Italian good practice recommendations on management of persons with Long-COVID

Treatments for Long COVID autonomic dysfunction: a scoping review

PURPOSE

For Long COVID autonomic dysfunction, we have summarized published evidence on treatment effectiveness, clinical practice guidelines, and unpublished/ongoing studies.

METHODS

We first interviewed 11 stakeholders (clinicians, clinician/researchers, payors, patient advocates) to gain clinical insights and identify key areas of focus. We searched Embase, CINAHL, Medline, PsycINFO, and PubMed databases for relevant English-language articles published between 1 January 2020 and 30 April 2024. We also searched several other resources for additional relevant guidelines (e.g., UpToDate) and unpublished/ongoing studies (e.g., the International Clinical Trials Registry Platform). All information was summarized narratively.

RESULTS

We included 11 effectiveness studies that investigated numerous treatment regimens (fexofenadine + famotidine, maraviroc + pravastatin, selective serotonin reuptake inhibitors, nutraceutical formulations, multicomponent treatments, heart rate variability biofeedback, inspiratory muscle training, or stellate ganglion block). One randomized trial reported benefits of a nutraceutical (SIM01) on fatigue and gastrointestinal upset. The 11 guidelines and position statements addressed numerous aspects of treatment, but primarily exercise/rehabilitation, fluid/salt intake, and the use of compression garments. The 15 unpublished/ongoing studies are testing nine different interventions, most prominently ivabradine and intravenous immunoglobulin.

CONCLUSION

Existing studies on the treatment of Long COVID autonomic dysfunction are often small and uncontrolled, making it unclear whether the observed pre-post changes were due solely to the administered treatments. Guidelines display some overlap, and we identified no direct contradictions. Unpublished/ongoing studies may shed light on this critical area of patient management.

Mechanisms of long COVID and the path toward therapeutics

Long COVID, a type of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PASC) defined by medically unexplained symptoms following infection with SARS-CoV-2, is a newly recognized infection-associated chronic condition that causes disability in some people. Substantial progress has been made in defining its epidemiology, biology, and pathophysiology. However, there is no cure for the tens of millions of people believed to be experiencing long COVID, and industry engagement in developing therapeutics has been limited. Here, we review the current state of knowledge regarding the biology and pathophysiology of long COVID, focusing on how the proposed mechanisms explain the physiology of the syndrome and how they provide a rationale for the implementation of a broad experimental medicine and clinical trials agenda. Progress toward preventing and curing long COVID and other infection-associated chronic conditions will require deep and sustained investment by funders and industry.

Clinical practice guidelines and expert consensus statements on rehabilitation for patients with COVID-19: a systematic review

OBJECTIVES

To appraise the quality of clinical practice guidelines (CPGs) and expert consensus statements on rehabilitation for patients with COVID-19, summarise recommendations of rehabilitation assessments and interventions and evaluate the heterogeneity of the recommendations.

DESIGN

Systematic review.

DATA SOURCES

PubMed and Embase databases and five online guideline repositories: The National Guideline Clearinghouse, Guidelines International Network, Scottish Intercollegiate Guidelines Network, National Institute for Health and Clinical Excellence and WHO were searched from their inception to August 2024. In addition, we reviewed reference lists of eligible citations and searched the grey literature on the relevant websites.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included CPGs and expert consensus statements which provided information about rehabilitation of patients with COVID-19. To be eligible, the CPGs and expert consensus statements were issued in English by a nationally or internationally recognised government authority, medical/academic society or organisation. If there were multiple versions of the guidelines, we included the latest one. The translations, interpretations and abstracts of guidelines were excluded.

DATA EXTRACTION AND SYNTHESIS

All recommendations on rehabilitation assessments and interventions for COVID-19 were extracted and summarised. Two reviewers independently evaluated the methodological quality with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and two other reviewers assessed the reporting quality using the Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement of included CPGs and expert consensus statements. We used the Measurement Scale of Rate of Agreement to evaluate the heterogeneity of the recommendations in different CPGs and expert consensus statements.

RESULTS

A total of 31 CPGs and expert consensus statements were included. 14 guidelines provided recommendations for rehabilitation assessments. At the early, development, critical and recovery stages of COVID-19, the most frequently recommended were exercise therapy (25.8%, 35.5%, 25.8% and 58.1%, respectively). According to AGREE II, 17 included guidelines were assessed as low methodological quality (35%-56%), 10 guidelines were rated as moderate quality (46%- 62%) and four had high quality (69%-79%). Among 31 eligible guidelines, the reporting rate of 22 items in the RIGHT checklist ranged from 10% to 100%. The included guidelines were consistent with the reference guidelines (80%-100%). Only one guideline existed minor (60%-80%) disagreements in respiratory muscle training relative to the reference guideline.

CONCLUSIONS

Rehabilitation assessments and interventions should be implemented consistently throughout the entire process of COVID-19. The recommendations should be tailored to each stage of COVID-19. The methodological and reporting qualities of several guidelines remain suboptimal. Therefore, developers should adhere strictly to the AGREE II standard and RIGHT checklist to formulate and publish CPGs and expert consensus statements with high quality.

PROSPERO REGISTRATION NUMBER

CRD42020190761.

An update of the literature about rehabilitation tools used in the treatment of COVID-19-related disabilities: a systematic review of literature

INTRODUCTION

The role of rehabilitation during and after the COVID-19 pandemia was influenced by the progressive acquisition of knowledge on the pathology with the adaptation of the rehabilitative instruments to the heterogeneous impairments of the patients. The aim of this systematic review is to describe the effects of the rehabilitation tools applied in the last three years in the different phases of the COVID-19 disease.

EVIDENCE ACQUISITION

A literature search of MEDLINE (PubMed), Scopus and Physiotherapy Evidence Database (PEDro) was conducted. 2994 participants were included in this systematic review: 1225 patients for acute-COVID, 1331 patients for post-COVID, 438 patients for long-COVID.

EVIDENCE SYNTHESIS

Of the initial 907 hits only 45 randomized controlled trials were included. The Cochrane library assessment tool was used to evaluate the risk of bias. The trials selected studied the effects of respiratory rehabilitation alone or in association with exercises, tele-rehabilitation, endurance training, virtual reality, electrostimulations in different settings and phases of the infection with the evaluation of clinical, quality of life and impairment outcome measures.

CONCLUSIONS

All the rehabilitations tool were used based on the experts' opinion and on the rules of good clinical practice, during and after the pandemic period. Despite the heterogeneity of the studies, the different outcome measures and the small sample sizes, pulmonary rehabilitation, tele-rehabilitation and low/moderate intensity aerobic and endurance exercises seemed to improve clinical and quality of life outcomes at short (8 weeks) and mean time (2 months) after treatments in all phases of the infection.

Impact of Spa Therapy on Symptoms and Quality of Life in Post-COVID-19 Patients with Chronic Conditions

Background: With limited pharmacological interventions, post-COVID-19 condition is a clinical challenge, and supplementary therapies are essential for symptom relief and enhancing quality of life (QoL). In our prospective observational study, we aimed to evaluate the impact of Salus per aquam (Spa) therapy on post-COVID-19 symptoms and QoL in individuals who suffer from chronic joint, musculoskeletal, skin, and/or respiratory conditions. Methods: A total of 159 individuals undergoing Spa therapy were enrolled, and 78 of them had post-COVID-19 symptoms, assessed using Visual Analogue Scale (VAS) and modified British Medical Research Council Questionnaire (mMRC-DS scales), as well as the Short Form 36 Health Status Survey (SF-36) questionnaire for QoL. Results: Spa therapy significantly reduced most post-COVID-19 symptoms, especially chronic fatigue, pain, brain fog, and persistent cough (all p < 0.05), as well as physical (+72%) and emotional (+66%) limitations. When stratified by sex, males showed a greater improvement from baseline, while females consistently displayed a higher amelioration in all QoL dimensions. Moreover, full vaccination with 3-4 doses significantly protected against SARS-CoV-2 re-infections and post-COVID-19 development (p < 0.05). Conclusions: Spa therapy demonstrated effectiveness in mitigating post-COVID-19 symptoms and enhancing QoL in patients suffering from chronic diseases.

An ecological comparison to inspect the aftermath of post COVID-19 condition in Italy and the United States

Post COVID-19 Condition (PCC) is a clinical syndrome following COVID-19 disease. PCC symptoms in adults entail significant productivity loss and reduced quality of life. This study aimed at estimating the epidemiological and economic burden of PCC among the working-age population of Italy and the US. This ecological analysis was conducted on data from January 2020 to April 2023, regarding population aged 18-64. PCC incidence for the US was retrieved from publicly reported estimates, while for Italy it was estimated from COVID-19 cases. Prevalence of factors associated with PCC and parameters to calculate temporary productivity losses (TPL) were retrieved. An estimated incidence rate ratio (eIRR) of PCC incidence in Italy and the US was calculated. TPL for reduced earnings and total quality-adjusted life years (QALYs) lost were also estimated. The ecological eIRR Italy/US was 0.842 [95%CI 0.672-1.015], suggesting that, holding COVID-19 cases constant, 15.8% fewer PCC cases have occurred in Italy compared to the US. Overall PCC cases were found to be 12.0 [95%CI 9.9-14.1] million in the US, with 1.9 [95%CI 1.6-2.3] million QALYs lost, and 2.4 [95%CI 1.8-3.0] million in Italy, with 0.4 [95%CI 0.3-0.5] million QALYs lost. Up to April 2023, the TPL was estimated to be Int$7.5 [95%CI 5.8-10.1] billion in Italy and $41.5 [95%CI 34.3-48.7] billion in the US. PCC has had a significant epidemiological and economic impact on the working-age population. The findings from this study may be of use for health planning and policy regarding PCC in working-age adults.

Gender medicine and sleep disorders: from basic science to clinical research

Several pivotal differences in sleep and sleep disorders are recognized between women and men. This is not only due to changes in hormonal balance during women's reproductive life, such as in pregnancy and menopause. Women are more likely to report insomnia and non-specific symptoms of apneas, such as fatigue or mood disturbance, compared to men. Thus, it is important for clinicians and researchers to take sex and gender differences into account when addressing sleep disorders in order to acknowledge the biology unique to women. We present a narrative review that delves into the primary sleep disorders, starting from basic science, to explore the impact of gender differences on sleep and the current status of research on women's sleep health.

Deaths related to post-COVID in Italy: a national study based on death certificates

Introduction

SARS-CoV-2 infection has been associated with the onset or persistence of symptoms in the long-term after the acute infection is resolved. This condition known as Post-COVID, might be particularly severe and potentially life-threatening. However, little is known on the impact of post-COVID condition on mortality. Aim of the present study is to assess and quantify Post-COVID deaths in Italy in years 2020 and 2021, based on an analysis of death certificates.

Methods

Data from the Italian National Cause of Death Register were analyzed. ICD-10 code U09.9, released by the World Health Organization in September 2020, was used to identify the 'Post-COVID' condition. Numbers of post-COVID deaths from October 2020 to December 2021 were analyzed. Rates of post-COVID deaths were calculated for the year 2021.

Results

Between October 2020 and December 2021, 4,752 death certificates reporting post-COVID condition were identified. Of these, 14.9% (n = 706) occurred between October and December 2020 and 85.1% (n = 4,046) in 2021. In 46.0% of post-COVID-related deaths, the underlying cause of death was COVID-19. Other frequent underlying causes were heart disease (14.3% of cases), neoplasms (9.2%), cerebrovascular diseases (6.3%) and Alzheimer's disease and other dementias (5.5%). The mortality rate related to post-COVID conditions in year 2021 was 5.1 deaths per 100 thousand inhabitants and it increased with increasing age. Men showed a higher mortality rate than women (4.3 deaths per 100 thousand in women and 6.0 deaths per 100 thousand in men).

Discussion

Post-COVID conditions contributed to a substantial number of deaths in Italy. Strategies to identify the population at risk of severe long-term consequences of SARS-CoV-2 infection and interventions aimed at reducing this risk must be developed.

Potential Anti-Inflammatory and Anti-Fatigue Effects of an Oral Food Supplement in Long COVID Patients

Long coronavirus disease (COVID) syndrome leads to chronic inflammatory state onset that can have a multisystem impact and compromise organ function. Moreover, long COVID syndrome is often characterized by the presence of chronic fatigue, which affects subjects' daily activities and worsens their quality of life. The aim of our double-blind, placebo-controlled randomized trial (protocol code RS 150.21, approved on 4 November 2021) was to evaluate the beneficial effects of the consumption of 2 cps/day, for two months, of an oral food supplement (OFS), based on Echinacea angustifolia, rosehip, propolis, royal jelly and zinc, in long COVID patients, compared to a two-month placebo period. The OFS's vitamin C content was equal to 22.17 mg/g (8.87 mg/capsule). The OFS's total polyphenol content was 43.98 mg/g gallic acid equivalents. At the end of the in vivo study, we highlighted a significant decrease in the inflammatory parameters in the OFS period, compared to the placebo period (neutrophil-to-lymphocyte ratio, p = 0.0455; monocyte to-lymphocyte ratio, p = 0.0005; C-reactive protein, p = 0.0145). Our study also highlighted a significant increase in vitamin D serum values (p = 0.0005) and, at the same time, an improvement in patients' life quality and a reduction in fatigue, monitored by the fatigue severity scale. This study showed the OFS's beneficial effects on the inflammatory state, fatigue and quality of life in long COVID patients.

Co-Morbidity Clusters in Post-COVID-19 Syndrome

Background: Post-COVID-19 syndrome, characterized by persistent symptoms emerging more than 12 weeks after acute infection, displays diverse manifestations. This study aimed to analyze co-existing organ dysfunctions in post-COVID-19 patients and explore their potential association with the acute COVID-19 episode and functional impairment. Methods: Data from 238 patients attending post-COVID-19 outpatient care between 1 March 2021 and 1 March 2022, after previous hospitalization for acute COVID-19, were retrospectively analyzed with 80 having comprehensive mapping of organ involvement. Results: The average time between acute episode and post-COVID-19 care was 149 days. Spirometry indicated significant abnormalities in lung function. Predominant symptoms included respiratory (75%), fatigue (73%), neurological (62.5%), and ear-nose-throat issues (51.25%). Multiorgan dysfunctions were observed in 87.5% of patients, contributing to an 18.33% reduction in health quality compared to pre-acute COVID-19 levels. Subgroup analysis identified four distinct post-COVID-19 syndrome subgroups, highlighting the coexistence of respiratory and neurological disorders as potential indicators and drivers of further organ involvement. Our results reveal that most patients with post-COVID-19 syndrome suffer from multiorgan disorders. Conclusions: The presence of coexisting respiratory and neurological symptoms suggests the involvement of other organ systems as well. The complexity of multiorgan involvement requires further studies to provide insights into the different symptom clusters and identify potential targets for personalized preventive and therapeutic interventions to improve patient outcome.

The Burden of Cardiovascular Disease in the Post-COVID Era

In 2019, before the COVID-19 pandemic, cardiovascular disease (CVD) was the leading cause of death. Since 2020, the pandemic has had far-reaching effects on the landscape of health care including CVD prevention and management. Recent decreases in life expectancy in the United States could potentially be explained by issues related to disruptions in CVD prevention and control of CVD risk factors from the COVID-19 pandemic. This article reviews the effects of the SARS-CoV-2 virus and the accompanying pandemic on CVD risk factor prevention and management in the United States. Potential solutions are also proposed for these patients.

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 Potential Role of Hypothalamic Phospholipid Liposomes in the Supportive Therapy of Some Manifestations of Post-COVID-19 Condition: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Brain Fog

Post-COVID-19 condition (commonly known as Long COVID) is a heterogeneous clinical condition in which Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and brain fog stand out among the different clinical symptoms and syndromes. Cerebral metabolic alterations and neuroendocrine disorders seem to constitute an important part of the pathophysiology of Post-COVID-19 condition (PCC). Given the substantial lack of specific drugs and effective therapeutic strategies, hypothalamic phospholipid liposomes, which have been on the market for several years as adjuvant therapy for cerebral metabolic alterations resulting from neuroendocrine disorders, might represent a potential option in an overall therapeutic strategy that aims to control PCC-associated symptoms and syndromes. Their pharmacological mechanisms and clinical effects strongly support their potential effectiveness in PCC. Our initial clinical experience seems to corroborate this rationale. Further controlled clinical research is warranted in order to verify this hypothesis.