31-3.07], P=0.0013) as main independent risk factors for in-hospital death in the total population. Metformin (HR 0.51 [0.34-0.78], P=0.0018) and renin-angiotensin-aldosterone system blockers (HR 0.56 [0.36-0.86], P=0.0088) use before admission were independent protective factors. In the ICU, chronic kidney disease (CKD) was identified as an independent risk factor for death (HR 4.96 [2.14-11.5], P<0.001).

CONCLUSION

In-hospital mortality due to the first wave of COVID-19 pandemic in Belgium was high in patients with diabetes. We found that advanced age and male gender were independent risk factors for in-hospital death. We also showed that metformin use before admission was associated with a significant reduction of COVID-19-related in-hospital mortality. Finally, we showed that CKD is a COVID-19-related mortality risk factor in patients with diabetes admitted in the ICU.

Ocular manifestations of COVID-19: A systematic review of current evidence

Introduction

COVID-19 caused by SARS-CoV-2, commonly presents with symptoms such as fever and shortness of breath but can also affect other organs. There is growing evidence pointing to potential eye complications. In this article, we aim to systematically review the ocular manifestations of COVID-19.

Methods

We conducted a systematic review to explore the ocular manifestations of COVID-19. We searched online databases including PubMed, Embase, Scopus, and Web of Science up to September 4, 2023. After a two-stage screening process and applying inclusion/exclusion criteria, eligible articles were advanced to the data extraction phase. The PRISMA checklist and Newcastle-Ottawa Scale (NOS) were used for quality and bias risk assessments.

Results

We selected and extracted data from 42 articles. Most of the studies were cross-sectional (n = 33), with the highest number conducted in Turkey (n = 10). The most frequent ocular manifestation was conjunctivitis, reported in 24 articles, followed by photophobia, burning, chemosis, itching, and ocular pain. Most studies reported complete recovery from these manifestations; however, one study mentioned visual loss in two patients.

Conclusion

In general, ocular manifestations of COVID-19 appear to resolve either spontaneously or with supportive treatments. For more severe cases, both medical treatment and surgery have been employed, with the outcomes suggesting that complete recoveries are attainable.

[Retrospective clinical-causal evaluation of a positive PCR for SARS-CoV-2 in hospitalised patients across the age spectrum in a primary care hospital]

INTRODUCTION

It is often discussed that a positive PCR for SARS-CoV-2 in hospitalized patients may not be causally linked to the hospital stay, but no scientific data are available from Germany. Therefore, we analyzed to what extent a positive PCR test could be assessed as causal or secondary to admission according to clinical criteria in a tertiary care hospital of the first 4 months of 2022.

METHODS

SARS-CoV-2-positive patients of RoMed-Klinikum Rosenheim/Bavaria from 01/01/2022 to 30/04/2022 were included. Patients were divided into a group with COVID-19 as direct reason for admission (CAW), and a group, in which this did not apply according to a comprehensive clinical assessment (nCAW). Patients with no clear allocation to these groups were counted separately. Categorization was based on a multilevel procedure and performed by an internist experienced in COVD-19 (M.H.). It included all available clinical, radiological, and laboratory findings as well as treatment decisions.

RESULTS

647 cases were included (age 10 days to 101 years, median 68 years; 49.5% women), including 13 patients in two admissions with positive PCR. 45.3% (n=293) were attributable to the group with COVID as the reason for admission, 48.8% (n=316) were not, no clear decision could be made in 35 patients, 3 patients were transferred from other clinics for isolation. In infants (up to 1 year), a positive PCR test was more frequently categorized as causative than in older patients. Leading symptoms of classification were found to be fatigue/fatigue, fever/chills, and cough on admission. Febrile convulsions accounted for the reason for admission in 10 cases of children (age 1.1-7.6 years). Length of stay did not differ significantly between groups (median (quartiles) 5 (2; 10) days for CAW, 5 (2; 12) for nCAW), nor did in-hospital mortality and median age of deceased or survivors.

DISCUSSION

A retrospective analysis of all clinical data revealed that positive SARS-CoV-2 PCR played a major and - according to clinical criteria - causative role for admission and hospitalization in nearly 50% of cases, whereas it was an incidental finding in just under 50%. These results confirm data from other countries and demonstrate that the role of a positive SARS-CoV-2 PCR test for hospitalization can only be answered by a comprehensive and elaborate analysis of individual data.

Lung regeneration: diverse cell types and the therapeutic potential

Lung tissue has a certain regenerative ability and triggers repair procedures after injury. Under controllable conditions, lung tissue can restore normal structure and function. Disruptions in this process can lead to respiratory system failure and even death, causing substantial medical burden. The main types of respiratory diseases are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and acute respiratory distress syndrome (ARDS). Multiple cells, such as lung epithelial cells, endothelial cells, fibroblasts, and immune cells, are involved in regulating the repair process after lung injury. Although the mechanism that regulates the process of lung repair has not been fully elucidated, clinical trials targeting different cells and signaling pathways have achieved some therapeutic effects in different respiratory diseases. In this review, we provide an overview of the cell type involved in the process of lung regeneration and repair, research models, and summarize molecular mechanisms involved in the regulation of lung regeneration and fibrosis. Moreover, we discuss the current clinical trials of stem cell therapy and pharmacological strategies for COPD, IPF, and ARDS treatment. This review provides a reference for further research on the molecular and cellular mechanisms of lung regeneration, drug development, and clinical trials.

SARS-CoV-2 immunity in animal models

The COVID-19 pandemic, which was caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a worldwide health crisis due to its transmissibility. SARS-CoV-2 infection results in severe respiratory illness and can lead to significant complications in affected individuals. These complications encompass symptoms such as coughing, respiratory distress, fever, infectious shock, acute respiratory distress syndrome (ARDS), and even multiple-organ failure. Animal models serve as crucial tools for investigating pathogenic mechanisms, immune responses, immune escape mechanisms, antiviral drug development, and vaccines against SARS-CoV-2. Currently, various animal models for SARS-CoV-2 infection, such as nonhuman primates (NHPs), ferrets, hamsters, and many different mouse models, have been developed. Each model possesses distinctive features and applications. In this review, we elucidate the immune response elicited by SARS-CoV-2 infection in patients and provide an overview of the characteristics of various animal models mainly used for SARS-CoV-2 infection, as well as the corresponding immune responses and applications of these models. A comparative analysis of transcriptomic alterations in the lungs from different animal models revealed that the K18-hACE2 and mouse-adapted virus mouse models exhibited the highest similarity with the deceased COVID-19 patients. Finally, we highlighted the current gaps in related research between animal model studies and clinical investigations, underscoring lingering scientific questions that demand further clarification.

Atrio-oesophageal fistula after radiofrequency ablation of atrial fibrillation misinterpreted as COVID-19 infection

Awareness of the various clinical manifestations and diagnostic pitfalls in patients with atrio-oesophageal fistula is necessary among healthcare professionals.

Advances in In Vitro Blood-Air Barrier Models and the Use of Nanoparticles in COVID-19 Research

Respiratory infections caused by coronaviruses (CoVs) have become a major public health concern in the past two decades as revealed by the emergence of SARS-CoV in 2002, MERS-CoV in 2012, and SARS-CoV-2 in 2019. The most severe clinical phenotypes commonly arise from exacerbation of immune response following the infection of alveolar epithelial cells localized at the pulmonary blood-air barrier. Preclinical rodent models do not adequately represent the essential genetic properties of the barrier, thus necessitating the use of humanized transgenic models. However, existing monolayer cell culture models have so far been unable to mimic the complex lung microenvironment. In this respect, air-liquid interface models, tissue engineered models, and organ-on-a-chip systems, which aim to better imitate the infection site microenvironment and microphysiology, are being developed to replace the commonly used monolayer cell culture models, and their use is becoming more widespread every day. On the contrary, studies on the development of nanoparticles (NPs) that mimic respiratory viruses, and those NPs used in therapy are progressing rapidly. The first part of this review describes in vitro models that mimic the blood-air barrier, the tissue interface that plays a central role in COVID-19 progression. In the second part of the review, NPs mimicking the virus and/or designed to carry therapeutic agents are explained and exemplified.

Applying the health belief model to examine college students' early stage adoption of non-pharmaceutical interventions in response to COVID-19

OBJECTIVE

Amidst the COVID-19 pandemic, colleges worked to minimize transmission through non-pharmaceutical interventions (NPIs). The objective of this study was to apply the Health Belief Model to assess correlates of US college students' early stage NPI uptake.

PARTICIPANTS

Sample includes 1,223 students from a medium-sized university who participated in an anonymous health survey.

METHODS

Logistic regression assessed associations between HBM factors and consistent adoption of five individual NPI strategies. Multivariate linear regression assessed HBM correlates of NPI adoption overall.

RESULTS

Correlates of NPI uptake varied by strategy. Only perceived NPI benefits were significantly associated with NPI adoption individually and overall. Perceived susceptibility was associated with use of hand sanitizer, facemasks, and general NPI adoption. Perceived severity was associated with avoidance of large social gatherings only.

CONCLUSION

The HBM appears valuable for understanding students' NPI adoption. Results suggest university health initiatives should prioritize education on the efficacy of particular preventive behaviors.

SARS-CoV-2 NSP14 MTase activity is critical for inducing canonical NF-κB activation

Upon SARS-CoV-2 infection, patients with severe forms of COVID-19 often suffer from a dysregulated immune response and hyperinflammation. Aberrant expression of cytokines and chemokines is associated with strong activation of the immunoregulatory transcription factor NF-κB, which can be directly induced by the SARS-CoV-2 protein NSP14. Here, we use NSP14 mutants and generated cells with host factor knockouts (KOs) in the NF-κB signaling pathways to characterize the molecular mechanism of NSP14-induced NF-κB activation. We demonstrate that full-length NSP14 requires methyltransferase (MTase) activity to drive NF-κB induction. NSP14 WT, but not an MTase-defective mutant, is poorly expressed and inherent post-translational instability is mediated by proteasomal degradation. Binding of SARS-CoV-2 NSP10 or addition of the co-factor S-adenosylmethionine (SAM) stabilizes NSP14 and augments its potential to activate NF-κB. Using CRISPR/Cas9-engineered KO cells, we demonstrate that NSP14 stimulation of canonical NF-κB activation relies on NF-κB factor p65/RELA downstream of the NEMO/IKK complex, while c-Rel or non-canonical RelB are not required to induce NF-κB transcriptional activity. However, NSP14 overexpression is unable to induce canonical IκB kinase β (IKKβ)/NF-κB signaling and in co-immunoprecipitation assays we do not detect stable associations between NSP14 and NEMO or p65, suggesting that NSP14 activates NF-κB indirectly through its methyltransferase activity. Taken together, our data provide a framework how NSP14 can augment basal NF-κB activation, which may enhance cytokine expression in SARS-CoV-2 infected cells.

Fiber Optic SPR POCT: A Novel Nucleic Acid Detection Biosensor for Environmental Viruses

In the post-COVID-19 pandemic era, the long-term surveillance of pathogens is still important. The rapid detection of pathogens facilitates the accurate and convenient real-time monitoring of microbial contamination and improves the management of diseases. Here, a novel surface plasmon resonance (SPR)-based point of care testing (POCT) approach of microorganism nucleic acids with the guidance of CRISPR enzyme is described, including the application of optical fiber-based detection of trace SARS-CoV2 virus in sewage water on SPR and validation of the plasmonic biosensor for the detection of single-nucleotide mutations in natural water samples.

Novel Advancements in COVID-19 and Neuroscience

From an initial cluster of cases reported in Wuhan, the SARS-Cov-2 infection has since spread globally, causing a pandemic that began on 11 March 2020 [...].

The effects of Chinese proprietary medicine and vaccination on patients with COVID-19: a retrospective study in Macao

BACKGROUND

COVID-19 is continuing to ravage globally and has resulted in a huge health and financial burden. Chinese proprietary medicines, such as Lianhua Qingwen (LHQW) and Huoxiang Zhengqi (HXZQ) capsules, have been recommended for non-high-risk patients with COVID-19 in China. Based on this, we described the baseline information, using status of LHQW and HXZQ capsules and inoculation history of quarantined patients in the second half of 2022 in Macao. Additionally, we analyzed the underlying association among medicines administration, vaccination and COVID-19 indices, in order to explore novel clues for the regular control and prevention of local epidemic situation in the future.

METHODS

A total of 976 patients in Macao quarantine hotels from June to August 2022 were included in the present study, of which, 857 subjects were followed-up for prognosis evaluation. During quarantine, the baseline demographic information, including sex, age, BMI, occupation and personal habits were collected. Additionally, the inoculation history, medicine employment status and cycle threshold (Ct) values were also reported. We interviewed the patients for collection of their symptoms at the beginning and end of quarantine, as well as prognostic ones. Basic statistical description of baseline information, vaccination history and medication were displayed. Chi-squared test or with continuous correction test was employed for comparison of dichotomous data between two or multiple groups. Binary logistic regression was applied to reveal the correlation between potential risk factors and Ct values or prognosis symptoms. We also used Cox regression model to identify the effect of different types of vaccine products on Ct value altering rate.

RESULTS

Patients who were female (52.0%), engaged in service industry (31.8%), from Macao native (65.8%), never took physical exercises (33.6%) and preferred irritated diet (59.5%) enjoyed more dominant proportions. Over 80% of participants were inoculated and 74.6% of them chose inactivated COVID-19 vaccine produced by China National Biotech Group (CNBG). Participants used LHQW capsules accounted for 92.1% and the duration of medicating lasted for one to two weeks. All of the reported symptoms were significantly ameliorated after quarantine and the duration of quarantine was concentrated on 21 days. People with different age, sex, occupation and region had different choices of HXZQ administration and vaccination. Additionally, middle dose (4-5 boxes) of LHQW capsules exhibited evidently negative association with positive Ct values (adjusted, - 0.037 ± 0.19, p = 0.04). Two doses of CNBG and one dose of mRNA vaccine had obvious protective effect on reducing Ct positive rate (p = 0.041). Meanwhile, symptoms after quarantine were significantly positive correlated with those in prognosis (adjusted, 1.38 ± 0.18, p < 0.0001).

CONCLUSION

Our study found that the administration of LHQW capsules was beneficial for Ct value turning negative, meanwhile, certain mixed inoculation may be the promoting factor to reduce the positive rate of Ct value. These findings provide data basis for the Chinese proprietary medicine treatment and mixed vaccination applying for prevention and control of local COVID-19 epidemic in the future.

Epidemic profile of common respiratory viruses in association SARS CoV-2 among SARI and ARI-two year study

BACKGROUND

COVID-19/SARS CoV-2 continue to pose a threat to human health and placed millions of livelihoods at risk. Surveillance for the other circulating seasonal viruses during this pandemic is necessary to understand the manifestations of the CoV-2 pandemic and their incidence.

METHODS

A detailed study survey was performed on subjects with acute respiratory infections (ARI) and severe acute respiratory infection (SARI) in the King Institute of Preventive Medicine and Research, Chennai from April 2020 to March 2022. A total of 1480 patients presenting with either SARI (41.8%) or ARI (58.1%) were screened for SARS CoV-2 and other respiratory viruses. The SARS CoV-2 real-time PCR was carried out using ICMR-approved kits and other respiratory viruses were detected using the commercially available real-time kit.

RESULTS

Out of the 620 SARI patients, 198 (31.9%) were positive for SARS CoV-2 RNA. Out of the 860 ARI patients, 352 (40.9%) were positive for SARS CoV-2 RNA. Among the 550 patients positive for SARS CoV-2, 7 (1.2%) were positive coexistent with other respiratory viruses. Among the 930 patients with negative SARS CoV-2, 222 (23.8%) were positive for other common respiratory viruses (p = 0.001). Influenza viruses (36.9%) predominated followed by RSV (31.9%) and Parainfluenza virus (13.5%).

CONCLUSION

This study suggests that viral coinfections are significantly higher among SARS CoV-2 negative individuals (23.8 vs. 1.2%). It is possibly due to viral interference and the competitive advantage of SARS CoV-2 in modulating the host immunity. Continuous surveillance is necessary for understanding the viral co-infection mechanisms.

Differential Ability of Spike Protein of SARS-CoV-2 Variants to Downregulate ACE2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 19 (COVID-19) and employs angiotensin-converting enzyme 2 (ACE2) as the receptor. Although the expression of ACE2 is crucial for cellular entry, we found that the interaction between ACE2 and the Spike (S) protein in the same cells led to its downregulation through degradation in the lysosomal compartment via the endocytic pathway. Interestingly, the ability of the S protein from previous variants of concern (VOCs) to downregulate ACE2 was variant-dependent and correlated with disease severity. The S protein from the Omicron variant, associated with milder disease, exhibited a lower capacity to downregulate ACE2 than that of the Delta variant, which is linked to a higher risk of hospitalization. Chimeric studies between the S proteins from the Delta and Omicron variants revealed that both the receptor-binding domain (RBD) and the S2 subunit played crucial roles in the reduced ACE2 downregulation activity observed in the Omicron variant. In contrast, three mutations (L452R/P681R/D950N) located in the RBD, S1/S2 cleavage site, and HR1 domain were identified as essential for the higher ACE2 downregulation activity observed in the Delta variant compared to that in the other VOCs. Our results suggested that dysregulation of the renin-angiotensin system due to the ACE2 downregulation activity of the S protein of SARS-CoV-2 may play a key role in the pathogenesis of COVID-19.

Is There a Causal Link Between Acute Myocarditis and COVID-19 Vaccination: An Umbrella Review of Published Systematic Reviews and Meta-Analyses

Introduction

A few months after the beginning of the coronavirus disease of 2019 (COVID-19) vaccination, several reports of myocarditis secondary to the vaccines were published, sometimes with fulminant cases, but until today there is no proven causal link between these 2 events, but with many hypotheses proposed.

Methods

A systematic review of current evidence regarding myocarditis after COVID-19 vaccination was performed by searching several databases including PubMed/Medline and Web of Science. The quality of Meta-analysis was assessed using the AMSTAR-2 tool as well as other qualitative criteria.

Results

Our umbrella review appraised 4 Meta-analysis of retrospective studies (range: 5-12), The number of vaccine doses included ranged from 12 to 179 million, with the number of myocarditis cases observed ranging from 343 to 1489. All types of vaccines were evaluated, with no exclusions. The overall incidence ranged from 0.89 to 2.36 cases of myocarditis per 100 000 doses of vaccine received. Heterogeny was assessed in 3 of the Meta-analysis, and was highly significant (>75%) in all included studies, and with a significant P-value (P < .05). Regarding publication bias, 3 of the Meta-analysis conducted the egger and begg regression, with a significant result in only 1. Regarding the assessment of the methodology by the AMSTAR-2 scale indicating that the quality was very critical in 1, low in 2, and moderate in 1 Meta-analysis.

Conclusion

The quality of current non-randomized evidence on real causality and incidence of myocarditis after COVID-19 vaccine is still low.

Retinoic Acid-Mediated Inhibition of Mouse Coronavirus Replication Is Dependent on IRF3 and CaMKK

The ongoing COVID-19 pandemic has revealed the shortfalls in our understanding of how to treat coronavirus infections. With almost 7 million case fatalities of COVID-19 globally, the catalog of FDA-approved antiviral therapeutics is limited compared to other medications, such as antibiotics. All-trans retinoic acid (RA), or activated vitamin A, has been studied as a potential therapeutic against coronavirus infection because of its antiviral properties. Due to its impact on different signaling pathways, RA's mechanism of action during coronavirus infection has not been thoroughly described. To determine RA's mechanism of action, we examined its effect against a mouse coronavirus, mouse hepatitis virus strain A59 (MHV). We demonstrated that RA significantly decreased viral titers in infected mouse L929 fibroblasts and RAW 264.7 macrophages. The reduced viral titers were associated with a corresponding decrease in MHV nucleocapsid protein expression. Using interferon regulatory factor 3 (IRF3) knockout RAW 264.7 cells, we demonstrated that RA-induced suppression of MHV required IRF3 activity. RNA-seq analysis of wildtype and IRF3 knockout RAW cells showed that RA upregulated calcium/calmodulin (CaM) signaling proteins, such as CaM kinase kinase 1 (CaMKK1). When treated with a CaMKK inhibitor, RA was unable to upregulate IRF activation during MHV infection. In conclusion, our results demonstrate that RA-induced protection against coronavirus infection depends on IRF3 and CaMKK.

Knowledge, attitudes and practices towards community-acquired pneumonia and COVID-19 among general population: a cross-sectional study

BACKGROUND

This study aimed to assess the knowledge, attitudes, and practices (KAP) of the general population to community-acquired pneumonia (CAP) and COVID-19.

METHODS

A cross-sectional study was conducted between September 2022 and February 2023, involving the general population from Ningbo Municipal Hospital of Traditional Chinese Medicine with a self-developed questionnaire.

RESULTS

A total of 637 valid questionnaires were collected, with the majority of participants being female (62.48%). The mean score for knowledge, attitudes, and practices were 7.60 ± 2.39 (possible range: 0-12), 43.20 ± 4.57 (possible range: 11-55), and 34.57 ± 4.95 (possible range: 10-50), respectively. Multivariate logistic regression analysis indicated that master's degree or above (OR = 6.04, 95% CI: 1.80-20.31, P = 0.004) and occupation in business or service careers (OR = 0.28, 95% CI: 0.17-0.48, P < 0.001) were independent associated with knowledge. The knowledge (OR = 1.32, 95%CI: 1.20-1.44, P < 0.001) and female gender (OR = 1.48, 95%CI: 1.03-2.14, P = 0.036) were independently associated with positive attitudes. Attitudes (OR = 1.34, 95%CI: 1.26-1.43, P < 0.001) and a monthly household income greater than 20,000 RMB (OR = 0.31, 95%CI: 0.15-0.64, P = 0.001) were independent associated with practices. Pearson correlation analysis revealed that knowledge positively correlated with attitude scores (r = 0.348, P < 0.001) and practice scores (r = 0.259, P < 0.001), and attitude and practice scores were also positively correlated (r = 0.563, P < 0.001). Structural equation modeling showed that knowledge predicted attitudes (β = 0.67, P < 0.001) and practices (β = 0.17, P = 0.017), while attitudes predicted practices (β = 0.58, P < 0.001).

CONCLUSION

General population had moderate knowledge, positive attitudes and average practices towards CAP and COVID-19.

Case report: A case of Acute Macular Neuroretinopathy secondary to Influenza A virus during Long COVID

Ocular abnormalities have been reported in association with viral infections, including Long COVID, a debilitating illness caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This report presents a case of a female patient diagnosed with Acute Macular Neuroretinopathy (AMN) following an Influenza A virus infection during Long COVID who experienced severe inflammation symptoms and ocular complications. We hypothesize that the rare occurrence of AMN in this patient could be associated with the immune storm secondary to the viral infection during Long COVID.

Effects of Pulmonary Rehabilitation on Respiratory Function and Thickness of the Diaphragm in Patients with Post-COVID-19 Syndrome: A Randomized Clinical Trial

BACKGROUND

Rehabilitation is an effective method for improving the overall health of patients who have experienced the long-term effects of COVID-19.

METHODS

The double-blind, randomized prospective study assessed the effectiveness of a 6-week rehabilitation program among post-COVID-19 patients. A total of 59 patients under treatment following COVID-19 were randomly divided into two groups. Both groups completed the same six-week comprehensive exercise training program supported by a respiratory muscle trainer (Threshold IMT) during out-patient sessions. The control group performed placebo IMT. Respiratory muscle strength, chest wall expansion, spirometry, and diaphragm ultrasonography measurements were taken before and after the six weeks.

RESULTS

The applied rehabilitation program improved respiratory muscle strength in both the study and control groups (p < 0.001). There was a significant chest circumference increase in the study group (p < 0.001). Spirometric parameters improved in both groups, with the study group showing a greater improvement: 8.02% in FEV1 (p < 0.001), 13.24% in FVC EX (p < 0.001) and 9.67% in PEF (p < 0.001). Rehabilitation also increased diaphragm thickness during maximum inhalation in both groups.

CONCLUSIONS

Based on the study findings, the specialized outpatient rehabilitation program developed for post-COVID-19 patients has proven to be effective and safe.

The analysis of low-dose glucocorticoid maintenance therapy in patients with primary nephrotic syndrome suffering from COVID-19

Objectives: This study aimed to describe the effects of low-dose (prednisolone acetate 2.5-7.5 mg/day) glucocorticoids (GCs) maintenance therapy in patients with primary nephrotic syndrome (NS) suffering from coronavirus disease 2019 (COVID-19). Methods: A single-center retrospective study of NS patients with COVID-19 infection in Zhongda Hospital Affiliated to Southeast University from 1 February 2022 to 31 March 2023 was conducted. All enrolled patients underwent renal biopsy for the pathological diagnosis and reached complete remission (CR) or near-CR before COVID-19 infection. According to the maintained therapy regimen, patients were divided into low-dose GCs group and non-GCs group. Results: A total of 125 patients were enrolled in the study. Their median age was 46.0 ± 15.6 years, and the median value of 24-h urine protein was 0.77 g. The majority of these patients received treatment for more than 6 months, with a significant portion achieving CR (29.6%) or near-CR (43.2%). The leading cause of NS was membranous nephropathy (52%). There were no significant differences in the baseline characteristics between low-dose GCs and non-GCs group. As compared to those in the non-GCs group, patients receiving low-dose GCs treatment showed less fatigue or muscle weakness, smell disorder, palpitations, decreased appetite, taste disorder, dizziness, sore throat or difficult to swallow and fever (p < 0.05). Moreover, patients in the low-dose GCs group were with higher median quality of life scores (85.0) than in the non-GCs group (p = 0.001). Further serum inflammatory factor analysis indicated that interleukin-6 (IL-6) levels in the non-GCs group were significantly higher than that in the low-dose GCs group (p < 0.05). Conclusion: Patients with NS in low-dose GCs maintenance therapy stage showed milder symptom, higher quality of life and decreased serum IL-6 levels compared to those, who were not on GCs maintenance therapy. These results suggest the beneficial effect of low-dose GCs therapy in NS patients with CR/near-CR suffering from COVID-19 infection.

Pharmacokinetics of recombinant human annexin A5 (SY-005) in patients with severe COVID-19

Objective: Annexin A5 is a phosphatidylserine binding protein with anti-inflammatory, anticoagulant and anti-apoptotic properties. Preclinical studies have shown that annexin A5 inhibits pro-inflammatory responses and improves organ function and survival in rodent models of sepsis. This clinical trial aimed to evaluate the pharmacokinetic (PK) properties of the recombinant human annexin A5 (SY-005) in severe COVID-19. Methods: This was a pilot randomized, double-blind, placebo-controlled trial. Severe COVID-19 patients were randomly assigned to receive intravenous 50 μg/kg (low dose, n = 3), 100 μg/kg (high dose, n = 5) of SY-005 or placebo (n = 5) every 12 h for 7 days. Plasma SY-005 levels were assessed using enzyme-linked immunosorbent assay (ELISA) and the PK parameters were determined using non-compartmental analysis. Results: All patients treated with SY-005 had a normal baseline estimated glomerular filtration rate (eGFR, 104-125 mL/min/1.73 m2). Both low and high doses of SY-005 were cleared within 6 h after intravenous administration. Plasma maximum concentrations (Cmax), half-life, clearance and volume distribution of low and high doses of SY-005 were 402.4 and 848.9 ng/mL, 0.92 and 0.96 h, 7.52 and 15.19 L/h, and 9.98 and 20.79 L, respectively. Daily pre-dose circulating annexin A5 levels were not significantly different when SY-005 was administered at the low or the high dose 12-h intervals. There was no significant effect on activated partial thromboplastin time (aPTT) or INR (international normalized ratio of prothrombin time) during 7 days of SY-005 treatment. Conclusion: SY-005 doses of 50 and 100 μg/kg were detectable and subsequently cleared from the plasma in severe COVID-19 patients with normal baseline renal function. There was no significant plasma SY-005 accumulation 6 h after drug administration and coagulation was not altered during 7 days of treatment. Clinical trials Registration: This study was registered with ClinicalTrials.gov (NCT04748757, first posted on 10 February 2021).

Gene crosstalk between COVID-19 and preeclampsia revealed by blood transcriptome analysis

Background

The extensive spread of coronavirus disease 2019 (COVID-19) has led to a rapid increase in global mortality. Preeclampsia is a commonly observed pregnancy ailment characterized by high maternal morbidity and mortality rates, in addition to the restriction of fetal growth within the uterine environment. Pregnant individuals afflicted with vascular disorders, including preeclampsia, exhibit an increased susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection via mechanisms that have not been fully delineated. Additionally, the intricate molecular mechanisms underlying preeclampsia and COVID-19 have not been fully elucidated. This study aimed to discern commonalities in gene expression, regulators, and pathways shared between COVID-19 and preeclampsia. The objective was to uncover potential insights that could contribute to novel treatment strategies for both COVID-19 and preeclampsia.

Method

Transcriptomic datasets for COVID-19 peripheral blood (GSE152418) and preeclampsia blood (GSE48424) were initially sourced from the Gene Expression Omnibus (GEO) database. Subsequent to that, we conducted a subanalysis by selecting females from the GSE152418 dataset and employed the "Deseq2" package to identify genes that exhibited differential expression. Simultaneously, the "limma" package was applied to identify differentially expressed genes (DEGs) in the preeclampsia dataset (GSE48424). Following that, an intersection analysis was conducted to identify the common DEGs obtained from both the COVID-19 and preeclampsia datasets. The identified shared DEGs were subsequently utilized for functional enrichment analysis, transcription factor (TF) and microRNAs (miRNA) prediction, pathway analysis, and identification of potential candidate drugs. Finally, to validate the bioinformatics findings, we collected peripheral blood mononuclear cell (PBMC) samples from healthy individuals, COVID-19 patients, and Preeclampsia patients. The abundance of the top 10 Hub genes in both diseases was assessed using real-time quantitative polymerase chain reaction (RT-qPCR).

Result

A total of 355 overlapping DEGs were identified in both preeclampsia and COVID-19 datasets. Subsequent ontological analysis, encompassing Gene Ontology (GO) functional assessment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, revealed a significant association between the two conditions. Protein-protein interactions (PPIs) were constructed using the STRING database. Additionally, the top 10 hub genes (MRPL11, MRPS12, UQCRH, ATP5I, UQCRQ, ATP5D, COX6B1, ATP5O, ATP5H, NDUFA6) were selected based on their ranking scores using the degree algorithm, which considered the shared DEGs. Moreover, transcription factor-gene interactions, protein-drug interactions, co-regulatory networks of DEGs and miRNAs, and protein-drug interactions involving the shared DEGs were also identified in the datasets. Finally, RT-PCR results confirmed that 10 hub genes do exhibit distinct expression profiles in the two diseases.

Conclusion

This study successfully identified overlapping DEGs, functional pathways, and regulatory elements between COVID-19 and preeclampsia. The findings provide valuable insights into the shared molecular mechanisms and potential therapeutic targets for both diseases. The validation through RT-qPCR further supports the distinct expression profiles of the identified hub genes in COVID-19 and preeclampsia, emphasizing their potential roles as biomarkers or therapeutic targets in these conditions.

The unfolded protein response pathway as a possible link in the pathogenesis of COVID-19 and sepsis

The global impact of the COVID-19 pandemic has been substantial. Emerging evidence underscores a strong clinical connection between COVID-19 and sepsis. Numerous studies have identified the unfolded protein response (UPR) pathway as a crucial pathogenic pathway for both COVID-19 and sepsis, but it remains to be investigated whether this signaling pathway operates as a common pathogenic mechanism for both COVID-19 and sepsis. In this study, single-cell RNA-seq data and transcriptome data for COVID-19 and sepsis cases were downloaded from GEO (Gene Expression Omnibus). By analyzing the single-cell transcriptome data, we identified B cells as the critical cell subset and the UPR pathway as the critical signaling pathway. Based on the transcriptome data, a machine learning diagnostic model was then constructed using the interleaved genes of B-cell-related and UPR-pathway-related genes. We validated the diagnostic model using both internal and external datasets and found the accuracy and stability of this model to be extremely strong. Even after integrating our algorithmic model with the patient's clinical status, it continued to yield identical results, further emphasizing the reliability of this model. This study provides a novel molecular perspective on the pathogenesis of sepsis and COVID-19 at the single-cell level and suggests that these two diseases may share a common mechanism.

Unveiling the future of COVID-19 patient care: groundbreaking prediction models for severe outcomes or mortality in hospitalized cases

Background

Previous studies have identified COVID-19 risk factors, such as age and chronic health conditions, linked to severe outcomes and mortality. However, accurately predicting severe illness in COVID-19 patients remains challenging, lacking precise methods.

Objective

This study aimed to leverage clinical real-world data and multiple machine-learning algorithms to formulate innovative predictive models for assessing the risk of severe outcomes or mortality in hospitalized patients with COVID-19.

Methods

Data were obtained from the Taipei Medical University Clinical Research Database (TMUCRD) including electronic health records from three Taiwanese hospitals in Taiwan. This study included patients admitted to the hospitals who received an initial diagnosis of COVID-19 between January 1, 2021, and May 31, 2022. The primary outcome was defined as the composite of severe infection, including ventilator use, intubation, ICU admission, and mortality. Secondary outcomes consisted of individual indicators. The dataset encompassed demographic data, health status, COVID-19 specifics, comorbidities, medications, and laboratory results. Two modes (full mode and simplified mode) are used; the former includes all features, and the latter only includes the 30 most important features selected based on the algorithm used by the best model in full mode. Seven machine learning was employed algorithms the performance of the models was evaluated using metrics such as the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, and specificity.

Results

The study encompassed 22,192 eligible in-patients diagnosed with COVID-19. In the full mode, the model using the light gradient boosting machine algorithm achieved the highest AUROC value (0.939), with an accuracy of 85.5%, a sensitivity of 0.897, and a specificity of 0.853. Age, vaccination status, neutrophil count, sodium levels, and platelet count were significant features. In the simplified mode, the extreme gradient boosting algorithm yielded an AUROC of 0.935, an accuracy of 89.9%, a sensitivity of 0.843, and a specificity of 0.902.

Conclusion

This study illustrates the feasibility of constructing precise predictive models for severe outcomes or mortality in COVID-19 patients by leveraging significant predictors and advanced machine learning. These findings can aid healthcare practitioners in proactively predicting and monitoring severe outcomes or mortality among hospitalized COVID-19 patients, improving treatment and resource allocation.

[Cochleovestibular manifestations in coronavirus infection]

One of the main causes of the of the inner ear pathology is a viral infection including SARS-CoV-2 virus. On the other hand the psycho-emotional state of patients also affects patients with hearing loss, tinnitus and dizziness, and an increase in depression and anxiety was revealed during the period of self-isolation. Goal of our study was to analyze cochleovestibular pathology in patients with COVID-19. The study involved 84 patients and the leading complaint was hearing loss - in 70 patients, tinnitus - in 54 patients, dizziness - in 50 patients. In addition, an increased anxiety background was found in patients, as well as signs of depression. Thus, the 2020 pandemic period was a high risk period for patients with inner ear pathology, which may be associated not only with the actual pathological effect of the virus on the auditory and vestibular system, but also with changes in the psycho-emotional status of patients.

SARS-CoV-2 Infection to Premature Neuronal Aging and Neurodegenerative Diseases: Is there any Connection with Hypoxia?

The pandemic of coronavirus disease-2019 (COVID-19), caused by SARS-CoV-2, has become a global concern as it leads to a spectrum of mild to severe symptoms and increases death tolls around the world. Severe COVID-19 results in acute respiratory distress syndrome, hypoxia, and multi- organ dysfunction. However, the long-term effects of post-COVID-19 infection are still unknown. Based on the emerging evidence, there is a high possibility that COVID-19 infection accelerates premature neuronal aging and increases the risk of age-related neurodegenerative diseases in mild to severely infected patients during the post-COVID period. Several studies correlate COVID-19 infection with neuronal effects, though the mechanism through which they contribute to the aggravation of neuroinflammation and neurodegeneration is still under investigation. SARS-CoV-2 predominantly targets pulmonary tissues and interferes with gas exchange, leading to systemic hypoxia. The neurons in the brain require a constant supply of oxygen for their proper functioning, suggesting that they are more vulnerable to any alteration in oxygen saturation level that results in neuronal injury with or without neuroinflammation. We hypothesize that hypoxia is one of the major clinical manifestations of severe SARS-CoV-2 infection; it directly or indirectly contributes to premature neuronal aging, neuroinflammation, and neurodegeneration by altering the expression of various genes responsible for the survival of the cells. This review focuses on the interplay between COVID-19 infection, hypoxia, premature neuronal aging, and neurodegenerative diseases and provides a novel insight into the molecular mechanisms of neurodegeneration.

Interaction between long noncoding RNA and microRNA in lung inflammatory diseases

BACKGROUND

Non-coding RNAs (ncRNAs) are a group of RNAs that cannot synthesize proteins, but are critical in gene expression regulation. Long non-coding RNAs (lncRNAs) and microRNAs (miRNAs), the two major family members, are intimately involved in controlling immune response, cell proliferation, apoptosis, differentiation and polarization, and cytokine secretion. Their interactions significantly influence lung inflammatory diseases and could be potential therapeutic targets.

OBJECTIVES

The review aims to elucidate the role of ncRNAs, especially the interactions between lncRNA and miRNA in lung diseases, including acute and chronic lung inflammatory diseases, as well as lung cancer. And provide novel insights into disease mechanisms and potential therapeutic methods.

METHODS

We conducted a comprehensive review of the latest studies on lncRNA and miRNA in lung inflammatory diseases. Our research involved searching through electronic databases like PubMed, Web of Science, and Scopus.

RESULTS

We explain the fundamental characteristics and functions of miRNA and lncRNA, their potential interaction mechanisms, and summarize the newly explorations on the role of lncRNA and miRNA interactions in lung inflammatory diseases.

CONCLUSIONS

Numerous lncRNAs and miRNAs have been found to partipicate in all stages of lung inflammatory diseases. While ncRNA-based therapies have been validated and developed, there remain challenges in developing more stable and effective drugs for clinical use.

Clinical Characteristics and Risk of Hypoxemia Development in Women Infected with SARS-CoV-2 during Pregnancy

PURPOSE

There is limited information on the clinical characteristics and prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy. The clinical features and risk factors for hypoxemia development were investigated in pregnant women with coronavirus disease-2019 (COVID-19).

MATERIALS AND METHODS

From August 2020 to February 2022, we performed a retrospective cohort study of 410 pregnant women with COVID-19. The clinical characteristics and prognoses were compared between pregnant COVID-19 patients requiring oxygen and those who did not.

RESULTS

Of 410 patients, 100 (24.4%) required oxygen therapy. Among them, fever [163 (52.6%) vs. 81 (81.0%), p<0.001] and cough [172 (56.4%) vs. 73 (73.0%), p=0.003] were more frequently observed than in non-oxygen group. The proportion of unvaccinated women was higher in oxygen group than in non-oxygen group [264 (85.2%) vs. 98 (98.0%), p=0.003]. During the Omicron wave, patients were more likely to have no oxygen requirement [98 (31.6%) vs. 18 (18.0%), p=0.009]. The risk of hypoxemic respiratory difficulty increased if SARS-CoV-2 infection occurred during the third trimester [adjusted odds ratio (aOR) 5.083, 95% confidence interval (CI): 1.095-23.593, p=0.038] and C-reactive protein (CRP) was elevated (≥1.0 mg/dL) at admission (aOR 5.878, 95% CI: 3.099-11.146, p<0.001). The risk was higher in unvaccinated patients (aOR 5.376, 95% CI: 1.193-24.390, p=0.028). However, the risk was lower in patients during the Omicron wave (aOR 0.498, 95% CI: 0.258-0.961, p=0.038).

CONCLUSION

A quarter of SARS-CoV-2-infected women developed hypoxemic respiratory difficulty during pregnancy. SARS-CoV-2 infection during the third trimester, CRP elevation at admission, and no vaccination increased the risk of hypoxemia in pregnant women.

Age and Comorbidity Profiles as Predictors of Mechanical Ventilation Duration in COVID-19 ICU Patients: A Retrospective Study in Saudi Arabia

Background The COVID-19 pandemic has highlighted the critical importance of understanding factors that impact outcomes for intensive care unit patients, especially those necessitating mechanical ventilation. This study aims to examine the influence of age and comorbidities on the duration of mechanical ventilation among COVID-19 patients in ICU settings, building on existing research that indicates the significant effects of these factors on patient outcomes. Methods A retrospective observational study was conducted involving COVID-19 patients in ICU who required mechanical ventilation. Selection criteria included ICU admission and the necessity for mechanical ventilation. Data collection focused on patient demographics, specifically age and comorbidities such as diabetes and hypertension, alongside the total duration of mechanical ventilation. The analysis utilized descriptive statistics, comparative methods, and regression modeling. Results The analysis revealed that older patients and those with certain comorbidities, notably diabetes and hypertension, typically experienced prolonged periods of mechanical ventilation. These findings are consistent with existing literature, underscoring the critical role of age and comorbidity in the management of COVID-19, in ICU patients. Conclusion This study sheds light on the significant factors influencing the duration of mechanical ventilation in COVID-19 ICU patients. The results emphasize the need for personalized treatment approaches in the ICU, particularly for older patients and those with specific comorbidities. These insights have substantial implications for clinical practice and public health, indicating the necessity for adaptable ventilation strategies and informed resource allocation. Furthermore, the findings pave the way for future research aimed at optimizing treatment protocols for diverse patient demographics in critical care settings.

Predicting Mortality of COVID-19 in Kidney Transplant Recipients With Developed Scores

OBJECTIVES

COVID-19 is a recently discovered β-subtype coronavirus infection due to SARS-CoV-2. Approximately 20% of COVID-19 patients have moderate to severe clinical manifestations and 5% progress to critical illness. Kidney transplant patients form a special group. In our study, we aimed to evaluate the success of the COVID-gram score and systemic immuno-inflammation index score in predicting the risk of mortality during hospitalization among kidney transplant patients.

MATERIALS AND METHODS

Our study included 50 kidney transplant patients with positive real-time reverse transcription polymerase chain reaction COVID-19 tests between March 2020 and March 2021. Risk scores were calculated using baseline clinical data collected retrospectively from the patient cohort.

RESULTS

The mean age was 54.3 ± 10.2. The mortality rate was 12%. When we compared the COVID-gram and systemic immuno-inflammation index scores between survivors and nonsurvivors, we did not find any difference.

CONCLUSIONS

Kidney and other solid-organ transplant patients are at greater risk of infection and mortality than other groups. Accurate risk-predicting tools are imperative for managing the COVID-19 pandemic with limited health resources.

Sex differences in the relationship between post-vaccination adverse reactions, decision regret, and WTP for the booster dose of COVID-19 vaccine in Taizhou, China

This study investigated sex differences in the relationship between post-vaccination adverse reactions, decision regret, and willingness to pay (WTP) for the booster dose of COVID-19 vaccines. This research carried out an online cross-sectional investigation among healthcare workers (HCWs) in Taizhou, China. In total, 1,054 respondents (165 males and 889 females) have received two-dose COVID-19 vaccination. We performed descriptive analysis, chi-square test, and mediation analysis on the exported data. In this study, 67 (40.6%) males and 429 (48.3%) females had WTP for the booster dose. Our study presented that decision regret mediated the effect of adverse reactions after vaccination on WTP for the booster dose in both male and female groups. In males, decision regret played a completely mediating role, while in females, it acted as a partial mediator. Sex differences in the relationship between post-vaccination side effects, decision regret, and WTP for the third dose were demonstrated in a sample of healthcare workers.

Long-term psychiatric disorders in families of severe COVID-19 patients

Aim

The present study aimed to describe in detail the changes to and assess the risk factors for poor long-term outcomes of psychiatric disorders in families of COVID-19 patients.

Methods

A single-center, retrospective study using questionnaires. Family members of patients admitted to the intensive care unit (ICU) with severe COVID-19 participated. Psychiatric disorders refer to the psychological distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient's family.

Results

Forty-six family members completed the survey and were analyzed. Anxiety, depression, and PTSD occurred in 24%, 33%, and 2% of family members, respectively, and psychiatric disorders occurred in 39%. On multivariable analysis, living in the same house with the patient was independently associated with a lower risk of psychiatric disorders in families of COVID-19 patients (OR, 0.180; 95% CI, 0.036-0.908; p = 0.038). Furthermore, four family members overcame psychiatric disorders, and six family members newly developed psychiatric disorders during the one-year follow-up period.

Conclusion

Approximately 40% of family members had long-term psychiatric disorders, and some of them overcame the psychiatric disorders, and some newly developed psychiatric disorders over the one-year follow-up. Living in the same house with the patient was possibly significantly associated with the reduction of long-term symptoms of psychiatric disorders, but this result must be interpreted with care. Further large studies are needed to examine the factors associated with the long-term mental status of family members.

Effectiveness of Rehabilitation Interventions on Adults With COVID-19 and Post-COVID-19 Condition. A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate the effectiveness of rehabilitation interventions for adults with COVID-19 and post COVID-19 condition (PCC) in all settings.

DATA SOURCES

PubMed, EMBASE, CINAHL, Scopus, Web of Science, and Physiotherapy Evidence Database were searched from inception to December 31st, 2021. PROSPERO registration number: CRD42021258553.

STUDY SELECTION

We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) according to the University of Alberta Evidence-based Practice Center.

DATA EXTRACTION

One author extracted data using a predetermined Excel form.

DATA SYNTHESIS

The meta-analysis indicates uncertain evidence about the effect of pulmonary rehabilitation and self-activities on exercise capacity (MD 65.06, 95% CI 42.87 to 87.25), respiratory function (forced expiratory volume in the first second [FEV1]: MD 0.16, 95% CI 0.05 to 0.28; FEV1/forced vital capacity [FVC]: MD 0.05, 95% CI 0.01 to 0.09; FVC: MD 0.19, 95% CI -0.03 to 0.42) and anxiety (MD -12.03, 95% CI -21.16 to -2.90) in mild COVID-19 and PCC patients. According to the narrative synthesis, including RCTs and NRSI, prone positioning seems to show improvements in vital parameters in severe COVID-19 post intensive care unit (ICU) discharge, pulmonary rehabilitation in activities of daily living, and qigong exercise and acupressure rehabilitation program, and "twist and raise" walking technique in reducing dyspnea and weakness in any degree of severity of COVID-19 and PCC. Functional electrical stimulation-cycling or early rehabilitation programs seem to support a faster recovery in patients with moderate COVID-19 after ICU discharge. Yoga and naturopathy, Mandala coloring, and respiratory exercise seem to reduce anxiety and depression in patients with moderate and mild COVID-19. Cognitive motor training seems to improve cognitive function in PCC patients.

CONCLUSIONS

There is very uncertain evidence about the effect of pulmonary rehabilitation on exercise capacity and respiratory function in patients with mild COVID-19 and PCC. Further high-quality research is required to improve the certainty of evidence available to support rehabilitation's crucial role in managing COVID-19.

The impact of COVID-19 on nurse alcohol consumption: A qualitative exploration

AIMS AND OBJECTIVES

To explore the long-term impact of the COVID-19 pandemic on nurse alcohol consumption.

BACKGROUND

The COVID-19 pandemic has caused immense disruption to healthcare services worldwide, and nurses have not been immune, experiencing burnout, declining mental health and ultimately, attrition from the profession. Increases in alcohol consumption have been reported across subsections of society, including those with pre-existing mental ill health and experiencing high stress, and exploring this phenomenon in nurses is essential for workforce well-being and sustainability.

DESIGN

Qualitative descriptive study design.

METHODS

Secondary analysis of individual, semi-structured interviews with nurses (N = 42) from diverse settings across Australia, including community, primary and hospital settings, conducted in July and August 2021. Data were analysed using structural coding and reported in accordance with the CORE-Q guidelines.

FINDINGS

Two key themes were found after analysis of the data: (1) factors influencing alcohol consumption (subthemes: workplace factors and external factors), and (2) the pandemic's influence on alcohol consumption (subthemes: increased consumption, moderation of consumption and alcohol as a reward).

CONCLUSIONS

Several participants described increased alcohol consumption because of the COVID-19 pandemic, particularly due to the stress of working in an environment where resources were scarce. Workplace factors such as overtime, missed breaks and heightened workload were all described as driving stress, and in turn increased alcohol consumption.

RELEVANCE TO CLINICAL PRACTICE

Increased alcohol consumption has been associated with burnout, absenteeism and intention to leave. The nursing profession is currently undergoing significant continuing stress providing care and management to patients with the SARS-CoV-2 virus, and increased alcohol consumption is a significant threat to personal and workforce well-being, workforce sustainability and quality nursing care.

Rating of Perceived Exertion Associated With Acute Symptoms in Athletes With Recent SARS-CoV-2 Infection: Athletes With Acute Respiratory InfEction (AWARE) VI Study

CONTEXT

SARS-CoV-2 infection can affect the exercise response in athletes. Factors associated with the exercise response have not been reported.

OBJECTIVE

To (1) describe heart rate (HR), systolic blood pressure (SBP), and rating of perceived exertion (RPE) responses to exercise in athletes with a recent SARS-CoV-2 infection and (2) identify factors affecting exercise responses.

DESIGN

Cross-sectional, experimental study.

PATIENTS OR OTHER PARTICIPANTS

Male and female athletes (age = 24.2 ± 6.3 years) with a recent (<28 days) SARS-CoV-2 infection (n = 72).

SETTING

A COVID-19 Recovery Clinic for athletes.

MAIN OUTCOME MEASURE(S)

Heart rate, SBP, and RPE were measured during submaximal exercise (modified Bruce protocol) at 10 to 28 days after SARS-CoV-2 symptom onset. Selected factors (demographics, sport, comorbidities, preinfection training variables, and symptoms during the acute phase of the infection) affecting the exercise response were analyzed using random coefficient (linear mixed) models.

RESULTS

Heart rate, SBP, and RPE increased progressively from rest to stage 5 of the exercise test (P = .0001). At stage 5 (10.1 metabolic equivalents), a higher HR and a higher SBP during exercise were associated with younger age (P = .0007) and increased body mass index (BMI; P = .009), respectively. Higher RPE during exercise was significantly associated with a greater number of whole-body (P = .006) and total number (P = .004) of symptoms during the acute phase of infection.

CONCLUSIONS

A greater number of symptoms during the acute infection was associated with a higher RPE during exercise in athletes at 10 to 28 days after SARS-CoV-2 infection. We recommend measuring RPE during the first exercise challenge after infection, as this may indicate disease severity and be valuable for tracking progress, recovery, and return to sport.

Influence of the coronavirus infectious disease 2019 pandemic on infectious disease practice and infection control in Japan: A web questionnaire survey

INTRODUCTION

Infection and mortality rates caused by the coronavirus infectious disease 2019 (COVID-19) pandemic were high. However, the influence of the COVID-19 pandemic on the clinical burden in medical facilities remains to be clarified in Japan.

MATERIALS AND METHODS

This study used a questionnaire-based web survey to clarify how the COVID-19 pandemic affected infectious disease practice and infection control. The questionnaire was sent to healthcare professionals at nationwide medical facilities between January 13, 2023, and February 15, 2023.

RESULTS

Responses were obtained from 1784 healthcare professionals throughout Japan. Hospital management of COVID-19 patients was the responsibility of 96.5% of respondents. Furthermore, 75.1% had experienced nosocomial spread of COVID-19. Manuals and infection control measures for COVID-19 have been arranged in most facilities. In many facilities, the timing of an infected employee's return to work was determined in accordance with the isolation period for coronavirus-positive patients with symptoms established by the Ministry of Health, Labor and Welfare in Japan. Approximately 30% of respondents reported that caring for COVID-19 patients, including the use of personal protective equipment, was their most stressful job. Approximately 50% of the respondents reported an increase in overtime hours. Approximately 90% of facilities are now capable of performing COVID-19 testing onsite.

CONCLUSION

Infection control for COVID-19 has been improved, and testing equipment for SARS-CoV-2 has been prepared. Patient care-related burdens and burdens caused by having to compensate for vacancies due to infected staff members have increased. In the future, a reduction in workload and role sharing should be considered.

Effects of traditional Chinese medicine on treatment outcomes in severe COVID-19 patients: a single-centre study

As the search for effective treatments for COVID-19 continues, the high mortality rate among critically ill patients in Intensive Care Units (ICU) presents a profound challenge. This study explores the potential benefits of traditional Chinese medicine (TCM) as a supplementary treatment for severe COVID-19. A total of 110 critically ill COVID-19 patients at the Intensive Care Unit (ICU) of Vulcan Hill Hospital between Feb., 2020, and April, 2020 (Wuhan, China) participated in this observational study. All patients received standard supportive care protocols, with a subset of 81 also receiving TCM as an adjunct treatment. Clinical characteristics during the treatment period and the clinical outcome of each patient were closely monitored and analysed. Our findings indicated that the TCM group exhibited a significantly lower mortality rate compared with the non-TCM group (16 of 81 vs 24 of 29; 0.3 vs 2.3 person/month). In the adjusted Cox proportional hazards models, TCM treatment was associated with improved survival odds (P < 0.001). Furthermore, the analysis also revealed that TCM treatment could partially mitigate inflammatory responses, as evidenced by the reduced levels of proinflammatory cytokines, and contribute to the recovery of multiple organic functions, thereby potentially increasing the survival rate of critically ill COVID-19 patients.

Household Transmission of SARS-CoV-2 in the Third Wave of the Pandemic with Special Reference to Clinico-epidemiological Characteristics

Background

Coronavirus disease 2019 (COVID-19) pandemic began in India in 2020. Despite successful vaccination, cases again started increasing from mid-December 2021. Therefore, this study was undertaken to find out the clinico-epidemiological characteristics and effectiveness of vaccination in the household transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in and around Pune.

Material and Methods

All samples received from December 15, 2021, till February 15, 2022, were included in the study. Samples received in viral transport medium (VTM) were extracted by the MagMAX RNA Extraction Kit, and reverse transcriptase-polymerase chain reaction (RT-PCR) was performed by the CoviPath Kit as per kit guidelines. Values of nucleocapsid (N) gene and open reading frame (ORF) less than 37 were considered positive. Clinico-epidemiological data were analyzed from the sample referral form (SRF).

Results

A total of 712 of 1032 household contacts of 271 families were positive. When geographical areas were compared, it was found that rural areas were affected more (63.76%) as compared to urban areas (36.24%). Males were more affected than females. The most commonly affected age group was 41-50 years (26.54%). Small families were found to have more household transmission. Mild symptoms were present in 97.89%. Among 271 infected individuals, seven were admitted to hospital, of which one patient died due to pneumonia. Two doses of vaccination were completed in 93.95%, and 3.79% had taken booster dose.

Conclusions

Data from this study showed that a high rate of transmission was observed in household contact despite two doses of vaccination. However, these vaccinated individuals had mild symptoms, maybe due to the effect of vaccination and infecting variant omicron.

What Is the Impact of Baseline Inflammatory and Hemostatic Indicators with the Risk of Mortality in Severe Inpatients with COVID-19: A Retrospective Study

The purpose of the study was to investigate baseline inflammatory, hemostatic indicators and new-onset deep vein thrombosis (DVT) with the risk of mortality in COVID-19 inpatients. In this single-center study, a total of 401 COVID-19 patients hospitalized in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were enrolled from December 1, 2022 to January 31, 2023. The basic information, first laboratory examination results, imaging examination, and outcome-related indicators were compared between patients in the moderate and severe subgroups. We found that baseline D-dimer and baseline absolute neutrophil count (ANC) levels were associated with new-onset DVT and death in severe hospitalized patients with COVID-19. The odds ratio (OR) of baseline D-dimer and baseline ANC with mortality was 1.18 (95% confidence interval [CI], 1.08-1.28; P < .001) and 1.13 (95% CI, 1.06-1.21; P < .001). Baseline ANC was associated with the risk of death in severe hospitalized COVID-19 patients, irrespective of the DVT status. In addition, a significantly higher serum neutrophil activity was observed in severe COVID-19 inpatients with DVT or those deceased during hospital stay. New-onset DVT partially mediated the association between baseline D-dimer (indirect effect: 0.011, estimated mediating proportion: 67.0%), baseline ANC (indirect effect: 0.006, estimated mediating proportion: 48.7%), and mortality in severe hospitalized patients with COVID-19. In summary, baseline D-dimer and baseline absolute neutrophil count (ANC) levels were associated with the mortality in severe hospitalized patients with COVID-19, especially DVT inpatients. New-onset DVT partially mediated the association between baseline D-dimer, baseline ANC, and mortality in severe hospitalized patients with COVID-19.

COVID-19 Pneumonia and Cytokine Storm Syndrome

Virus-associated cytokine storm syndrome (CSS) has been recognized for a long time and the classic viruses associated are the herpes viruses EBV, CMV, and HHV-8 as described in chapters IVa,b. In addition, pandemic viruses such as influenza, SARS, and MERS can result in severe CSS that might ultimately lead to severe acute respiratory distress syndrome (ARDS) and death [1-3]. A new pandemic caused by SARS-CoV-2 that started in 2019 has defined another chapter in the virus-associated CSS. The clinical spectrum of SARS-CoV-2 infection has many faces. In most people, it will be asymptomatic, but it can also result in severe COVID-19 pneumonia, ARDS, and multiorgan failure depending on age, comorbidities, and immune status [4]. In addition, this pandemic has known many different stages and developed in a unique way in the first 2 years. It started in a setting where there was no immunity to the virus and after a year, highly effective vaccines were introduced and herd immunity built up over time. However, vaccine effectiveness was waning over time depending on multiple factors, and novel variant strains of the virus circulated across different areas in the world. Antiviral therapy was developed and introduced, and treatment changed from giving no immunomodulatory treatment, followed by the introduction of corticosteroids [5], and later the addition of more targeted strategies such as JAK inhibitors [6] and blocking IL-6 signaling [7]. Therefore, the scientific literature published on COVID-19 must be seen in the context of a highly dynamic and rapidly changing pandemic, making it difficult to compare results from early studies to more recent reports even within 2 years. Still, a lot has been learned over a very short period. It has become apparent that severe COVID-19 is predominantly a disease of immune dysregulation with components that can be defined as CSS. It has unique features and overlapping characteristics with other CSSs, and immunological treatment addressing the CSS has been extensively explored, which will be described here.

The Effect of Angiotensin-Converting Enzyme Insertion/Deletion Polymorphism on the Severity and Death Rate of COVID-19 in Iranian Patients

The study was designed to assess the association of ACE I/D polymorphism with the severity and prognosis of COVID-19 in the Iranian population. Hence, 186 adult patients were categorized into three clinical groups based on the severity of COVID-19: 1) Outpatients or mildly symptomatic patients as control (n = 71); 2) Hospitalized patients or severe symptomatic cases (n = 53); 3) Inpatients led to ICU/death or critically ill patients needed mechanical ventilation (n = 62). The possible association of ACE I/D polymorphism with the risk of comorbidities and serum level of C-reactive protein was evaluated in two severe cases. The results showed that the frequency of D and I alleles are 69.35% and 30.65%, respectively, in the total population. The analysis of allelic frequencies via Fisher's exact test confirmed significantly higher frequency of D allele in both severe groups than that in the mild one, 78.31% in Hospitalized patients (OR = 2.56; 95% CI 1.46 to 4.46; p-value = 0.0011) and 74.19% in Inpatients led to ICU/death (OR = 2.04; 95% CI = 1.22 to 3.43; p-value = 0.0094) compared to 58.45% in Outpatients. The results of genotype proportions displayed an association between COVID-19 severity and DD genotype. Overall, our findings in Iranian patients supported the undeniable role of the DD genotype in the intensity of the disease, comparable to other populations. Furthermore, there is no definite evidence regarding the protective effect of the I allele in our inquiry.

Blood circulating bacterial DNA in hospitalized old COVID-19 patients

BACKGROUND

Coronavirus disease COVID-19 is a heterogeneous condition caused by SARS-CoV-2 infection. Generally, it is characterized by interstitial pneumonia that can lead to impaired gas-exchange, acute respiratory failure, and death, although a complex disorder of multi-organ dysfunction has also been described. The pathogenesis is complex, and a variable combination of factors has been described in critically ill patients. COVID-19 is a particular risk for older persons, particularly those with frailty and comorbidities. Blood bacterial DNA has been reported in both physiological and pathological conditions and has been associated with some haematological and laboratory parameters but, to date, no study has characterized it in hospitalized old COVID-19 patients The present study aimed to establish an association between blood bacterial DNA (BB-DNA) and clinical severity in old COVID-19 patients.

RESULTS

BB-DNA levels were determined, by quantitative real-time PCRs targeting the 16S rRNA gene, in 149 hospitalized older patients (age range 65-99 years) with COVID-19. Clinical data, including symptoms and signs of infection, frailty status, and comorbidities, were assessed. BB-DNA was increased in deceased patients compared to discharged ones, and Cox regression analysis confirmed an association between BB-DNA and in-hospital mortality. Furthermore, BB-DNA was positively associated with the neutrophil count and negatively associated with plasma IFN-alpha. Additionally, BB-DNA was associated with diabetes.

CONCLUSIONS

The association of BB-DNA with mortality, immune-inflammatory parameters and diabetes in hospitalized COVID-19 patients suggests its potential role as a biomarker of unfavourable outcomes of the disease, thus it could be proposed as a novel prognostic marker in the assessment of acute COVID-19 disease.

Development and Validation of a Highly Sensitive Multiplex Immunoassay for SARS-CoV-2 Humoral Response Monitorization: A Study of the Antibody Response in COVID-19 Patients with Different Clinical Profiles during the First and Second Waves in Cadiz, Spain

There is still a long way ahead regarding the COVID-19 pandemic, since emerging waves remain a daunting challenge to the healthcare system. For this reason, the development of new preventive tools and therapeutic strategies to deal with the disease have been necessary, among which serological assays have played a key role in the control of COVID-19 outbreaks and vaccine development. Here, we have developed and evaluated an immunoassay capable of simultaneously detecting multiple IgG antibodies against different SARS-CoV-2 antigens through the use of Bio-PlexTM technology. Additionally, we have analyzed the antibody response in COVID-19 patients with different clinical profiles in Cadiz, Spain. The multiplex immunoassay presented is a high-throughput and robust immune response monitoring tool capable of concurrently detecting anti-S1, anti-NC and anti-RBD IgG antibodies in serum with a very high sensitivity (94.34-97.96%) and specificity (91.84-100%). Therefore, the immunoassay proposed herein may be a useful monitoring tool for individual humoral immunity against SARS-CoV-2, as well as for epidemiological surveillance. In addition, we show the values of antibodies against multiple SARS-CoV-2 antigens and their correlation with the different clinical profiles of unvaccinated COVID-19 patients in Cadiz, Spain, during the first and second waves of the pandemic.

Microglial Inflammatory Responses to SARS-CoV-2 Infection: A Comprehensive Review

Coronavirus disease 2019 (COVID-19) is primarily a respiratory disease causing a worldwide pandemic in the year of 2019. SARS-CoV-2 is an enveloped, positive-stranded RNA virus that could invade the host through spike protein and exhibits multi-organ effects. The Brain was considered to be a potential target for SARS-CoV-2 infection. Although neuropsychiatric symptoms and cognitive impairments were observed in COVID-19 patients even after recovery the mechanism of action is not well documented. In this review, the contribution of microglia in response to SARS-CoV-2 infection was discussed aiming to design a therapeutic regimen for the management of neuroinflammation and psycho-behavioral alterations. Priming of microglia facilitates the hyper-activation state when it interacts with SARS-CoV-2 known as the 'second hit'. Moreover, the microgliosis produces reactive free radicals and pro-inflammatory cytokines like IL-1β, IFN-γ, and IL-6 which ultimately contribute to a 'cytokine storm', thereby increasing the occurrence of cognitive and neurological dysfunction. It was reported that elevated CCL11 may be responsible for psychiatric disorders and ROS/RNS-induced oxidative stress could promote major depressive disorder (MDD) and phenotypic switching. Additionally, during SARS-CoV-2 infection microglia-CD8+ T cell interaction may have a significant role in neuronal cell death. This cytokine-mediated cellular cross-talking plays a crucial role in pro-inflammatory and anti-inflammatory balance within the COVID-19 patient's brain. Therefore, all these aspects will be taken into consideration for developing novel therapeutic strategies to combat SARS-CoV-2-induced neuroinflammation.

COVID-19 vaccination and corneal allograft rejection- a review

Aim

To provide a comprehensive literature review on the perceived correlation between COVID-19 vaccination and corneal allograft rejection, and to characterize risk factors, time course, graft outcomes and proposed immunological basis.

Methods

A literature review was conducted in August 2023 using 4 electronic databases: PubMed, EMBASE, MEDLINE and Scopus. Articles were sourced using key words associated with COVID-19 vaccination and corneal graft. All articles were screened for relevance by abstract review. Duplicates and articles related to COVID-19 infection were excluded. No time limits were set. Additional literature searches regarding cause of corneal graft rejection, rates of graft rejection associated with other vaccines and the cellular mechanism of rejection were also performed.

Results

262 articles were identified from the literature search. 37 papers were included in the analysis based on defined inclusion criteria. This consisted of systematic reviews (n=6), review articles (n=5), retrospective studies (n=3), case series (n=8), letter to the editor (n=1) and case reports (n= 14). The majority of reported allograft rejections were in penetrating keratoplasties. Risk factors for COVID-19 vaccination associated rejection were previous allograft rejection episodes, repeat grafts and penetrating keratoplasty. Most reported rejection episodes were mild and resolved with treatment. Notably, several studies reported nil increase in corneal allograft rejection episodes over the COVID-19 vaccination period. Rejection episodes are associated with a broad spectrum of other vaccines and the complete pathophysiology is undetermined.

Conclusion

Corneal allograft rejection appears to be a rare complication of COVID-19 vaccination most frequently observed in high-risk corneal transplants. The true extent of this correlation remains controversial; however, clinician awareness of this risk is essential to its mitigation. Patient counselling around symptom monitoring following vaccination and discussion around topical steroid prophylaxis may be prudent.

Transcriptomic analysis of sorted lung cells revealed a proviral activity of the NF-κB pathway toward SARS-CoV-2

Investigations of cellular responses to viral infection are commonly performed on mixed populations of infected and uninfected cells or using single-cell RNA sequencing, leading to inaccurate and low-resolution gene expression interpretations. Here, we performed deep polyA+ transcriptome analyses and novel RNA profiling of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected lung epithelial cells, sorted based on the expression of the viral spike (S) protein. Infection caused a massive reduction in mRNAs and long non-coding RNAs (lncRNAs), including transcripts coding for antiviral factors, such as interferons (IFNs). This absence of IFN signaling probably explained the poor transcriptomic response of bystander cells co-cultured with S+ ones. NF-κB pathway and the inflammatory response escaped the global shutoff in S+ cells. Functional investigations revealed the proviral function of the NF-κB pathway and the antiviral activity of CYLD, a negative regulator of the pathway. Thus, our transcriptomic analysis on sorted cells revealed additional genes that modulate SARS-CoV-2 replication in lung cells.

Bibliometric analysis of scientific papers on adverse reactions to COVID-19 vaccines published between 2019 and 2023

The Coronavirus Disease 2019 (COVID-19) pandemic has now persisted globally for four years, resulting in a staggering death toll of over 4 million individuals. The COVID-19 vaccine has emerged as a highly effective tool in controlling the spread of this virus. However, as the number of individuals receiving COVID-19. In this context, the investigation of adverse reactions related to COVID-19 vaccines holds paramount importance in relevant research. The purpose is to evaluate the current research status regarding adverse reactions associated with COVID-19 vaccines, offering insights for future research. A total of 3,746 articles were included in this analysis, and there has been a notable upward trajectory in the volume of published articles. The CiteSpace v6.1.R6, VOSviewer, SCImago Graphica, and Excel 2019 were employed to analyze and visualize the results. The institutions, countries, journals, authors, co-cited references, and keywords of these articles were analyzed. Furthermore, this study delves into the characteristics of articles on adverse reactions associated with COVID-19 vaccines. It was observed that the number of studies on COVID-19 vaccines has increased year by year since 2019 and witnessed a surge in output in 2021. The vast majority of studies have affirmed the overall safety of COVID-19 vaccines, with adverse reactions tending to be more concentrated in specific diseases. These findings provide valuable ideas for future research in this field and suggest the importance of strengthening international cooperation on adverse reactions to COVID-19 vaccines.

Epidemiological surveillance of respiratory viral infections in SARS-CoV-2-negative samples during COVID-19 pandemic in Iran

BACKGROUND

To improve the patient care, public health surveillance, and infection control, it is crucial to identify the presence and frequency of the common respiratory infections in individuals with COVID-19 symptoms but tested negative for SARS-CoV-2. This study aimed to shed light on this during the COVID-19 pandemic in Iran.

METHODS

In this cross-sectional study, a total of 1,002 patients with acute respiratory infection who had negative SARS-CoV-2 test results and referred to Valfajr Health Center, the National Collaborating Laboratory of Influenza and COVID-19 National Reference Laboratory at Pasteur Institute of Iran were recruited between January 2020 and January 2022. Nasopharyngeal and oropharyngeal swab samples were collected to detect 17 common respiratory viruses via TaqMan one-step real-time multiplex PCR. Demographic and clinical data of the participants were obtained from their electronic medical records.

RESULTS

In total, 218 samples (21.8%) were tested positive for at least one respiratory virus infection. Most of the common investigated respiratory viruses belonged to the years 2020 and 2022. The number of investigated patients in 2021 was few, which highlights the impact of health measures following the COVID-19 pandemic in Iran. Influenza A was the most common virus (5.8%), while adenovirus had the lowest prevalence (0.1%). Although the rate of respiratory virus infection was higher in men (24%) compared to women (19.3%), this difference was not statistically significant (P = 0.069). The prevalence of respiratory viruses had an inverse association with increasing age, with the highest rate (55.6%) observed in the age group below 2 years and the lowest rate (12.7%) in those above 65 years.

CONCLUSION

Our findings underscore the significance of adopting a comprehensive approach to respiratory infections detection and management. These results can be employed for the development of syndromic surveillance systems and implementation of the effective infection control measures. Furthermore, the results contribute to better understanding of the dynamics of respiratory viruses, both during pandemic periods and in non-pandemic contexts.

Classification of patients with COVID-19 by blood RNA endotype: a prospective cohort study

IMPORTANCE

In this study, whole-blood RNAs (prolactin and toll-like receptor 3) involved in the prognosis of patients with COVID-19 were identified. The RNA endotypes classified by these important RNAs highlight the possibility of stratifying the COVID-19 patient population and the need for targeted therapy based on these phenotypes.