Involvement of the Nervous System in SARS-CoV-2 Infection

Efficacy and safety of deferoxamine in moderately ill COVID-19 patients: An open label, randomized controlled trial

BACKGROUND

Deferoxamine is a potent iron chelator that could remove iron from the virus, and severe acute respiratory syndrome coronavirus 2 requires iron to replication. Also, deferoxamine has antioxidant and cytokine-modulating effects. Therefore, we evaluated the efficacy and safety of deferoxamine in patients with moderate coronavirus disease 2019 (COVID-19).

METHODS

In this randomized controlled trial, patients with moderate COVID-19 were randomly assigned in a 1:1 ratio to the deferoxamine group (received a solution of 500 mg deferoxamine divided into 4 doses a day through a nebulizer for 7 days) and the control group. The main outcomes were viral clearance, oxygen saturation (SPO2), body temperature, and respiratory rate (RR). Intensive care unit admission, hospital length of stay, and hospital mortality were also assessed.

RESULTS

A total of 62 patients, with 30 in the deferoxamine group and 32 in the control group, were randomly assigned. There was no statistically significant improvement in viral clearance after the intervention ended in the deferoxamine group (36.7%) compared to the control group (34.4%). The results showed there was no significant difference between the analyzed groups in terms of SPO2, body temperature, RR, and the number of patients with a worse prognosis (SPO2 < 96%, temperature ≥ 37.5 °C, or RR ≥ 16/min) at the end of the study. There were no significant differences seen between the groups in terms of intensive care unit admission, hospital length of stay, hospital mortality, and the occurrence of adverse medication events during the follow-up period.

CONCLUSION

Deferoxamine had no significant impact on improving moderately ill patients with COVID-19. However, it was well-tolerated in the patients, and this intervention demonstrated a safe profile of adverse events.

Cognitive dysfunctions in the course of SARS‑CoV‑2 virus infection, including NeuroCOVID, frontal syndrome and cytokine storm (Review)

During the coronavirus disease 2019 (COVID-19) pandemic, cognitive impairment of varying degrees of severity began to be observed in a significant percentage of patients. The present study discussed the impact of immunological processes on structural and functional changes in the central nervous system and the related cognitive disorders. The purpose of the present review was to analyse and discuss available information from the scientific literature considering the possible relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection and cognitive impairment, including NeuroCOVID, frontal syndrome and cytokine storm. A systematic literature review was conducted using: Google Scholar, Elsevier and the PubMed database. When searching for materials, the following keywords were used: 'cognitive dysfunctions', 'SARS-CoV-2', 'COVID-19', 'Neuro-SARS2', 'NeuroCOVID', 'frontal syndrome', 'cytokine storm', 'Long COVID-19'. A total of 96 articles were included in the study. The analysis focused on the characteristics of each study's materials, methods, results and conclusions. SARS-CoV-2 infection may induce or influence existing cognitive disorders of various nature and severity. The influence of immunological factors related to the response against SARS-CoV-2 on the disturbance of cerebral perfusion, the functioning of nerve cells and the neuroprotective effect has been demonstrated. Particular importance is attached to the cytokine storm and the related difference between pro- and anti-inflammatory effects, oxidative stress, disturbances in the regulation of the hypothalamic-pituitary-adrenal axis and the stress response of the body.

EEG signatures of cognitive decline after mild SARS-CoV-2 infection: an age-dependent study

BACKGROUND

Current research on the neurological impact of SARS-CoV-2 primarily focuses on the elderly or severely ill individuals. This study aims to explore the diverse neurological consequences of SARS-CoV-2 infection, with a particular focus on mildly affected children and adolescents.

METHODS

A cohort study was conducted to collect pre- and post-infection resting-state electroencephalogram (EEG) data from 185 participants and 181 structured questionnaires of long-term symptoms across four distinct age groups. The goal was to comprehensively evaluate the impact of SARS-CoV-2 infection on these different age demographics. The study analyzed EEG changes of SARS-CoV-2 by potential biomarkers across age groups using both spatial and temporal approaches.

RESULTS

Spatial analysis indicated that children and adolescents exhibit smaller changes in brain network and microstate patterns post-infection, implying a milder cognitive impact. Sequential linear analyses showed that SARS-CoV-2 infection is associated with a marked rise in low-complexity, synchronized neural activity within low-frequency EEG bands. This is evidenced by a significant increase in Hjorth activity within the theta band and Hjorth mobility in the delta band. Sequential nonlinear analysis indicated a significant reduction in the Hurst exponent across all age groups, pointing to increased chaos and complexity within the cognitive system following infection. Furthermore, linear regression analysis based on questionnaires established a significant positive relationship between the magnitude of changes in these neural indicators and the persistence of long-term symptoms post-infection.

CONCLUSIONS

The findings underscore the enduring neurological impacts of SARS-CoV-2 infection, marked by cognitive decline and increased EEG disarray. Although children and adolescents experienced milder effects, cognitive decline and heightened low-frequency electrical activity were evident. These observations might contribute to understanding potential anxiety, insomnia, and neurodevelopmental implications.

The efficacy and safety of ginger (Zingiber officinale) rhizome extract in outpatients with COVID-19: A randomized double-blind placebo-control clinical trial

BACKGROUND

Ginger, a potent antiviral, anti-inflammatory, and antioxidant remedy, is a potential therapeutic option for COVID-19. However, there was not enough clinical evidence about ginger and COVID-19. We evaluated the efficacy and safety of ginger on clinical and paraclinical features in outpatients with COVID-19.

METHODS

In this randomized controlled trial, the outpatients with confirmed COVID-19 were randomly assigned in a 1:1 ratio to receive ginger (1000 mg 3 times a day for 7 days) or placebo. The primary outcome was viral clearance after the end of the intervention. Oxygen saturation (SPO2), body temperature, respiratory rate (RR), hospital admission, and the incidence of adverse events were also assessed.

RESULTS

A total of 84 patients (42 in the ginger and 42 in the control groups) were randomized. The viral clearance was not statistically improved in the ginger group (41.6%) compared to the placebo group (42.8%). The findings indicated that SPO2, body temperature, and RR had no significant difference between the groups at the end of the intervention. The imaging finding indicated pulmonary infiltrate significantly reduced on the 7th day of the intervention in the ginger group. The percentage of patients with SPO2 <96% in the ginger group decreased over the study compared to the placebo group. Moreover, the need for hospital admission and the incidence of adverse drug events were not different between the groups over the follow-up period.

CONCLUSIONS

Ginger had no significant impact on the clinical and paraclinical parameters of patients. However, this intervention demonstrated a safe profile of adverse events and reduced pulmonary infiltrate.

TRIAL REGISTRATION

The trial was registered as IRCT20200506047323N1.

Adherence to the nordic diet is associated with anxiety, stress, and depression in recovered COVID-19 patients, a case-control study

BACKGROUND

Follow-up of COVID-19 recovered patients to discover important adverse effects on other organs is required. The psychological health of COVID-19 patients may be affected after recovery.

AIM

We aimed to evaluate the association between adherence to the Nordic diet (ND) and psychological symptoms caused by COVID-19 after recovery.

METHOD

Dietary data on 246 qualified adults (123 cases and 123 controls). The dietary intake in this case-control study was calculated by a reliable and valid food frequency questionnaire (FFQ). Depression Anxiety Stress Scale (DASS), Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Short-Form Health Survey (SF-36) were used to analyze participant's anxiety, stress, depression, sleep quality, insomnia, and quality of life of participants.

RESULTS

There was a significant inverse relationship between total anxiety, stress, and depression scores and the intake of whole grains (P < 0.05). Furthermore, there was a significant inverse association between depression and fruit intake (P < 0.05). A significant negative correlation was found between insomnia and sleep quality and the intake of root vegetables (P < 0.05). In the multinomial-regression model, a significant association between the Nordic diet and anxiety, stress, and depression was found only in the case group (OR = 0.719, 95% CI 0.563-0.918, p-value = 0.008; OR = 0.755, 95% CI 0.609-0.934, P-value = 0.010, and, OR = 0.759, 95% CI 0.602-0.956, P-value = 0.019 respectively).

CONCLUSION

Adherence to the Nordic diet might reduce anxiety, stress, and depression in recovered COVID-19 patients.

Clinical manifestations and EEG findings in children infected with COVID-19 and exhibiting neurological symptoms

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has many neurological manifestations, and its effects on the nervous system are increasingly recognized. There has been no systematic analysis of electroencephalography (EEG) characteristics in children exhibiting neurological symptoms of Coronavirus disease 2019 (COVID-19). The primary aim of this study was to describe the EEG characteristics caused by COVID-19 infection in children who were showing neurological symptoms and to assess the relationship between COVID-19-related EEG changes and clinical features in these children.

METHOD

This study included 125 pediatric patients infected with SARS-CoV2 and showing neurological symptoms, and their continuous EEG was recorded. In addition, the demographic and clinical characteristics of these patients were analyzed and the correlation between the two was investigated.

RESULTS

Abnormal EEG findings were detected in 31.20% (N = 39) of the patients. Abnormal discharges (43.59%) were the most common EEG abnormalities, followed by background abnormalities (41.03%). The proportion of patients diagnosed with febrile seizure was higher in the normal EEG group than in the abnormal EEG group (P = 0.002), while the opposite was true for epilepsy and encephalitis/encephalopathy (P = 0.016 and P = 0.003, respectively). The independent associated factors of abnormal EEG were age and total length of stay (P < 0.001 and P = 0.003, respectively). Non-specific EEG abnormalities were found in COVID-19-related encephalitis/encephalopathy.

CONCLUSION

Our study corroborated that a small group of pediatric patients infected by COVID-19 and showing neurological symptoms may exhibit abnormal EEG. This study could help improve the understanding of clinical and EEG characteristics in children with COVID-19 and inform triage policies in other hospitals during the COVID-19 pandemic.

Efficacy and safety of licorice (Glycyrrhiza glabra) in moderately ill patients with COVID-19: a randomized controlled trial

Licorice extract (glycyrrhizin), a potent antiviral, anti-inflammatory, and antioxidant remedy, is a potential therapeutic option for COVID-19. We evaluated the efficacy and safety of licorice in patients with moderate COVID-19. In this study, 60 patients with confirmed COVID-19 were randomly assigned in a 1:1 ratio to receive licorice (at a dose of 760 mg three times a day for seven days) or control groups. The primary outcomes were SPO2, body temperature, and respiratory rate (RR) after the end of the intervention. The findings indicated that SPO2, body temperature, and RR had no significant difference between the groups at the end of the intervention. However, CRP and ALT improved in the licorice group toward the baseline. The number of patients with worse prognoses, LOS, mortality, and the incidence of adverse events were not different between the groups at the end of the study. Licorice had no beneficial effect on the clinical symptoms of COVID-19. Moreover, this intervention demonstrated a safe profile of adverse events. The confirmation of the results of this preparatory trial requires more detailed multiple-center trials with a larger sample size.

First-Onset Psychosis After COVID-19 Infection: A Systematic Review of the Literature

BACKGROUND

The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP).

OBJECTIVE

The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP.

METHODS

A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria.

RESULTS

Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms.

CONCLUSIONS

This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly.

Dean Y, Kishk RM, Elsaid NMAB, Salem A, Shah J, Aiash H, Eida M. Assessment of post-traumatic stress disorder and health-related quality of life among patients recovered from mild-to-moderate COVID-19 and their close contacts: A cross-sectional study

The pandemic of COVID-19 is a traumatic event with distressing implications for mental health and several aspects of life. This study aimed to assess Post-traumatic Stress Disorder (PTSD) and Health-Related Quality of Life (HRQoL) among patients who experienced mild-to-moderate COVID-19 and their household contacts. This cross-sectional descriptive study was conducted between May 2020 and November 2020, in Ismailia and Suez governorates. A convenient sampling method was used. The sample size was calculated according to the prevalence of PTSD in COVID-19 patients to be 200 adult participants from both sexes, 100 patients with history of recent COVID-19 infection (up to 2 months after recovery) and their close family. COVID-19 was confirmed by a nasal swab sample tested by PCR in addition to suggestive symptoms and/or positive computed tomography lung findings. Data was collected by using the Arabic version of the Post-Traumatic Stress disorder checklist 5 (PCL5-PTSD) and the Arabic version of Health-Related Quality of Life (HRQoL). The questionnaire was collected through interviews at the Endemic and Infectious diseases and Family medicine outpatient clinics. Of the 200 studied participants, evidence of PTSD was found in 112 (56%) participants; all COVID-19 cases and 12 of their close-contact relatives. Impaired HRQoL was evident in 107 (53.5%) participants; all the COVID-19 cases and 7 contacts. The mean values total scores of the PTSD and HRQoL and its domains were significantly higher among cases compared to their contacts. The most frequently impaired domain was social (55%), psychological (54.5%), impairment (53.5%) followed by physical (48.5%) and the least was health perception (33.5%). The mean values of PTSD, HRQoL and their domains were significantly higher among participants who recalled respiratory symptoms and who had comorbid illness. The odds ratio of PTSD and HRQoL was 0.27 (95% CI: 0.2-0.36) and 0.3 (95% CI: 0.23-0.39) in participants who had more than a case of COVID-19 within their families. All the studied COVID-19 participants showed PTSD and impaired HRQoL, compared to 12% and 7% of their contacts, respectively. Past COVID-19 was associated with impairment of all domains of HRQoL and the most affected were the physical, psychological and impairment domains.

Frailty after COVID-19: The wave after?

The COVID-19 pandemic poses an ongoing public health challenge, with a focus on older adults. Given the large number of older persons who have recovered from COVID-19 and reports of long-lasting sequelae, there is reasonable concern that the COVID-19 pandemic may lead to a long-term deterioration in the health of older adults, i.e., a potential "wave of frailty." Therefore, it is critical to better understand the circumstances surrounding the development of frailty as a result of COVID-19, as well as the underlying mechanisms and factors contributing to this development. We conducted a narrative review of the most relevant articles published on the association between COVID-19 and frailty through January 2023. Although few studies to date have addressed the effects of COVID-19 on the onset and progression of frailty, the available data suggest that there is indeed an increase in frailty in the elderly as a result of COVID-19. Regarding the underlying mechanisms, a multicausal genesis can be assumed, involving both direct viral effects and indirect effects, particularly from the imposed lockdowns with devastating consequences for the elderly: decreased physical activity, altered diet, sarcopenia, fatigue, social isolation, neurological problems, inflammation, and cardiovascular morbidity are among the possible mediators. Since the COVID-19 pandemic is leading to an increase in frailty in the elderly, there is an urgent need to raise awareness of this still little-known problem of potentially great public health importance and to find appropriate prevention and treatment measures.

Neurological manifestations associated with SARS-CoV-2 infection: an updated review

SARS-CoV-2 is a single-stranded RNA virus that belongs to the group of seven coronaviruses that affect humans, and its infection causes the COVID-19 disease. The association between the COVID-19 condition and risk factors of neurological manifestations is unclear to date. This review aims to update the main neurological manifestations associated with SARS-CoV-2 disease. First, we present the hypothesis of the neuroinvasion mechanisms of SARS-CoV-2. Then, we discuss the possible symptoms related to patients with COVID-19 infection in the central and peripheral nervous systems, followed by the perspectives of diagnosis and treatment of possible neurological manifesta-tions. The hypothesis of the neuroinvasion mechanism includes direct routes, as the virus crosses the blood-brain barrier or the ACE2 receptor pathway role, and indirect pathways, such as malfunctions of the immune system and vascular system dysregulation. Various studies report COVID-19 consequences, such as neuroanatomic alterations and cognitive impairment, besides peripheral condi-tions, such as anosmia, ageusia, and Guillain Barré Syndrome. However, the het-erogeneity of the studies about neurologic damage in patients after COVID-19 infection precludes any generalization of current findings. Finally, new studies are necessary to understand the adequate diagnosis, therapeutic method of early treatment, and risk group of patients for neurological manifestations of COVID-19 post-infection.

Therapeutic Potential of the Purinergic System in Major Depressive Disorder Associated with COVID-19

Neuroinflammation is closely related to the development of depression, since the latter is caused, among other factors, by inflammatory processes, mainly related to the activation of microglia and expression of specific genes, which occurs during the neuroinflammatory process. Thus, COVID-19 is an important risk factor for the development of depression, since in addition to generating the feeling of stress, which also increases the activity of the immune system, it is also the cause of pathological processes and physiological ones that lead to the development of neuroinflammation, microglial activation, gene expression dysfunction and decreased concentration of available serotonin. That said, drugs are being used to combat COVID-19 to reduce the oxidative stress presented in the disease. Thus, tramadol and fluoxetine are highlighted as drugs used, however, although they present some positive results, such as the reduction of pro-inflammatory cytokines, they are also associated with negative effects such as dependence, pulmonary, cardiac and brain impairment. From this, the purinergic system is highlighted in the literature as a possible therapeutic target. This is because its mechanisms are related to the regulation of microglia, astrocytes and the physiology of important neurotransmitters and hormones. Added to this, there is a modulation of inflammatory activity, especially with regard to the P2X7 receptors of this system. The latter is an important target for the treatment of depression and COVID-19, since positive results were obtained through the genetic exclusion of this receptor and the use of selective antagonists.

Adherence to dietary approaches to stop hypertension (DASH) diet in relation to psychological function in recovered COVID-19 patients: a case–control study

Background

Follow-up of patients after recovery from coronavirus disease 2019 (COVID-19) and identifying the adverse effects of the disease in other organs is necessary. Psychiatric symptoms can persist after patients recover from the infection.

Aim

We aimed to examine the adherence to the dietary approach to stop hypertension (DASH) diet in relation to psychological function in individuals who have recovered from COVID-19.

Method

This case–control study was conducted on 246 eligible adults (123 cases and 123 controls). A valid and reliable food frequency questionnaire (FFQ) was used to determine dietary intake. Depression, anxiety and stress, insomnia, sleep quality, and quality of life of participants were evaluated using DASS, Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and SF-36 questionnaires, respectively.

Results

There was a significant inverse correlation between total depression score with vegetables, depression, anxiety, and stress score and dietary intake of nuts, legumes, and whole grains (p < 0.05). There was a significant positive correlation between stress scores and the intake of red and processed meat (P < 0.05). In multivariate-adjusted regression model, a significant association was found between adherence to DASH diet and depression and stress only in case group (OR = 0.7863, 95% CI 0.746–0.997, p = 0.046 and OR = 0.876, 95% CI 0.771–0.995, p = 0.042, respectively).

Conclusion

Adherence to a DASH diet might be associated with depression and stress reduction in recovered COVID-19 patients.

N-3 polyunsaturated fatty acids block the trimethylamine-N-oxide- ACE2- TMPRSS2 cascade to inhibit the infection of human endothelial progenitor cells by SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) is a novel coronavirus that infects many types of cells and causes cytokine storms, excessive inflammation, acute respiratory distress to induce failure of respiratory system and other critical organs. In this study, our results showed that trimethylamine-N-oxide (TMAO), a metabolite generated by gut microbiota, acts as a regulatory mediator to enhance the inerleukin-6 (IL-6) cytokine production and the infection of human endothelial progenitor cells (hEPCs) by SARS-CoV-2. Treatment of N-3 polyunsaturated fatty acids (PUFAs) such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) could effectively block the entry of SARS-CoV-2 in hEPCs. The anti-infection effects of N-3 PUFAs were associated with the inactivation of NF-κB signaling pathway, a decreased expression of the entry receptor angiotensin-converting enzyme 2 (ACE2) and downstream transmembrane serine protease 2 in hEPCs upon the stimulation of TMAO. Treatment of DHA and EPA further effectively inhibited TMAO-mediated expression of IL-6 protein, probably through an inactivation of MAPK/p38/JNK signaling cascades and a downregulation of microRNA (miR)-221 in hEPCs. In conclusion, N-3 PUFAs such as DHA and EPA could effectively act as preventive agents to block the infection of SARS-CoV-2 and IL-6 cytokine production in hEPCs upon the stimulation of TMAO.

Neuro-Immune Interactions in Severe COVID-19 Infection

SARS-CoV-2 is a new coronavirus that has affected the world since 2019. Interstitial pneumonia is the most common clinical presentation, but additional symptoms have been reported, including neurological manifestations. Severe forms of infection, especially in elderly patients, present as an excessive inflammatory response called "cytokine storm", which can lead to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Little is known about the relationship between symptoms and clinical outcomes or the characteristics of virus-host interactions. The aim of this narrative review is to highlight possible links between neurological involvement and respiratory damage mediated by pathological inflammatory pathways in SARS-CoV-2 infection. We will focus on neuro-immune interactions and age-related immunity decline and discuss some pathological mechanisms that contribute to negative outcomes in COVID-19 patients. Furthermore, we will describe available therapeutic strategies and their effects on COVID-19 neurological symptoms.

Nursing Management Of The Patient Developing Quadriplegia Due To Neurological Involvement After Covid-19: A Case Report

COVID-19 first emerged in China, spread quickly, and was declared a pandemic by the World Health Organization. Neurological complications have led to important symptoms in patients diagnosed with COVID-19. These symptoms have substantially affected patients' quality of life, caused them to depend on others, and prolonged their recovery processes with anxiety and hopelessness. In this case report, the care process applied to an individual who developed quadriplegia due to neurological involvement after COVID-19, according to the "Nursing Model Based on Activities of Living", is shared. With effective evidence-based nursing care, the patient's quality of life was improved, existing problems were alleviated, and the patient was protected against complications.

Pharmacological Potential of Flavonoids against Neurotropic Viruses

Flavonoids are a group of natural compounds that have been described in the literature as having anti-inflammatory, antioxidant, and neuroprotective compounds. Although they are considered versatile molecules, little has been discussed about their antiviral activities for neurotropic viruses. Hence, the present study aimed to investigate the pharmacological potential of flavonoids in the face of viruses that can affect the central nervous system (CNS). We carried out research from 2011 to 2021 using the Pubmed platform. The following were excluded: articles not in the English language, letters to editors, review articles and papers that did not include any experimental or clinical tests, and papers that showed antiviral activities against viruses that do not infect human beings. The inclusion criteria were in silico predictions and preclinical pharmacological studies, in vitro, in vivo and ex vivo, and clinical studies with flavonoids, flavonoid fractions and extracts that were active against neurotropic viruses. The search resulted in 205 articles that were sorted per virus type and discussed, considering the most cited antiviral activities. Our investigation shows the latest relevant data about flavonoids that have presented a wide range of actions against viruses that affect the CNS, mainly influenza, hepatitis C and others, such as the coronavirus, enterovirus, and arbovirus. Considering that these molecules present well-known anti-inflammatory and neuroprotective activities, using flavonoids that have demonstrated both neuroprotective and antiviral effects could be viewed as an alternative for therapy in the course of CNS infections.

Blood-brain Barrier Damage is Pivotal for SARS-CoV-2 Infection to the Central Nervous System

Transsynaptic transport is the most accepted proposal to explain the SARS-CoV-2 infection of the CNS. Nevertheless, emerging evidence shows that neurons do not express the SARS-CoV-2 receptor ACE2, which highlights the importance of the blood-brain barrier (BBB) in preventing virus entry to the brain. In this study, we examine the presence of SARS-CoV-2 messenger ribonucleic acid (mRNA) and the cytokine profile in cerebrospinal fluids (CSF) from two patients with a brain tumor and COVID-19. To determine the BBB damage, we evaluate the Q- albumin index, which is an indirect parameter to assess the permeability of this structure. The Q-albumin index of the patient with an intraventricular brain tumor suggests that the BBB is undamaged, preventing the passage of SARS-CoV-2 and pro-inflammatory molecules. The development of brain tumors that disrupt the BBB (measured by the Q-albumin index), in this case, a petroclival meningioma (Case 1), allows the free passage of the SARS-CoV-2 virus and probably lets the free transit of pro-inflammatory molecules to the CNS, which leads to a possible activation of the microglia (astrogliosis) and an exacerbated immune response represented by IL-13, IFN-γ, and IL-2 trying to inhibit both the infection and the carcinogenic process.

Cerebral microvascular complications associated with SARS-CoV-2 infection: How did it occur and how should it be treated?

Cerebral microvascular disease has been reported as a central feature of the neurological disorders in patients with SARS-CoV-2 infection that may be associated with an increased risk of ischemic stroke. The main pathomechanism in the development of cerebrovascular injury due to SARS-CoV-2 infection can be a consequence of endothelial cell dysfunction as a structural part of the blood-brain barrier (BBB), which may be accompanied by increased inflammatory response and thrombocytopenia along with blood coagulation disorders. In this review, we described the properties of the BBB, the neurotropism behavior of SARS-CoV-2, and the possible mechanisms of damage to the CNS microvascular upon SARS-CoV-2 infection.

Neurological long-COVID in the outpatient clinic: Two subtypes, two courses

INTRODUCTION

Symptoms referable to central and peripheral nervous system involvement are often evident both during the acute phase of COVID-19 infection and during long-COVID. In this study, we evaluated a population of patients with prior COVID-19 infection who showed signs and symptoms consistent with neurological long-COVID.

METHODS

We prospectively collected demographic and acute phase course data from patients with prior COVID-19 infection who showed symptoms related to neurological involvement in the long-COVID phase. Firstly, we performed a multivariate logistic linear regression analysis to investigate the impact of demographic and clinical data, the severity of the acute COVID-19 infection and hospitalization course, on the post-COVID neurological symptoms at three months follow-up. Secondly, we performed an unsupervised clustering analysis to investigate whether there was evidence of different subtypes of neurological long COVID-19.

RESULTS

One hundred and nine patients referred to the neurological post-COVID outpatient clinic. Clustering analysis on the most common neurological symptoms returned two well-separated and well-balanced clusters: long-COVID type 1 contains the subjects with memory disturbances, psychological impairment, headache, anosmia and ageusia, while long-COVID type 2 contains all the subjects with reported symptoms related to PNS involvement. The analysis of potential risk-factors among the demographic, clinical presentation, COVID 19 severity and hospitalization course variables showed that the number of comorbidities at onset, the BMI, the number of COVID-19 symptoms, the number of non-neurological complications and a more severe course of the acute infection were all, on average, higher for the cluster of subjects with reported symptoms related to PNS involvement.

CONCLUSION

We analyzed the characteristics of neurological long-COVID and presented a method to identify well-defined patient groups with distinct symptoms and risk factors. The proposed method could potentially enable treatment deployment by identifying the optimal interventions and services for well-defined patient groups, so alleviating long-COVID and easing recovery.

SARS-CoV-2 impairs the disassembly of stress granules and promotes ALS-associated amyloid aggregation

The nucleocapsid (N) protein of SARS-CoV-2 has been reported to have a high ability of liquid-liquid phase separation, which enables its incorporation into stress granules (SGs) of host cells. However, whether SG invasion by N protein occurs in the scenario of SARS-CoV-2 infection is unknow, neither do we know its consequence. Here, we used SARS-CoV-2 to infect mammalian cells and observed the incorporation of N protein into SGs, which resulted in markedly impaired self-disassembly but stimulated cell cellular clearance of SGs. NMR experiments further showed that N protein binds to the SG-related amyloid proteins via non-specific transient interactions, which not only expedites the phase transition of these proteins to aberrant amyloid aggregation in vitro, but also promotes the aggregation of FUS with ALS-associated P525L mutation in cells. In addition, we found that ACE2 is not necessary for the infection of SARS-CoV-2 to mammalian cells. Our work indicates that SARS-CoV-2 infection can impair the disassembly of host SGs and promote the aggregation of SG-related amyloid proteins, which may lead to an increased risk of neurodegeneration.

Antidepressant Drugs and COVID-19: A Review of Basic and Clinical Evidence

The COVID-19 pandemic has encouraged the repurposing of existing drugs as a shorter development strategy in order to support clinicians with this difficult therapeutic dilemma. There is evidence to support the theory that some antidepressants can reduce concentrations of different cytokines in humans and animals and, recently, the antiviral activity of some antidepressants against SARS-CoV-2 has been reported. The aims of this narrative review are to evaluate the possible role of antidepressants in the treatment of COVID-19 infection and the possible benefits and risks of patients taking antidepressants for mental disorders and COVID-19 infection. A review was performed to analyse the current literature to identify the role of antidepressant medication in the treatment of COVID-19 patients. The electronic search was completed in MEDLINE and MedRxiv/BioRxiv for published literature and in ClinicalTrials.gov for ongoing clinical trials. The results show some evidence from preclinical data and observational studies about the possible efficacy of some specific antidepressants for treating COVID-19 infection. In addition, two published phase II studies testing fluvoxamine showed positive results for clinical deterioration and hospitalization rate versus a placebo. Seven ongoing clinical trials testing fluvoxamine, fluoxetine, and tramadol (as per its anti-inflammatory and antidepressant effect) are still in the early phases. Although the available evidence is limited, the sum of the antiviral and anti-inflammatory preclinical studies and the results from several observational studies and two phase II clinical trials provide the basis for ongoing clinical trials evaluating the possible use of antidepressants for COVID-19 infection in humans. Further investigations will be needed to support the possible use of antidepressants for this application.

Peripapillary Nerve Fiber Layer Thickness and Optic Nerve Head Parameters in Patients Recovered from COVID-19: A Longitudinal Study

Purpose

To quantify the longitudinal changes of the optic nerve head (ONH) parameters and peripapillary retinal nerve fiber layer (pRNFL) thickness in patients recovered from coronavirus disease 2019 (COVID-19) using spectral-domain optical coherence tomography (OCT) analysis.

Materials and Methods

In an observational longitudinal study, in patients recovered from COVID-19, ONH OCT images were recorded at least two weeks after recovery from the systemic disease as the baseline and after one and three-month follow-up. Ganglion cell complex (GCC) analysis, ONH parameters, and pRNFL thickness changes were measured.

Results

A total of 36 eyes from 18 recovered COVID-19 patients including eleven (61.2%) females were studied. The average age was 35.5 ± 7.5 years. The pRNFL thickness in the nasal lower sector significantly decreased from 77 ± 18 μm in the first post-COVID-19 month to 74 ± 10 μm in the third month (P=0.8). The average, superior, and inferior pRNFL thickness remained unchanged. The average cup volume significantly decreased from 0.27 ± 0.15 mm³ at baseline to 0.19 ± 0.15 mm³ in the third post-COVID-19 visit (P=0.028). In terms of ONH morphologies including rim, disc and cup to disc area, and the vertical and horizontal ratio, the changes were not significant over the 3-month study period. Focal loss volume and global loss volume values were not changed significantly.

Conclusion

Localized defect in the nasal lower sector of pRNFL is observed in 3-month post-recovery from COVID-19. Larger studies with longer follow-ups are required to reveal the exact changes in ONH parameters.

Patterns of self-reported recovery from chemosensory dysfunction following SARS-CoV-2 infection: insights after 1 year of the pandemic

BACKGROUND

The coronavirus disease (COVID-19), due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), causes chemosensory dysfunction.

AIMS/OBJECTIVES

To determine the characteristics of chemosensory dysfunction and to identify factors associated with chemosensory complete recovery and time to recovery.

MATERIALS AND METHODS

This cross-sectional study included all patients presenting with chemosensory dysfunction and confirmed SARS-CoV-2 infection from May to August 2020 who underwent telemedicine follow-up after 1 year to assess their chemosensory recovery.

RESULTS

A total of 372 patients were included, of which 53.8% were male. The mean age ± SD was 37.45 ± 13.44. The majority experienced combined (olfactory and gustatory) dysfunction (85.7%), and 315 patients (84.7%) had complete loss of chemosensory function. The independent predictors associated with a low likelihood of complete recovery were parosmia (aOR 0.16, p < .001), upper respiratory tract symptoms (aOR 0.28, p = .001), and dyspnoea (aOR 0.21, p < .001), whereas the factors associated with a long recovery period were parosmia (aOR 12.04, p = .002), headache (aOR 7.19, p = .007), and hypertension (aOR 7.76, p = .039).

CONCLUSIONS

A full recovery outcome was predominant. The presence of parosmia was linked to both an incomplete recovery and a long time to recovery.

SIGNIFICANCE

Parosmia and respiratory symptoms are implicated in the incomplete recuperation of chemosensory function.

Evidence of Microglial Immune Response Following Coronavirus PHEV Infection of CNS

Porcine hemagglutinating encephalomyelitis virus (PHEV) is a highly neurotropic coronavirus that invades the host central nervous system (CNS) and causes neurological dysfunction. Microglia are key immune cells in the CNS, however, whether and how they response to PHEV infection remains unclear. Herein, microglial activation and proliferation were detected in the CNS of PHEV-infected mice, as along with the proinflammatory response. Moreover, the production of proinflammatory cytokines induced by moderately activated microglia limited viral replication in the early stage of infection. Microglial depletion assays showed that during late infection, excess activation of microglia aggravated neurological symptoms, BBB destruction, and peripheral monocyte/macrophage infiltration into the CNS. Using an in vitro brain slice model, PHEV was identified to specifically and moderately induce microglial activation in the absence of peripheral immune cells infiltration. Consistently, macrophage clearance from circulating blood indicated that peripheral monocytes/macrophages crossing the BBB of mice were responsible for excess activation of microglia and CNS damage in late PHEV infection. Overall, our findings provide evidence supporting a dual role for microglia in the host CNS in response to coronavirus PHEV invasion.

Midwives' Knowledge and Preparedness in Providing Maternity Care During COVID-19 Pandemic in Dodoma Region, Tanzania: A Cross-Sectional Study

Background

COVID-19 pandemic has a high impact on the health of pregnant women and healthcare providers worldwide.

Objective

This study aims to assess midwives' knowledge and preparedness in providing maternity care during COVID-19 pandemic.

Methods

A cross-sectional analytical hospital-based study that included 116 midwives, who were working in labor ward, was conducted in the Dodoma region of Tanzania from March to June 2021. The Chi-square test and Fisher's exact test were used to assess the association between the categorical variables. The predictors of midwives' knowledge and preparedness were determined using binary logistic regression analysis. Statistical analysis was performed using SPSS version 23.0; p < .05 was considered to be significant.

Results

Of the midwives studied, 63 (54.3%) had adequate knowledge about COVID-19 and only 30 (25.9%) were adequately prepared on provision of maternal care. Having diploma/bachelor level of education (AOR  =  2.62, 95%CI  =  1.08-6.36, p  =  .033), being trained on COVID-19 (AOR  =  3.65, 95%CI  =  1.11-12.00, p  =  .033) and working in urban health facilities (AOR = 3.65, 95%CI  =  1.17-13.98, p  =  .002) were the significant determinants of midwives' knowledge on COVID-19. Working at a health center (AOR  =  0.19, 95%CI  =  0.03-1.32. p  =  .033), being trained on COVID-19 (AOR  =  0.04, 95%CI  =  0.01-0.14, p  =  .000 and having adequate knowledge on COVID-19 (AOR  =  0.20, 95%CI  =  0.03-1.32, p  =  .032) were determinants of midwives' preparedness on provision of maternal care.

Conclusion

Knowledge and preparedness in the provision of maternity care during the COVID-19 pandemic were low. Emphasis should be put on training midwives on IPC when providing maternity care. This may help in preventing the spread of infectious diseases including COVID-19 as we observed in the present study.

Effects of β-Blockers on the Sympathetic and Cytokines Storms in Covid-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a causative virus in the development of coronavirus disease 2019 (Covid-19) pandemic. Respiratory manifestations of SARS-CoV-2 infection such as acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) leads to hypoxia, oxidative stress, and sympatho-activation and in severe cases leads to sympathetic storm (SS). On the other hand, an exaggerated immune response to the SARS-CoV-2 invasion may lead to uncontrolled release of pro-inflammatory cytokine development of cytokine storm (CS). In Covid-19, there are interactive interactions between CS and SS in the development of multi-organ failure (MOF). Interestingly, cutting the bridge between CS and SS by anti-inflammatory and anti-adrenergic agents may mitigate complications that are induced by SARS-CoV-2 infection in severely affected Covid-19 patients. The potential mechanisms of SS in Covid-19 are through different pathways such as hypoxia, which activate the central sympathetic center through carotid bodies chemosensory input and induced pro-inflammatory cytokines, which cross the blood-brain barrier and activation of the sympathetic center. β2-receptors signaling pathway play a crucial role in the production of pro-inflammatory cytokines, macrophage activation, and B-cells for the production of antibodies with inflammation exacerbation. β-blockers have anti-inflammatory effects through reduction release of pro-inflammatory cytokines with inhibition of NF-κB. In conclusion, β-blockers interrupt this interaction through inhibition of several mediators of CS and SS with prevention development of neural-cytokine loop in SARS-CoV-2 infection. Evidence from this study triggers an idea for future prospective studies to confirm the potential role of β-blockers in the management of Covid-19.

Neurological complications and infection mechanism of SARS-COV-2

Currently, SARS-CoV-2 has caused a global pandemic and threatened many lives. Although SARS-CoV-2 mainly causes respiratory diseases, growing data indicate that SARS-CoV-2 can also invade the central nervous system (CNS) and peripheral nervous system (PNS) causing multiple neurological diseases, such as encephalitis, encephalopathy, Guillain-Barré syndrome, meningitis, and skeletal muscular symptoms. Despite the increasing incidences of clinical neurological complications of SARS-CoV-2, the precise neuroinvasion mechanisms of SARS-CoV-2 have not been fully established. In this review, we primarily describe the clinical neurological complications associated with SARS-CoV-2 and discuss the potential mechanisms through which SARS-CoV-2 invades the brain based on the current evidence. Finally, we summarize the experimental models were used to study SARS-CoV-2 neuroinvasion. These data form the basis for studies on the significance of SARS-CoV-2 infection in the brain.

How COVID-19 can cause autonomic dysfunctions and postural orthostatic syndrome? A Review of mechanisms and evidence

Coronavirus disease 2019 (COVID-19) is a viral disease spread by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Because the recent pandemic has resulted in significant morbidity and mortality, understanding various aspects of this disease has become critical. SARS-CoV-2 can affect a variety of organs and systems in the body. The autonomic nervous system plays an important role in regulating body functions, and its dysfunction can cause a great deal of discomfort for patients. In this study, we focused on the effect of COVID-19 on the autonomic system and syndromes associated with it, such as postural orthostatic syndrome (POTS).

The myocardial and neuronal infectivity of SARS-CoV-2 and detrimental outcomes

The epidemiological outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), alias COVID-19, began in Wuhan, Hubei, China, in late December and eventually turned into a pandemic that has led to over 3.71 million deaths and over 173 million infected cases worldwide. In addition to respiratory manifestations, COVID-19 patients with neurological and myocardial dysfunctions exhibit a higher risk of in-hospital mortality. The immune function tends to be affected by cardiovascular risk factors and is thus indirectly related to the prognosis of COVID-19 patients. Many neurological symptoms and manifestations have been reported in COVID-19 patients; however, detailed descriptions on the prevalence and characteristic features of these symptoms are restricted due to insufficient data. It is thus advisable for clinicians to be vigilant for both cardiovascular and neurological manifestations to detect them at an early stage to avoid inappropriate management of COVID-19 and to address the manifestations adequately. Patients with severe COVID-19 are notably more susceptible to developing cardiovascular and neurological complications than non-severe COVID-19 patients. This review focuses on the consequential outcomes of COVID-19 on cardiovascular and neuronal functions, including other influencing factors.

Aeromedical Implications of Long-Term COVID-19 Sequelae

BACKGROUND: While many COVID-19 studies focus on acute effects of the infection, few examine the intermediate and long-term sequelae of the illness. Studies have shown that a good portion of patients have chronic effects in several body systems for several months or longer. Such effects can potentially adversely impact pilot performance in flight. We sought to determine the long-term effects of COVID-19 infection, how such effects can affect pilot performance, and how to best evaluate pilots for aeromedical flight clearance.METHODS: We used the PubMed literature search engine to review peer-reviewed articles that focused on the intermediate and long-term effects of COVID-19 infection. Chronic signs and symptoms were subdivided based on the particular body organ system affected. Merging information obtained from case reviews, article reviews, and aeromedical standards, we created a risk stratification guide to assist with the aeromedical disposition of affected pilots.RESULTS: Long-term effects of COVID-19 infection can last for several months or longer. The most common effects are fatigue, weakness, pulmonary diffusion defects, depression, and anxiety.DISCUSSION: This review article focuses on the most common intermediate- and long-term COVID-19 conditions of aeromedical significance and the corresponding course of actions recommended for the aeromedical examiner. Aeromedical evaluation should take into consideration factors related to the pilot, aircraft type, and specific aviation environment. Such evaluation may include diagnostic testing, medical specialist consultation, preflight simulation in an altitude chamber, human centrifuge testing, and/or a flight simulator checkride.Ko SY, Nguyen NK, Lee CL, Lee LA, Nguyen KUT, Lee EC. Aeromedical implications of long-term COVID-19 sequelae. Aerosp Med Hum Perform. 2021; 92(11):898-907.

A review of ischemic stroke in COVID-19: currently known pathophysiological mechanisms

Coronavirus disease 2019 (COVID-19), the third type of coronavirus pneumonia after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), is spreading widely worldwide now. This pneumonia causes not only respiratory symptoms but also multiple organ dysfunction, including thrombotic diseases such as ischemic stroke. The purpose of this review is to explore whether COVID-19 is a risk factor for ischemic stroke and its related pathophysiological mechanisms. Based on the high thrombosis rate and frequent strokes of COVID-19 patients, combined with related laboratory indicators and pathological results, the discussion is mainly from two aspects: nerve invasion and endothelial dysfunction. SARS-CoV-2 can directly invade the CNS through blood-borne and neuronal retrograde pathways, causing cerebrovascular diseases. In addition, the endothelial dysfunction in COVID-19 is almost certain. Cytokine storm causes thromboinflammation, and downregulation of ACE2 leads to RAS imbalance, which eventually lead to ischemic stroke.

Infection of Human Cells by SARS-CoV-2 and Molecular Overview of Gastrointestinal, Neurological, and Hepatic Problems in COVID-19 Patients

The gastrointestinal tract is the body's largest interface between the host and the external environment. People infected with SARS-CoV-2 are at higher risk of microbiome alterations and severe diseases. Recent evidence has suggested that the pathophysiological and molecular mechanisms associated with gastrointestinal complicity in SARS-CoV-2 infection could be explained by the role of angiotensin-converting enzyme-2 (ACE2) cell receptors. These receptors are overexpressed in the gut lining, leading to a high intestinal permeability to foreign pathogens. It is believed that SARS-CoV-2 has a lesser likelihood of causing liver infection because of the diminished expression of ACE2 in liver cells. Interestingly, an interconnection between the lungs, brain, and gastrointestinal tract during severe COVID-19 has been mentioned. We hope that this review on the molecular mechanisms related to the gastrointestinal disorders as well as neurological and hepatic manifestations experienced by COVID-19 patients will help scientists to find a convenient solution for this and other pandemic events.

A comprehensive review of COVID-19 biology, diagnostics, therapeutics, and disease impacting the central nervous system

The ongoing COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly transmissible disease. SARS-CoV-2 is estimated to have infected over 153 million people and to have caused over 3.2 million global deaths since its emergence in December 2019. SARS-CoV-2 is the seventh coronavirus known to infect humans, and like other coronaviruses, SARS-CoV-2 infection is characterized by a variety of symptoms including general flu-like symptoms such as a fever, sore throat, fatigue, and shortness of breath. Severe cases often display signs of pneumonia, lymphopenia, acute kidney injury, cardiac injury, cytokine storms, lung damage, acute respiratory distress syndrome (ARDS), multiple organ failure, sepsis, and death. There is evidence that around 30% of COVID-19 cases have central nervous system (CNS) or peripheral nervous system (PNS) symptoms along with or in the absence of the previously mentioned symptoms. In cases of CNS/PNS impairments, patients display dizziness, ataxia, seizure, nerve pain, and loss of taste and/or smell. This review highlights the neurological implications of SARS-CoV-2 and provides a comprehensive summary of the research done on SARS-CoV-2 pathology, diagnosis, therapeutics, and vaccines up to May 5.

Is there a common pathophysiological mechanism between COVID-19 and depression?

COVID-19 is a disease caused by SARS-CoV-2 and was initially considered to cause serious damage to the respiratory system. Over time, it has been found to affect other organs due to its ability to bind to the ACE2 receptor (type 2 angiotensin-converting enzyme), which can be found in various tissues, including the central nervous system. In addition, a large formation of pro-inflammatory cytokines responsible for various lesions was observed during the evolution of this disease. Our objective was to demonstrate the molecular mechanisms involved in the infection that may demonstrate the relationship between COVID-19 and the development of depressive conditions. Based on the main medical databases (LiLacs, SciELO, Bireme, Scopus, EBSCO, and PubMed) and using the terms 'coronavirus infections' AND 'Inflammation' AND 'depression' AND 'cytokines', we conducted an integrative review of articles published in 2020. Considering this stage of Covid-19 and the inflammatory component of depression, this review showed a relationship between these two conditions based on common pathophysiological mechanisms indicating possible depressive disorders in surviving patients, especially in the most severe cases. The role of inflammatory cytokines and the presence of ACE-2 receptors on the cell surface appear to be the common pathophysiological mechanism between COVID-19 and depression.

Acute necrotic hemorrhagic leukoencephalitis related to COVID-19: a report of 2 cases

Acute necrotic hemorrhagic leukoencephalitis (ANHLE) is a subform of acute disseminating leukoencephalitis which is a post viral or vaccination uncommon disease with poor prognosis. Radiological findings include multiple or diffuse lesions involving the white matter and sparing the cortex with or without rim enhancement. In addition to areas of hemorrhages with possible involvement of basal ganglia and thalami. We describe the imaging findings for 2 cases of ANHLE; a 59-years-old male and a 47-years-old female. Both of them were tested positive of SARS-COVID2 with presentation of consciousness loss and respiratory failure. CT and MRI brain show global white matter changes associated with acute hemorrhagic necrosis, although uncommon, are compatible with postviral acute necrotic hemorrhagic leukoencephalitis with end point of death for the first patient and coma for the second patient.

A wide spectrum of neurological manifestations in pediatrics patients with the COVID-19 infection: a case series

Neurological symptoms in COVID-19 patients can also be found in the pediatric population, but they are usually described as mild symptoms. Herein, we described a case series of four pediatric patients with severe and highly heterogeneous central and peripheral nervous system manifestations. The objective was to report neurological manifestations of COVID-19 in children and adolescents. The design is case series. The participants are four children and adolescents with confirmed COVID-19. The main outcome and measures are as follows: Clinical data were gathered from electronic medical records, and data of all neurologic symptoms were checked by a trained neurologist. We reported four pediatric patients with COVID-19 and different neurologic symptoms. Case 1 was a 16-year-old girl with a sensory and motor polyradiculopathy with RT-qPCR for COVID-19 and dengue both detected in CSF that improved after appropriate treatment. Case 2 was a 15-year-old boy with Guillain-Barre syndrome and had good response after using human immunoglobulin. Case 3 was a 5-year-old girl with acute intracranial hypertension that improved after going through lumbar puncture and using acetazolamide. Case 4 was a 2-month-old male infant with focal epileptic seizures that recovered after antiepileptic treatment. We highlight the need to consider different neurologic manifestations as part of the COVID-19 clinical spectrum.

Cellular and Molecular Effects of SARS-CoV-2 Linking Lung Infection to the Brain

In December 2019, a new viral disease emerged and quickly spread all around the world. In March 2020, the COVID-19 outbreak was classified as a global pandemic and by June 2021, the number of infected people grew to over 170 million. Along with the patients' mild-to-severe respiratory symptoms, reports on probable central nervous system (CNS) effects appeared shortly, raising concerns about the possible long-term detrimental effects on human cognition. It remains unresolved whether the neurological symptoms are caused directly by the SARS-CoV-2 infiltration in the brain, indirectly by secondary immune effects of a cytokine storm and antibody overproduction, or as a consequence of systemic hypoxia-mediated microglia activation. In severe COVID-19 cases with impaired lung capacity, hypoxia is an anticipated subsidiary event that can cause progressive and irreversible damage to neurons. To resolve this problem, intensive research is currently ongoing, which seeks to evaluate the SARS-CoV-2 virus' neuroinvasive potential and the examination of the antibody and autoantibody generation upon infection, as well as the effects of prolonged systemic hypoxia on the CNS. In this review, we summarize the current research on the possible interplay of the SARS-CoV-2 effects on the lung, especially on alveolar macrophages and direct and indirect effects on the brain, with special emphasis on microglia, as a possible culprit of neurological manifestation during COVID-19.

Fetal Brain Injury Models of Fetal Alcohol Syndrome: Examination of Neuronal Morphologic Condition Using Sholl Assay

The lack of a convenient in vitro human neuronal model to study alcohol-induced neurodegenerative diseases, such as fetal alcohol syndrome (FAS), prompted us to develop human neuronal culture and in vitro human FAS model by incubating cells with physiologically relevant EtOH concentration (50 mM). Here, we describe the detailed method of isolation of human neuronal culture, and ability to analyze neurites extension using Sholl assay. We utilized highly efficient transfection method of neuronal cells to study morphology of neurons with or without EtOH treatment.

A Case Report of Late-Onset Neonatal Meningitis Caused by SARS-CoV-2

Introduction: Central nervous system involvement by SARS-CoV-19 appears to be very rare in neonates. We report a case of viral meningitis in a neonate admitted to Kerman Afzalipour Hospital in Southeastern Iran. Case Presentation: The patient was a 15-day-old neonate who presented with lethargy, fever, and poor feeding the day before admission. After the initial evaluation and experimental treatment, viral meningitis was diagnosed with SARS- CoV-19 by polymerase chain reaction (PCR) analysis of cerebrospinal fluid. Empirical treatment was done with antibiotics and supportive care. After viral meningitis was confirmed, the antibiotics were discontinued. In a follow-up two weeks later, the neonate had a good condition with no particular problem. Conclusions: This report is a case of SARS-CoV-2 meningitis in a neonate. Therefore, if there is epidemiological evidence, the central nervous system involvement due to this virus should also be considered in neonates.

COVID-19: a new emerging respiratory disease from the neurological perspective

Coronavirus disease 2019 (COVID-19) has become a challenging public health catastrophe worldwide. The newly emerged disease spread in almost all countries and infected 100 million persons worldwide. The infection is not limited to the respiratory system but involves various body systems and may lead to multiple organ failure. Tissue degenerative changes result from direct viral invasion, indirect consequences, or through an uncontrolled immune response. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads to the brain via hematogenous and neural routes accompanied with dysfunction of the blood-brain barrier. The involvement of the central nervous system is now suspected to be among the main causes of death. The present review discusses the historical background of coronaviruses, their role in previous and ongoing pandemics, the way they escape the immune system, why they are able to spread despite all undertaken measures, in addition to the neurological manifestations, long-term consequences of the disease, and various routes of viral introduction to the CNS.

SARS-CoV-2 invasion of the central nervous: a brief review

There is increasing evidence of the ability of the novel coronavirus to invade the central nervous system (CNS). But how does a respiratory virus invade the highly protected CNS? Here, we reviewed available literature and case reports to determine CNS involvement in COVID-19, and to identify potential regions of the brain that may be affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its possible route of entry into the brain to identify its pathogenicity. Based on the symptoms, the parietal lobe and the cerebellum are the likely targets of SARS-CoV-2; however, further work is needed to elucidate this. The presence of ACE2, used by SARS-CoV-2 for cell entry, in the brain as well as detection of the virus in the cerebrospinal fluid, further assert that SARS-COV-2 targets the brain, and therefore, medical practitioners should take that into account when dealing with patients suffering from COVID-19.

SARS-CoV-2 Poorly Replicates in Cells of the Human Blood-Brain Barrier Without Associated Deleterious Effects

Various neurological symptoms have been associated to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection including headache, fever, anosmia, ageusia, but also, encephalitis, Guillain-Barre syndrome and ischemic stroke. Responsible for the current coronavirus disease (COVID-19) pandemic, SARS-CoV-2 may access and affect the central nervous system (CNS) by several pathways such as axonal retrograde transport or through interaction with the blood-brain barrier (BBB) or blood-cerebrospinal fluid (CSF) barrier. Here, we explored the molecular and cellular effects of direct SARS-CoV-2 infection of human BBB cells. We observed low replication of SARS-CoV-2 that was accompanied by very moderate inflammatory response. Using a human in vitro BBB model, we also described low replication levels without strong inflammatory response or modulation of endothelium integrity. Finally, using serum samples from COVID-19 patients, we highlighted strong concentrations of pro-inflammatory factors that did not perturb BBB integrity after short term exposure. Altogether, our results show that the main mechanism of brain access following SARS-CoV-2 infection does not seem to be directed by brain infection through endothelial cells.

Rationale and study design of an early care, therapeutic education, and psychological intervention program for the management of post-intensive care syndrome and chronic pain after COVID-19 infection (PAIN-COVID): study protocol for a randomized controlled trial

BACKGROUND

Critically ill patients with COVID-19 are an especially susceptible population to develop post-intensive care syndrome (PICS) due to acute respiratory distress syndrome (ARDS). Patients can suffer acute severe pain and may have long-term mental, cognitive, and functional health deterioration after discharge. However, few controlled trials are evaluating interventions for the prevention and treatment of PICS. The study hypothesis is that a specific care program based on early therapeutic education and psychological intervention improves the quality of life of patients at risk of developing PICS and chronic pain after COVID-19. The primary objective is to determine whether the program is superior to standard-of-care on health-related quality of life at 6 months after hospital discharge. The secondary objectives are to determine whether the intervention is superior to standard-of-care on health-related quality of life, incidence of chronic pain and degree of functional limitation, incidence of anxiety, depression, and post-traumatic stress syndrome at 3 and 6 months after hospital discharge.

METHODS

The PAINCOVID trial is a unicentric randomized, controlled, patient-blinded superiority trial with two parallel groups. The primary endpoint is the health-related quality of life at 6 months after hospital discharge, and randomization will be performed with a 1:1 allocation ratio. This paper details the methodology and statistical analysis plan of the trial and was submitted before outcome data were available. The estimated sample size is 84 patients, 42 for each arm. Assuming a lost to follow-up rate of 20%, a sample size of 102 patients is necessary (51 for each arm).

DISCUSSION

This is the first randomized clinical trial assessing the effectiveness of an early care therapeutic education, and psychological intervention program for the management of PICS and chronic pain after COVID-19. The intervention will serve as proof of the need to implement early care programs at an early stage, having an incalculable impact given the current scenario of the pandemic.

TRIAL REGISTRATION

This study is being conducted in accordance with the tenets of the Helsinki Declaration and has been approved by the authors' institutional review board Comité Ético de Investigación Clínica del Hospital Clínic de Barcelona (approval number: HCB/2020/0549) and was registered on May 9, 2020, at clinicaltrials.gov ( NCT04394169 ).

Investigating the potential mechanisms of depression induced-by COVID-19 infection in patients

The new coronavirus (COVID-19) has emerged now in the world as a pandemic. The SARS-CoV-2 infection causes variant common symptoms, such as dry cough, tiredness, dyspnea, fever, myalgia, chills, headache, chest pain, and conjunctivitis. Different organs may be affected by COVID-19, such as the respiratory system, gastrointestinal tract, kidneys, and CNS. However, the information about the COVID-19 infection in the CNS is insufficient. We do know that the virus can enter the central nervous system (CNS) via different routes, causing symptoms such as dizziness, headache, seizures, loss of consciousness, and depression. Depression is the most common disorder among all neurological symptoms following COVID-19 infection, although the mechanism of COVID-19-induced depression is not yet clear.

The aim of the present study is to investigate the probable mechanisms of COVID-19-induced depression.

The reasons for depression in infected patients may be due to social and pathological factors including social quarantine, economic problems, stress, changes in the HPA axis, inflammation due to the entry of proinflammatory cytokines into the CNS, production of inflammatory cytokines by microglia, mitochondrial disorders, damage to the hippocampus, and malnutrition.

By evaluating different factors involved in COVID-19-induced depression, we have concluded that depression can be minimized by controlling stress, preventing the cytokine storm with appropriate anti-inflammatory drugs, and proper nutrition.

Molecular Mechanisms of Palmitic Acid Augmentation in COVID-19 Pathologies

The coronavirus disease 2019 (COVID-19) pandemic has claimed over 2.7 million lives globally. Obesity has been associated with increased severity and mortality of COVID-19. However, the molecular mechanisms by which obesity exacerbates COVID-19 pathologies are not well-defined. The levels of free fatty acids (FFAs) are elevated in obese subjects. This study was therefore designed to examine how excess levels of different FFAs may affect the progression of COVID-19. Biological molecules associated with palmitic acid (PA) and COVID-19 were retrieved from QIAGEN Knowledge Base, and Ingenuity Pathway Analysis tools were used to analyze these datasets and explore the potential pathways affected by different FFAs. Our study found that one of the top 10 canonical pathways affected by PA was the coronavirus pathogenesis pathway, mediated by key inflammatory mediators, including PTGS2; cytokines, including IL1β and IL6; chemokines, including CCL2 and CCL5; transcription factors, including NFκB; translation regulators, including EEF1A1; and apoptotic mediators, including BAX. In contrast, n-3 fatty acids may attenuate PA's activation of the coronavirus pathogenesis pathway by inhibiting the activity of such mediators as IL1β, CCL2, PTGS2, and BAX. Furthermore, PA may modulate the expression of ACE2, the main cell surface receptor for the SARS-CoV-2 spike protein.

Central and peripheral nervous system involvement by COVID-19: a systematic review of the pathophysiology, clinical manifestations, neuropathology, neuroimaging, electrophysiology, and cerebrospinal fluid findings

BACKGROUND

SARS-CoV-2 can affect the human brain and other neurological structures. An increasing number of publications report neurological manifestations in patients with COVID-19. However, no studies have comprehensively reviewed the clinical and paraclinical characteristics of the central and peripheral nervous system's involvement in these patients. This study aimed to describe the features of the central and peripheral nervous system involvement by COVID-19 in terms of pathophysiology, clinical manifestations, neuropathology, neuroimaging, electrophysiology, and cerebrospinal fluid findings.

METHODS

We conducted a comprehensive systematic review of all the original studies reporting patients with neurological involvement by COVID-19, from December 2019 to June 2020, without language restriction. We excluded studies with animal subjects, studies not related to the nervous system, and opinion articles. Data analysis combined descriptive measures, frequency measures, central tendency measures, and dispersion measures for all studies reporting neurological conditions and abnormal ancillary tests in patients with confirmed COVID-19.

RESULTS

A total of 143 observational and descriptive studies reported central and peripheral nervous system involvement by COVID-19 in 10,723 patients. Fifty-one studies described pathophysiologic mechanisms of neurological involvement by COVID-19, 119 focused on clinical manifestations, 4 described neuropathology findings, 62 described neuroimaging findings, 28 electrophysiology findings, and 60 studies reported cerebrospinal fluid results. The reviewed studies reflect a significant prevalence of the nervous system's involvement in patients with COVID-19, ranging from 22.5 to 36.4% among different studies, without mortality rates explicitly associated with neurological involvement by SARS-CoV-2. We thoroughly describe the clinical and paraclinical characteristics of neurological involvement in these patients.

CONCLUSIONS

Our evidence synthesis led to a categorical analysis of the central and peripheral neurological involvement by COVID-19 and provided a comprehensive explanation of the reported pathophysiological mechanisms by which SARS-CoV-2 infection may cause neurological impairment. International collaborative efforts and exhaustive neurological registries will enhance the translational knowledge of COVID-19's central and peripheral neurological involvement and generate therapeutic decision-making strategies.

REGISTRATION

This review was registered in PROSPERO 2020 CRD42020193140 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020193140.

Neurological and cognitive sequelae of Covid-19: a four month follow-up

Central and peripheral nervous system involvement during acute COVID-19 is well known. Although many patients report some subjective symptoms months after the infection, the exact incidence of neurological and cognitive sequelae of COVID-19 remains to be determined. The aim of this study is to investigate if objective neurological or cognitive impairment is detectable four months after SARS-CoV-2 infection, in a group of patients who had mild–moderate COVID-19. A cohort of 120 health care workers previously affected by COVID-19 was examined 4 months after the diagnosis by means of neurological and extensive cognitive evaluation and compared to a group of 30 health care workers who did not have COVID-19 and were similar for age and co morbidities. At 4 month follow-up, 118/120 COVID-19 cases had normal neurological examination, two patients had neurological deficits. COVID-19 patients did not show general cognitive impairment at MMSE. In COVID-19 cases the number of impaired neuropsychological tests was not significantly different from non COVID-19 cases (mean 1.69 and 1 respectively, Mann–Whitney p = n.s.), as well as all the mean tests’ scores. Anxiety, stress and depression scores resulted to be significantly higher in COVID-19 than in non COVID-19 cases. The results do not support the presence of neurological deficits or cognitive impairment in this selected population of mild–moderate COVID-19 patients four months after the diagnosis. Severe emotional disorders in patients who had COVID-19 in the past are confirmed.

Neuropilins: C-end rule peptides and their association with nociception and COVID-19

Viral internalization is aided by host cell surface receptors. In the case of SARS-CoV-2 and SARS-CoV, the primary host receptor is the angiotensin-converting enzyme 2 (ACE2). Considering the disparities in the transmission rate and viral tropism of the two coronaviruses, additional host factors were suspected. Recently, a novel host factor for SARS-CoV-2 entry, neuropilin-1 (NRP-1) has been identified. These receptors potentiate viral infection in the presence of other host factors like ACE2. Through its C-end rule (CendR) motif exposed following furin processing, the SARS-CoV-2 spike protein binds to the CendR pocket of NRP-1 and achieves cell entry through endocytosis. The binding of SARS-CoV-2 spike protein to the NRP-1 receptor interferes with the docking of its endogenous ligand VEGF-A, signaling that would otherwise promote nociception. This review looks at the function of neuropilins and how it contributes to SARS-CoV-2 infection and nociception.