Stroke Associated with SARS-CoV-2 Infection and its Pathogenesis: A Systematic Review

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

Omega-3 polyunsaturated fatty acids and the psychiatric post-acute sequelae of COVID-19: A one-year retrospective cohort analysis of 33,908 patients

BACKGROUND

Early prevention and management of psychiatric symptoms in long COVID (or post-COVID-19 conditions) are crucial for reducing long-term disability. Existing clinical guidelines recommend the use of omega-3 polyunsaturated fatty acids (PUFAs) as a promising therapeutic approach for various common psychiatric disorders due to their anti-inflammatory and neuroprotective characteristics. This study aims to investigate the potential efficacy of omega-3 PUFAs in alleviating the psychiatric sequelae following COVID-19.

METHODS

This 1-year retrospective cohort study used the TriNetX electronic health records network to examine the effects of omega-3 PUFAs supplements on psychiatric sequelae in adults diagnosed with COVID-19. Using propensity-score matching, the study compared those who used omega-3 PUFAs supplements with those who did not, assessing outcomes including depression, anxiety disorders, insomnia, and other somatic conditions up to a year after COVID-19 diagnosis.

RESULTS

In 16,962 patients who received omega-3 PUFAs supplements and 2,248,803 who did not, omega-3 supplementation significantly reduced the risk of developing psychiatric sequelae post-COVID-19 diagnosis (HR, 0.804; 95% CI, 0.729 to 0.888). Specifically, the risks for depression (HR, 0.828; 95% CI, 0.714 to 0.960), anxiety disorders (HR, 0.833; 95% CI, 0.743 to 0.933), and insomnia (HR, 0.679; 95% CI, 0.531 to 0.869) were reduced in the omega-3 group. This effect was consistent across sex, race, 18-59 age group, and patients with less than two doses of the COVID-19 vaccine. The omega-3 group also had a lower risk of cough and myalgia, but no significant difference was noted for other symptoms like chest pain, abnormal breathing, abdominal issues, fatigue, headache, and cognitive symptoms.

CONCLUSION

Omega-3 PUFAs may require re-evaluation as a preventive strategy against adverse mental health outcomes post-COVID-19 in placebo-controlled clinical trials.

The effect of nirmatrelvir-ritonavir on the long-term risk of neuropsychiatric sequelae following COVID-19

The retrospective cohort was conducted to assess the effect of nirmatrelvir-ritonavir (NMV-r) on the long-term risk of neuropsychiatric sequela following COVID-19. TriNetX research network was used to identify nonhospitalized adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 infection or were diagnosed with COVID-19 between March 1, 2020 and July 1, 2022. Further propensity score matching method was used to create two matched cohorts with and without receiving NMV-r. The primary outcome was the incidence of neuropsychiatric sequela within a 90-day to 1-year period following a diagnosis of COVID-19. After screening 119 494 527 electronic health records, two matched cohorts of each 27 194 patients were identified. During the follow-up period, the NMV-r group demonstrated a reduced risk of any neuropsychiatric sequelae compared to the control group (odds ratio [OR], 0.634; 95% confidence interval [CI], 0.604-0.667). In comparison with the control group, the patient treated with NMV-r exhibited a markedly diminished risk of developing neurocognitive sequela (OR, 0.377; 95% CI, 0.325-0.439) and psychiatric sequela (OR, 0.629; 95% CI, 0.593-0.666). In addition, patients treated with NMV-r had a significantly reduced risk of developing dementia (OR, 0.365; 95% CI, 0.255-0.522), depression (OR, 0.555; 95% CI, 0.503-0.612), insomnia (OR, 0.582; 95% CI, 0.508-0.668) and anxiety disorder (OR, 0.645 95% CI, 0.600-0.692). Moreover, the beneficial effect of NMV-r on the neuropsychiatric sequelae was observed across further subgroup analyses. Among nonhospitalized COVID-19 patients, who at risk of disease progression, the use of NMV-r is associated with a reduction in the long-term risk of neuropsychiatric sequela, including dementia, depression, insomnia and anxiety disorder. It may be necessary to re-evaluate the use of NMV-r, as a preventive measure to reduce the risk of severe acute disease and post-acute adverse mental health outcomes.

Elevated IL-18 predicts poor prognosis in critically ill COVID-19 patients at a Brazilian hospital in 2020–21

Background: A dysregulated inflammatory response contributes to decline in patients with COVID-19. This cross-sectional study evaluated biomarkers of unvaccinated patients admitted to the intensive care unit of a hospital in Fortaleza, Brazil. Methods: Twenty cytokines were quantified upon hospital admission; clinical and laboratory data were analyzed, as well as sociodemographic data, to search for an association with clinical outcomes, including fatal (n = 40) or recovered cases (n = 38). Results: Fatal cases exhibited significantly higher levels of IL-18 (p = 0.009); deceased patients were older (p = 0.0001), had a lower number of platelets (p = 0.0063) and higher neutrophil–lymphocyte ratio (p = 0.0230) than those who recovered. Conclusion: These findings indicate that IL-18 is a possible marker to predict poor prognosis in critically ill patients with COVID-19.

Endothelial Dysfunction in COVID-19: A Unifying Mechanism and a Potential Therapeutic Target

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) generated a worldwide emergency, until the declaration of the pandemic in March 2020. SARS-CoV-2 could be responsible for coronavirus disease 2019 (COVID-19), which goes from a flu-like illness to a potentially fatal condition that needs intensive care. Furthermore, the persistence of functional disability and long-term cardiovascular sequelae in COVID-19 survivors suggests that convalescent patients may suffer from post-acute COVID-19 syndrome, requiring long-term care and personalized rehabilitation. However, the pathophysiology of acute and post-acute manifestations of COVID-19 is still under study, as a better comprehension of these mechanisms would ensure more effective personalized therapies. To date, mounting evidence suggests a crucial endothelial contribution to the clinical manifestations of COVID-19, as endothelial cells appear to be a direct or indirect preferential target of the virus. Thus, the dysregulation of many of the homeostatic pathways of the endothelium has emerged as a hallmark of severity in COVID-19. The aim of this review is to summarize the pathophysiology of endothelial dysfunction in COVID-19, with a focus on personalized pharmacological and rehabilitation strategies targeting endothelial dysfunction as an attractive therapeutic option in this clinical setting.