Impaired exercise capacity in post-COVID syndrome: The role of VWF-ADAMTS13 axis

Background: Post-COVID syndrome (PCS) is an increasingly recognised complication of acute SARS-CoV- 2 infection, characterised by persistent fatigue, reduced exercise tolerance, chest pain, shortness of breath and cognitive slowing. Acute COVID-19 is strongly linked with increased risk of thrombosis;a prothrombotic state. Elevated Von Willebrand Factor (VWF) Antigen (Ag):ADAMTS13 ratio is associated with severity of acute COVID-19 infection. Aim(s): We hypothesised that the pro-thrombotic state is implicated in the pathogenesis of PCS. We investigated specialist coagulation parameters associated with reduced exercise capacity in patients with PCS to identify the utility of these parameters to determine ongoing disease activity. We also investigated if an association exists between elevated VWF(Ag):ADAMTS13 ratio and impaired exercise capacity in patients with PCS. Method(s): Retrospective analysis of VWF(Ag):ADAMTS13 ratio in patients with PCS at a dedicated post-COVID clinic. VWF(Ag):ADAMTS13 ratio was correlated with symptoms including exercise capacity as assessed by 1 minute sit-to- stand (STS) test and/or 6 minute walk test (6MWT). Peripheral oxygen desaturation >=3% for 6MWT and STS test, and increase in lactate>1 from baseline during 6MWT were taken as markers of impaired exercise capacity. Result(s): Elevated VWF(Ag):ADAMTS13 ratio (>=1.5) was found to be four times (OR 4.3) more likely in patients with impaired exercise capacity. 20% (56/276) had impaired exercise capacity, of which 55% (31/56) had a raised VWF(Ag):ADAMTS13 ratio >=1.5 (p < 0.0001). A higher median VWF(Ag):ADAMTS13 ratio of 1.5 (IQR 1.2-1.7) in patients with abnormal exercise testing compared to 1.1 (IQR 0.9-1.4) in patients with normal exercise testing was found (p < 0.0001). FVIII and VWF(Ag) were elevated in 26% and 18% respectively and support a hypercoagulable state in patients with PCS. Conclusion(s): These findings suggest possible ongoing microvascular/ endothelial dysfunction in the pathogenesis of PCS and highlight the potential role for prophylactic anticoagulation in the management of these patients.

Demonstrating New-onset orWorsened Sudomotor Function post COVID-19

Objective: Identify if SARS-CoV-2 virus is triggering and/or worsening dysautonomia by reviewing the function of autonomic patients pre-COVID-19 and post-COVID-19 infection, as well as new onset autonomic patients post-COVID-19 infection. Background: Autonomic dysfunction may be part of acute and long COVID-19 infection. Design/Methods: Six participants were enrolled and divided into two groups. The first group of 4 volunteers reported worsened autonomic symptoms post-COVID-19 infection. These individuals had first autonomic test prior to COVID-19 pandemic outbreak (July 2019- December 2019). Autonomic function testing was repeated in these participants, 6 months to 1- year post-COVID-19 infection (June, 2021). The second group of 2 volunteers reported newonset autonomic symptoms post-COVID-19 infection and were tested March-May, 2021. All participants were screened for known causes of autonomic dysfunction and had normal neurophysiological studies (EMG/NCS), no hypertension/hyperlipidemia or thyroid dysfunction, no diabetes/prediabetes, no vitamin deficiencies, no history of HIV, hepatitis, or syphilis, no prior radiation or chemical exposure and no evidence of monoclonal gammopathy, or autoimmune condition. Participants were diagnosed with COVID-19 via PCR testing, and tested again via SARS-CoV-2 capsid-antibody test. Results: All volunteers were female (age: 21-37y) and endorsed orthostatic intolerance. Gastrointestinal symptoms (5/6), new-onset paresthesias, drier skin (3/6), and sexual dysfunction (2/6) were reported. Dysgeusia reported in 50%, but was not demonstrated on neurological examination. Parasympathetic autonomic function remained stable 6-months to 1- year post-COVID-19 infection and not demonstrated in participants with new-onset symptoms. Sympathetic-adrenergic dysfunction as new-onset orthostatic hypotension and abnormalities on blood-pressure response to Valsalva was found in 50% of participants. Sympathetic cholinergic (sudomotor) dysfunction was demonstrated in ALL participants. Worsened, or new-onset, sudomotor dysfunction was demonstrated in those with mild or normal sudomotor function on pre-COVID-19 autonomic testing Conclusions: Sudomotor dysfunction was demonstrated as worsened or new-sequelae to COVID-19 infection. COVID-19 may be responsible for new-onset or worsened small-fiber neuropathy in this sample.

The Role of the Teacher as Assessor: Developing Student Teachers' Assessment Identity

The closure of schools across the globe due to the Covid-19 pandemic had the potential to have a catastrophic impact on a fundamental pillar of initial teacher education: school placement. This paper maps a new “site” of professional practice for “school placement” called “Teacher Online Programme” (TOP) using Xu and Brown's (2016) conceptual framework of teacher assessment literacy in practice. Its main focus lies in the integration of the assessment baseline knowledge into the programme under the seven elements proposed by the framework. A case study methodology informed the approach taken. Data was collected and analysed in three phases: the Teaching Online Programme Year 3 (TOP3) initiative;Student-teacher and Tutor Questionnaires and Student-teacher and Tutor focus group interviews. The findings highlight the complex and multifaceted process of building teacher assessment identity which nests in the larger purposes for education. They encourage an emergentist and collaborative approach to assessment knowledge and view working in communities of practice as a threshold for creativity and innovation. © 2021 Social Science Press. All rights reserved.

Neuropsychology consultation to identify learning disorders in children and adolescents: a proposal based on lessons learned during the COVID-19 pandemic.

Learning disorders are common neurodevelopmental conditions, occurring both idiopathically and in the context of other medical conditions. They are frequently comorbid with other neurodevelopmental and psychiatric conditions. Delayed identification and treatment have been associated with significant negative psychosocial consequences. The need for pediatric neuropsychologists to efficiently screen for learning disorders is likely to increase in the months and years following the COVID-19 pandemic, which has severely disrupted access to educational services, especially for children who also face racial and economic disparities. In this paper, we describe a consultation model that can be used to screen for learning disorders and can be completed using both in-person and telemedicine visits. Implementation may result in earlier intervention for struggling children, increase access to neuropsychological services without increasing wait times for comprehensive evaluations, and provide opportunities for collaborations with other health professionals (e.g., pediatricians, therapists, psychiatrists, and neurologists).

Vertical transmission, maternal thrombocytopenia, & postpartum haemorrhage in coronavirus infection - a case report

Objective New evidence is emerging regarding the effects of Coronavirus (COVID-19) in pregnancy. We report this case to highlight COVID-19 complications and challenges in the 3rd trimester of pregnancy. Case report A 35 years old, Para 1, had an uneventful pregnancy up to 36 weeks' gestation, when she was admitted with reduced fetal movements, feeling unwell, fever, and cough with a positive COVID-19 PCR. She was febrile, tachycardiac, and normotensive with no proteinuria. Symptomatic treatment was commenced with infection control measures. Cardiotocograph (CTG) was reassuring initially. Her platelet count was 66 9 109/L and her liver function tests (LFT) were mildly deranged. Peripheral blood film showed no signs of Microangiopathic hemolytic anemia. The hematologist suggested that thrombocytopenia was most likely related to COVID-19 & her isolated mildly prolonged APTT was corrected by Vitamin K. She was induced in view of intermittent decelerations on CTG and progressive thrombocytopenia. However, CTG became abnormal and she had a lower segment cesarean section under General Anastasia (because of thrombocytopenia). She delivered a 2.8 kg baby boy (APGAR score of 6 and 9 at 5 and 10 mins respectively, normal cord pH). Delivery was complicated by a Postpartum hemorrhage of 2 L, for which she was transfused one unit of platelets, and two units of red cells, along with oxytocics and antibiotics. Neonate was COVID-19 positive and had hyperbilirubinemia, which settled subsequently. The subsequent recovery of the mother was uneventful, with improvement in her platelet count and LFT. She was discharged home with her baby on the 4th postoperative day after the debriefing. She was prescribed thromboprophylaxis for 6 weeks and followed up as an outpatient. Discussion The management of COVID-19 in pregnancy should include a multidisciplinary approach, foeto-maternal surveillance, infection control measures, delivery planning, and psychological support. Rasmussen SA advocates the use of empiric antibiotics for secondary bacterial infection risk & mechanical support in case of respiratory compromise. Thrombocytopenia is a known complication of COVID-19 in pregnancy. Thromboprophylaxis is challenging in such patients and depends on risks and benefits, clotting profile, and the timing of delivery. Moreover, the differential diagnosis for epigastric pain in pregnancy with COVID-19 infection varies from gastritis and preeclampsia to hepatic and myocardial injury. Vertical transmission is a known risk of maternal COVID-19 infection. Conclusion As obstetric teams face COVID-19 pandemic associated foeto-maternal challenges, there is a need for holistic interventions for caveats arising from COVID-19 complications.