Bone fragility during the COVID-19 pandemic: the role of macro- and micronutrients.

Bone fragility is the susceptibility to fracture due to poor bone strength. This condition is usually associated with aging, comorbidities, disability, poor quality of life, and increased mortality. International guidelines for the management of patients with bone fragility include a nutritional approach, mainly aiming at optimal protein, calcium, and vitamin D intakes. Several biomechanical features of the skeleton, such as bone mineral density (BMD), trabecular and cortical microarchitecture, seem to be positively influenced by micro- and macronutrient intake. Patients with major fragility fractures are usually poor consumers of dairy products, fruit, and vegetables as well as of nutrients modulating gut microbiota. The COVID-19 pandemic has further aggravated the health status of patients with skeletal fragility, also in terms of unhealthy dietary patterns that might adversely affect bone health. In this narrative review, we discuss the role of macro- and micronutrients in patients with bone fragility during the COVID-19 pandemic.

The role of acute rehabilitation in COVID-19 patients.

BACKGROUND: In the published literature there is scarce data on the importance of acute rehabilitation in patients suffering from COVID-19 disease. AIM: Evaluation of the feasibility of respiratory and neuromuscular rehabilitation treatment in stable acute COVID-19 inpatients. DESIGN: The study was designed as an observational prospective investigation of two cohorts respectively identified as Mild/Moderate and Stable Severe COVID-19 disease. All patients received a rehabilitation treatment consisting of breathing exercises, range of motion exercises and strengthening exercises, with the main difference in intensity and progression of treatment, depending on individual capacity of patient. SETTING: Inpatients with diagnosed mild to moderate, or stable severe COVID-19 infection were included in the study. POPULATION: Acute COVID-19 inpatients. METHODS: Patients were divided into two groups depending on the severity of disease: "mild to moderate group" (MMG) and "stable severe group" (SSG). Functional outcomes included the Barthel Index (BI), Six Minute Walk Test (6MWT), Borg Scale for dyspnea, "Time Up and Go" Test (TUG), "Sit To Stand" test (STS), "One Leg Stance Test" (OLST) and Beck Depression Inventory (BDI) were evaluated at baseline and after rehabilitative treatment, on discharge. RESULTS: We included 147 acute COVID-19 inpatients (75 male and 72 female), mean aged 63.90±13.76 years. There were noticeable statistically significant improvements in all observed measurements in both groups. Comparison between groups showed significant difference in MMG compared to SSG in all functional outcomes: TUG (P<0.001), STS (P<0.001), OLST (P<0.001), BDI (P=0.008), BI (P<0.001), and Borg scale for dyspnea (P<0.001). Despite the significant improvements of BI in SSG, the obtained values showed that the patients were still not functionally independent. CONCLUSIONS: Acute respiratory and neuromuscular rehabilitation program is a feasibile, but also effective and safe method for improving functional status in patients with COVID-19 infection. CLINICAL REHABILITATION IMPACT: Results of the present study implicate that a supervised early rehabilitation program, implemented in the treatment of patients with COVID-19 disease in the acute phasis a feasible way for significant improvement of patient's functional outcomes. Early rehabilitation should be included into clinical protocols for the treatment of patients with COVID-19.

Bone fragility: conceptual framework, therapeutic implications, and COVID-19-related issues.

Bone fragility is the susceptibility to fracture even for common loads because of structural, architectural, or material alterations of bone tissue that result in poor bone strength. In osteoporosis, quantitative and qualitative changes in density, geometry, and micro-architecture modify the internal stress state predisposing to fragility fractures. Bone fragility substantially depends on the structural behavior related to the size and shape of the bone characterized by different responses in the load-deformation curve and on the material behavior that reflects the intrinsic material properties of the bone itself, such as yield and fatigue. From a clinical perspective, the measurement of bone density by DXA remains the gold standard for defining the risk of fragility fracture in all population groups. However, non-quantitative parameters, such as macro-architecture, geometry, tissue material properties, and microcracks accumulation can modify the bone's mechanical strength. This review provides an overview of the role of different contributors to bone fragility and how these factors might be influenced by the use of anti-osteoporotic drugs and by the COVID-19 pandemic.

Functioning issues in inpatients affected by COVID-19-related moderate pulmonary impairment: a real-practice observational study.

OBJECTIVE: To investigate the correlations between clinical, functional, and radiological outcomes in inpatients with coronavirus disease 2019 (COVID-19). METHODS: In this observational study, we recruited inpatients affected by moderate COVID-19 disease. The clinical evaluation comprised the Cumulative Illness Rating Scale (CIRS), numerical rating scale (NRS), modified Rankin scale (mRS), and the modified Borg dyspnea scale (mBDS). Respiratory involvement was assessed with computed tomography (CT) and graded with a CT-severity score (CT-SS). We retrospectively assessed functioning using the International Classification of Functioning, Disability and Health (ICF) codes of the Clinical Functioning Information Tool (ClinFIT) COVID-19 in the acute phase. Correlation analysis was performed 1) between clinical, instrumental, and functional parameters and 2) between ICF categories. RESULTS: The data showed statistically significant moderate correlations between CT-SS and the following categories: b152 "emotional functions" and b440 "respiratory functions". CONCLUSION: This is the first study to use the ICF framework in people with a moderate form of COVID-19 in the acute phase. Considering the correlations between some ICF categories and radiological findings, our results support the use of the ClinFIT COVID-19 for a comprehensive assessment of COVID-19 patients.

The Effectiveness of Behavioral Interventions in Adults with Post-Traumatic Stress Disorder during Clinical Rehabilitation: A Rapid Review.

BACKGROUND: This review examined the effectiveness of behavioral interventions for adults with post-traumatic stress disorder (PTSD) triggered by physical injury or medical trauma. It discusses implications in support of rehabilitation management for COVID-19 survivors diagnosed with PTSD. METHODS: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Interim Guidance from the Cochrane Rapid Reviews Methods Group. The authors searched for randomized control trials in PubMed, Embase, and CENTRAL databases up to 31 March 2021. RESULTS: Five studies (n = 459) met the inclusion criteria. Each study measured a different comparison of interventions. The certainty of the evidence was judged to be very low for all outcomes. Post-traumatic stress disorder symptom reduction was found to be in favor of trauma-focused cognitive-behavioral therapy, cognitive therapy, and cognitive-behavioral therapy. Cognitive function improvements were observed in favor of the cognitive processing therapy control intervention. CONCLUSIONS: Overall, there is uncertainty about whether behavioral interventions are effective in reducing PTSD symptoms and improving functioning and quality of life when the disorder is triggered by a physical or medical trauma rather than a psychological trauma. Further research should investigate their efficacy in the context of rehabilitation management and gather evidence on this population.

The Effectiveness of Behavioral Interventions in Adults with Post-Traumatic Stress Disorder during Clinical Rehabilitation: A Rapid Review

Background: This review examined the effectiveness of behavioral interventions for adults with post-traumatic stress disorder (PTSD) triggered by physical injury or medical trauma. It discusses implications in support of rehabilitation management for COVID-19 survivors diagnosed with PTSD. Methods: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Interim Guidance from the Cochrane Rapid Reviews Methods Group. The authors searched for randomized control trials in PubMed, Embase, and CENTRAL databases up to 31 March 2021. Results: Five studies (n = 459) met the inclusion criteria. Each study measured a different comparison of interventions. The certainty of the evidence was judged to be very low for all outcomes. Post-traumatic stress disorder symptom reduction was found to be in favor of trauma-focused cognitive-behavioral therapy, cognitive therapy, and cognitive-behavioral therapy. Cognitive function improvements were observed in favor of the cognitive processing therapy control intervention. Conclusions: Overall, there is uncertainty about whether behavioral interventions are effective in reducing PTSD symptoms and improving functioning and quality of life when the disorder is triggered by a physical or medical trauma rather than a psychological trauma. Further research should investigate their efficacy in the context of rehabilitation management and gather evidence on this population.

Cochrane Rehabilitation: 2020 annual report.

During its fourth year of existence, Cochrane Rehabilitation went on to promote evidence-informed health decision-making in rehabilitation. In 2020, the outbreak of the COVID-19 pandemic has made it necessary to alter priorities. In these challenging times, Cochrane Rehabilitation has firstly changed its internal organisation and established a new relevant project in line with pandemic needs: the REH-COVER (Rehabilitation - COVID-19 evidence-based response) action. The aim was to focus on the timely collection, review and dissemination of summarised and synthesised evidence relating to COVID-19 and rehabilitation. Cochrane Rehabilitation REH-COVER action has included in 2020 five main initiatives: 1) rapid living systematic reviews on rehabilitation and COVID-19; 2) interactive living evidence map on rehabilitation and COVID-19; 3) definition of the research topics on "rehabilitation and COVID-19" in collaboration with the World Health Organization (WHO) rehabilitation programme; 4) Cochrane Library special collection on Coronavirus (COVID-19) rehabilitation; and 5) collaboration with COVID-END for the topics "rehabilitation" and "disability." Furthermore, we are still carrying on five different special projects: Be4rehab; RCTRACK; definition of rehabilitation for research purposes; ebook project; and a prioritization exercise for Cochrane Reviews production. The Review Working Area continued to identify and "tag" the rehabilitation-relevant reviews published in the Cochrane library; the Publication Working Area went on to publish Cochrane Corners, working more closely with the Cochrane Review Groups (CRGs) and Cochrane Networks, particularly with Cochrane Musculoskeletal, Oral, Skin and Sensory Network; the Education Working Area, the most damaged in 2020, tried to continue performing educational activities such as workshops in different online meetings; the Methodology Working Area organized the third and fourth Cochrane Rehabilitation Methodological (CRM) meetings respectively in Milan and Orlando; the Communication Working Area spread rehabilitation evidences through different channels and translated the contents in different languages.

Rehabilitation of Neuromuscular Diseases During COVID-19: Pitfalls and Opportunities.

The outbreak of COVID-19 caused by SARS-CoV-2 has spread worldwide with a huge impact on the healthcare system. Compared to the previous coronaviruses-related pandemics, COVID-19 is more transmissible with potential systemic involvement and peculiar neurological manifestations, such as Guillan-Barrè syndrome up to critical illness myopathy, occurring in the intensive care setting. In this clinical scenario, people living with a neuromuscular disease (NMD) represent a vulnerable category with a high risk of a severe course of COVID-19. Moreover, in the NMD population, the management of respiratory and muscular impairments after SARS-CoV-2 infection might be troubling in terms of both pharmacological and rehabilitative approaches. To date, rehabilitation is still an unmet need in this population with several implications on NMD progression with and without SARS-CoV-2 infection. In particular, rehabilitation intervention for patients with NMD after COVID-19 are lacking. Therefore, in the current paper, we analyze the critical issues of COVID-19 on NMDs patients and propose a home-based rehabilitation program targeted for this population after mild to moderate SARS-CoV-2 infection.

Post-Acute COVID-19 Rehabilitation Network Proposal: From Intensive to Extensive and Home-Based IT Supported Services.

Management of COVID-19 post-acute syndrome is an emerging health issue in rehabilitation. This article aims to present a proposal, based on the principles of clinical governance, health management and information technology (IT), and to respond to the need for a structured organization model for post-acute COVID-19 rehabilitation. The authors present a regional-based model of a network of clinicians and healthcare managers using a dedicated IT platform to achieve both effectiveness and efficiency objectives, to ensure coordination of the available resources and the most appropriate rehabilitative treatment for patients. The proposed post-acute COVID-19 rehabilitation network has been designed according to the model of a clinical management project within the Italian national healthcare system, and its context is an easily adjustable model for the European healthcare systems. The authors base the project on current laws and scientific guidelines in rehabilitation in Italy and in Europe and use the SWOT analysis technique to assess the proposal feasibility. The primary aims of the project are: (1) standardizing the minimum assessment tools of post-COVID-19 patients with disabilities; (2) ensuring an individual rehabilitation project for each patient with international classification of functioning, disability and health (ICF) coding and (3) reporting the activity performance with appropriate indicators. The secondary aims are: (1) developing educational programs for patients and care givers also aimed at acquiring better empowerment and positive behavior; (2) creating a regional database for data collection and (3) improving IT, and specifically tele-rehabilitation, as a suitable approach during the COVID-19 emergency and also in the future. Expected results are: continuum of care; effectiveness, efficacy and appropriateness in the delivery of rehabilitation treatments through a standardized minimum assessment and the wording of the individual rehabilitation project and a precise reporting of performance indicators to measure the effectiveness of clinical activities and the satisfaction of patients and caregivers. The assessment of results will be analyzed at three and six months to implement corrective actions according to the concept of continuous improvement of the Deming cycle. The IT remote approach allows the patient to meet the needs of proximity of care and empowerment, and, at the same time, to contain the spread of infection. This project could have a significant healthcare impact ensuring a more efficient and effective management of the demand of rehabilitation post-acute COVID-19, expanding the professional skills of the rehabilitation team members, improving both clinical and process data, in addition to optimal allocation of available economic resources.

Incidence and Persistence of Viral Shedding in COVID-19 Post-acute Patients With Negativized Pharyngeal Swab: A Systematic Review.

After the global spread of a severe acute respiratory syndrome caused by a coronavirus (SARS-CoV-2), factors that influence viral diffusion have gained great attention. Human-to-human transmission mainly occurs through droplets, but viral RNA clearance in different biological fluids in coronavirus disease 2019 (COVID-19) remains unclear. We aimed to correlate the presence and the relevant temporal patterns of SARS-CoV-2 viral RNA in biological specimens (stool, urine, blood, and tears) of the transmission with clinical/epidemiological features in patients with COVID-19. We focused on the time window between the positivity of reverse transcriptase-polymerase chain reaction (RT-PCR) tests from different specimens. We used the Mantel-Cox log rank test to verify the differences in terms of viral shedding duration, while we employed the Mann-Whitney U-test for subgroup analysis. This review protocol was registered with PROSPERO number: CRD42020183629. We identified 147 studies; we included 55 (1,348 patients) for epidemiological analysis, of which we included 37 (364 patients) for statistical analysis. The most frequently used specimens other than respiratory tract swabs were stool samples (or anal/rectal swabs), with a positivity rate of 48.8%, followed by urine samples, with a positivity rate of 16.4%; blood samples showed a positivity rate of 17.5%. We found that fecal positivity duration (median 19 days) was significantly (p < 0.001) longer than respiratory tract positivity (median 14 days). Limited data are available about the other specimens. In conclusion, medical and social communities must pay close attention to negativization criteria for COVID-19, because patients could have longer alternative viral shedding.