In Central America, the COVID-19 pandemic coexists with a devastating epidemic of chronic kidney disease of unknown origin. The consequences of these overlapping health crises remain largely unknown.We assessed vulnerability to and impact of the first wave of COVID-19 on participants in a cohort study of chronic kidney disease (CKD) in El Salvador (n = 229). Participants were contacted by phone during August and September 2020. We queried changes to employment, healthcare access, household income and food security due to the pandemic (from March 2020 until the time of the interview) and COVID-19-associated symptoms during that time.We reached 94% of the cohort (n = 215). Nearly 40% of participants reported an unexpected change in employment or work activities and 8.8% reported new unemployment due to the pandemic. Participants with CKD (n = 27) had higher odds of reporting new income insecurity, food insecurity, and reductions in medical care access due to the pandemic. COVID-19-associated symptoms (an approximation of disease) were reported in 7.0% (n = 15). Participants with CKD were more likely to report COVID-19-associated symptoms compared to those without CKD, although these differences were not statistically significant.Overall, participants with CKD suffered greater economic consequences as a result of the pandemic and may have experienced higher incidence of COVID-19 disease, although laboratory diagnostics would be required to draw this conclusion. Longitudinal analyses are required to comprehensively evaluate the implications of the pandemic for individuals with CKD in Central America. As of March 2022, COVID-19 has caused over 450 million reported cases and more than six million deaths worldwide .As of December 2021, COVID-19 was a leading cause of death in four Mesoamerican nations , surpassing heart disease, cancers and other chronic diseases . Social In El Salvador, the government’s rapid response to the pandemic and stringent lockdown in the spring of 2020 was one of the strictest in the world. On March 11, 2020, government leaders instituted broad shutdowns of all public services to mitigate transmission of SARS-CoV-2 within the country. These quarantine measures remained in place for nearly three months. As of October 2022, the country of approximately 6.5 million has reported more than 202,000 cases and more than 4,230 deaths .In El Salvador, the COVID-19 pandemic exists concurrently with a devastating epidemic of chronic kidney disease primarily affecting young working-age men living along the Pacific coast. Referred to globally as chronic kidney disease of unknown origin (CKDu) or Mesoamerican Nephropathy (MeN), it is not preceded by traditional risk factors including diabetes or hypertension . CKD .At each round of follow-up, we shared clinical laboratory results of the prior round with each individual. Participants with eGFR < 60 mL/min/1.73 mWhile CKD was identified early on as a risk factor for COVID-19 infection and severity in high-income countries 14, thereTo maintain contact and assess the vulnerability of our study participants during the first wave of COVID-19, we administered questionnaires via phone with MANOS participants in El Salvador in August and September 2020. We hypothesized that MANOS participants were impacted broadly by the pandemic, through changes in employment, healthcare access, and income or food insecurity. We also hypothesized that participants with CKD, due to loss of healthcare access, and those working in non-agricultural industries, due to loss of employment, would experience worse economic and occupational impacts of the pandemic compared to others. We considered associations between self-reported symptoms of COVID-19 and important lifestyle and quality of life changes with our most recent kidney health data, specifically comparing the experiences of our participants with CKD to those without CKD.Comité Nacional de Ética de las Investigaciones en Salud). All methods were carried out in accordance with relevant guidelines and regulations and all participants provided informed consent.Salvadoran MANOS investigators initiated phone contact with study participants actively enrolled at this time in the MANOS cohort in El Salvador (n = 229) during August and September of 2020. Interviews were conducted in Spanish by Salvadoran MANOS team members who were not blinded to participant CKD status, as they were engaged in the past in reporting eGFR data back to participants. All study protocols were approved by the Institutional Review Board at Boston University Medical Campus (#H-35819) and the Salvadoran National Ethics Committee for Health Research . Symptom questionnaires were adapted from those collected in the PhenX COVID-19 Protocol library to reflect those symptoms commonly experienced by diagnosed COVID-19 patients . We aske2 at two time points separated by at least three months [2 in two of the first four rounds of our study follow-up, each separated by six months, from 2018–2020. We used age-adjusted logistic regression  to compare odds of new food insecurity, income insufficiency and reduced access to medical care, comparing participants with CKD to those without CKD. Logistic regression was also used to explore the association between three or more symptoms associated with COVID-19 infection and current agricultural work (Y/N) and concurrent CKD (Y/N), after adjusting for age. All analyses were conducted in Stata IC/16.1.Changes to employment, use of PPE and physical distancing, food insecurity, income insufficiency and access to healthcare were evaluated descriptively in sum and by industry. Participants who reported three or more concurrent COVID-19-associated symptoms were designated as a suspected cases. We evaluated incidence of three or more concurrent self-reported COVID-19-associated symptoms during the study period as an approximation of disease incidence. We compared approximated disease incidence between participants with and without CKD. Per our existing protocols, kidney function was determined using serum creatinine to estimate glomerular filtration rate (eGFR) using the serum creatinine-based CKD-EPI equation . CKD wase months . We consOur team successfully reached 215 participants with the COVID-19 phone questionnaire (response rate: 93.9%). Median age was 30 years  and 16.7% of participants (n = 36) were 40 years or older. As earlier noted, all participants were male. Among those in the COVID-19 study, 27 participants (12.6%) were identified as having CKD on the basis of eGFR measurements from samples collected prior to the pandemic.One hundred thirty-six participants (62.3%) were actively employed in agricultural industries at the time of the phone interview, including 35 (16.3%) in sugarcane, 89 (41.4%) in corn production and eight (3.7%) in mostly small-scale subsistence farming . The majOver 38% of MANOS participants (n = 81) reported a change in their job due to the pandemic . The larTwelve participants (5.6%) reported severe reductions to household income due to the pandemic (which we termed new income insecurity) to the extent that they were newly unable to afford basic necessities . Eight oThirty-one participants (14.4%) indicated that due to the pandemic their households experienced either occasional or frequent food insecurity, defined as occasionally or frequently having not enough food for household members . Of thosSixty-seven individuals (31.2%) indicated that they had newly experienced moderate or severe reductions in access to medical care due to the pandemic . Of thesEighteen participants (8.4%) reported three or more COVID-19-associated symptoms . COVID-1In age-adjusted logistic regression, agricultural work was associated with a 23% reduction in odds of COVID-19-associated symptoms compared to non-agricultural work  . CKD staOur findings indicate that working-aged men in El Salvador experienced notable instability in employment, new income and food security, and reduced access to medical care during the early months of the COVID-19 pandemic. Participants with CKD appeared to suffer greater economic hardships associated with pandemic-related disruptions and may have experienced incidence of COVID-19 disease, although laboratory diagnostics would be required to draw this conclusion.Approximately 40% of study participants reported a change to their work due to the pandemic, with nearly 9% indicating new unemployment due to the pandemic. These findings are suggestive of widespread employment instability in the region and may be particularly acute for workers who are employed through informal arrangements or seasonal contracts. While all MANOS participants were employed in a defined set of industries at baseline enrollment in 2018 , reports of participants changing work due to the pandemic to be employed across a larger variety of industries and jobs indicates that some study participants sought non-traditional, perhaps temporary, work during this period. The long-term implications of these findings are important areas for future study, both into the later months of the pandemic and in the post-pandemic economy. Despite these employment shifts, we note that more than 90% of MANOS participants were actively employed when contacted for this study, reinforcing the ‘essential’ nature of their work and that many working age men in the country did continue to work in spite of the pandemic lockdown.Despite uncertainty around our estimates of COVID-19 disease, incidence of COVID-19-associated symptoms in the cohort in El Salvador from March through September 2020 (7.0%) appears high in comparison to the country as a whole. For reference, as of December 2021, the total positive case count represents 1.2% of the country’s population. Our findings are clearly limited by our symptoms-based assessment, which provides an imperfect estimation of disease incidence compared to laboratory-based diagnostics  which were in limited supply in the region at the time. Our use of a symptoms-based estimation of infection is consistent with other efforts at the time , and evi1921Given limited diagnostics in the region during the early months of the pandemic, it remains possible that government statistics also reflect an underestimate of disease burden from this early pandemic period. We note that the majority of participants who were tested for COVID-19 were employed in corn production, although we do not know if this testing was due to a disease cluster, symptoms, or surveillance. Additional information would inform a more comprehensive understanding of our testing data. Furthermore, symptoms-based assessment would clearly not depict asymptomatic infection, which may be higher than 30% of all COVID-19 infections 24. RestrAlthough there is large statistical uncertainty, we observed higher incidence of COVID-19-associated symptoms among participants with CKD compared to those without CKD. These observations, while not determinative, may suggest that persons with CKD experience greater susceptibility to symptomatic COVID-19. Our sample size prevented us from evaluating industry as a risk factor in these adjusted COVID-19 models; however, such studies are warranted. The long-term consequences of COVID-19 infection on the progression of CKD in Central America and on kidney health among persons at risk remains an important area for our future study.Notably, individuals with CKD experienced greater risk of food insecurity, income loss and reductions in access to medical care compared to those without CKD, although our findings do not inform the specific reasons for this association. In a region with elevated prevalence of CKD, these implications of the COVID-19 pandemic are particularly concerning. Additionally, reduced access to medical care during the pandemic poses a significant health risk to individuals with CKD, who require regular engagement with health professionals to successfully manage the disease. Loss of regular medical care is particularly devastating for individuals with more advanced disease and a critical area for intervention. Further analyses should consider specific forms of healthcare access that were lost during the pandemic and the implications for CKD patients.We observed lower odds of COVID-19-associated symptoms among participants working in agriculture compared to those in non-agricultural industries. Evidence indicates that SARS-CoV-2 does not transmit effectively outdoors, and it is possible that our findings support this conclusion . Our obsOur study indicates significant negative effects of the early months of the pandemic on wellbeing and health of MANOS participants and their household members. Notably, more than 14% of participants reported new food insecurity during this time period and more than 5% indicated a loss of income resulting in an inability to purchase basic household necessities. These difficulties occurred despite governmental efforts to address income and food insecurity early in the pandemic. In May 2020, the El Salvadorian government initiated income and food support to households not covered by the pension system . These payments included $300 per household and 2.7 million food baskets to lower-income households in the spring of 2021 . We assuThe effect of new income and food insecurity could be particularly devastating on families already experiencing poverty 29. In pa30Our study is limited to the first six months of the pandemic. It is possible that data from later months of the pandemic would reflect different experiences with COVID-19 among MANOS participants. At baseline, all MANOS participants, including those with CKD, were employed full-time. As full-time workers, the overall health of our participants may contribute to reduced susceptibility to severe COVID-19. As a result, our findings may underestimate the incidence of COVID-19 among individuals with CKDu in the region, including those who are unable to work. It is possible that the participants who we failed to reach for this study differed from those enrolled in MANOS in a way that biased our estimates, although the directionality of such a potential effect is unclear. The timeframe of this study (March through September 2020) reflected the early wave of the pandemic, but it is feasible that we underestimated COVID-19 symptoms among those who were contacted earlier in the study period when the disease was less prevalent. While there is no difference in timing of contact by CKD status, the time required to contact participants likely led to an underestimate of symptoms among those interviewed earlier in the study period. We were unable to reach all participants with CKD for this substudy; this reflects both general loss to follow up prior to the pandemic as well as potential loss specific to the pandemic or this substudy. It is possible that our estimates regarding the negative effects of the pandemic associated with CKD were attenuated as a result.We note that our study overlapped with the final months of the sugarcane growing season and included the rainy season, during which sugarcane workers are typically employed in other industries. While we specifically queried pandemic-related employment changes as distinct from regular, seasonal changes to employment, it is possible reports from sugarcane workers incorporate both predicted and unexpected employment changes. We did not comprehensively capture transport to and from work in our study, and it is possible that associations observed are due to transportation compared to occupational exposures or other factors. It is also possible that unemployment status peaked earlier in the study months, suggesting that persons contacted earlier in the study period were more likely to report unemployment. Follow-up studies of the longer-term implications of the pandemic for employment in El Salvador would be needed to fully address these potential concerns. Finally, some COVID-19 symptoms, specifically fever, muscle ache and fatigue, may be associated with acute kidney injury (AKI) events, as there are reports of such in the literature 33. It isFindings from our study identified significant economic disruption and morbidity within this working-age cohort in El Salvador during the first six months of the pandemic. There is scant information on incidence or community health in Central America during the pandemic, and in many regions the COVID-19 pandemic is overlaid with an ongoing epidemic of CKD in the region. The intersections of these crises warrant immediate intervention. Continued attention to Central American communities is necessary to attenuate the effects of the COVID-19 pandemic.The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


Work-related stress is significantly higher among healthcare workers (HCWs) than in the general population. Elevated occupational stress has been linked to burnout syndrome and depression. Moreover, medical professionals working during infectious disease outbreaks are at especially high risk for these problems. The aim of the present study was to examine the mental health status of HCWs and possible predictors of mental health status related to the COVID-19 outbreak utilizing a complex comprehensive model.In a countrywide cross-sectional survey among HCWs (N = 2087), work-related stress, COVID-19 -related objective work factors  and subjective work factors , perceived stress, work-related stress, burnout and depression were assessed between the second and third wave of COVID-19 pandemic in Hungary.COVID-19-related objective factors did not predict directly stress, burnout, and depression, whereas feelings of insecurity and unpredictability in relation to the COVID-19 situation at work had a significant medium-sized total effect  on burnout and depression.In order to prevent subsequent mental health problems during crisis situations, such as the COVID-19 pandemic, healthcare management should create a more predictable work environment and a safer work experience for healthcare workers and provide mental health support. Work-related stress has been found to be significantly higher among healthcare workers (HCWs) than among the general population, which also impacts negatively on their mental health –3. The eAccording to a recent systematic review, psychiatric morbidity among physicians ranged from 17% to 52% . DepressThe emotional and mental vulnerability of HCWs is even more important during pandemics. As in any epidemiological crisis situations, HCWs are particularly exposed to stress at work. Therefore, the novel coronavirus disease 2019 (COVID-19) outbreak is likely to have had a significant impact on the mental health of HCWs. Among HCWs, the probability of infection is extremely high, and many professionals are forced to work in a changed work environment with an increased workload .Previous research has suggested that medical professionals working during infectious disease outbreaks are at high risk for PTSD, depression, and burnout syndrome . EarlierAn umbrella review concerning the mental health impacts of the COVID-19 pandemic among HCWs reported a 24.9% prevalence of anxiety disorders and 24.8% prevalence of depression . AnotherSeveral studies have also examined the differences in mental health impact of viral outbreaks between nurses and physicians. Both previous studies carried out during the 2003 SARS outbreak, and the more recent ones during the COVID-19 pandemic have reported poorer mental health outcomes among nurses compared to other medical professional staff –23. A SpIt is important to highlight the predictive factors of high anxiety and depression levels among HCWs who feel less secure during their frontline work . Many stThe acute care of COVID-19 patients has been a significant burden on healthcare in Hungary. According to the Hungarian governmental webpage (koronavirus.gov.hu), the average number of new COVID-19 infections per million population during the study period was 257 (SD = 146). During the same period, the average number of hospital admissions per million people was 449 (SD = 83), and the average number of patients on ventilators per million people was 38 (SD = 11). The latest available official statistical data shows the number of acute hospital beds was 4271 per million inhabitants , which mBased on the aforementioned considerations, the aim of the present study was to examine the mental health status (including depression and burnout syndrome) of HCWs and its possible predictors related to the COVID-19 outbreak. Compared to previous studies, the present one examined the relationship between mental health indicators and the possible predictive factors in a complex model . The goaMembers of the Hungarian Medical Chamber (HMC) and Hungarian Chamber of Health Professionals (HCHP) were sent the link to the survey. A total of 3321 individuals started the survey during the data collection period between January 14 and March 5, 2021, between the second and third wave of COVID-19 pandemic in Hungary. The data of participants were included if they completed at least the 90% of the survey (N = 2260). Sixty-four respondents were excluded after anomaly detection in items of the psychometric scales using the SPSS ‘DETECTANOMLY’ function. A further 109 respondents who reported that they were not physicians or HCWs were also excluded from the final sample. The final sample, following omissions based on the aforementioned criteria, comprised 2087 individuals , with ages ranging from 21 to 87 years . All participants were actively working as HCWs and none of the participants were retired. One-third were physician HCWs (33.78%) and 66.22% were non-physician HCWs; 38.06% worked in direct COVID-19 healthcare departments , and 61.94% worked in non-COVID-19-related departments. Approximately one in six participants (16.72%) were relocated during the pandemic, while the remainder were not (83.28%).Qualtrics. The survey was pretested and adjusted in a pilot with HCWs. A link to the survey was sent to members of the HMC and HCHP accompanied by a short description about the study. All participants gave their informed and voluntary consent for participation and could withdraw at any time. Participants were given feedback based on evaluation of the Beck Depression Inventory. Psychological aid was offered for all participants, provided by a cooperating treatment service provider.APA ethical standards were followed in the conduct of the study, and the study was approved by the ELTE Eötvös Loránd University Research Ethics Committee. An online survey was developed using not agree at all) to 7 (fully agree). The first item assessed changes in workload (“The amount of work I do has increased”), the second item assessed work-related insecurity (“I feel less secure in my work”), and the third item assessed work-related unpredictability (“My job schedule is more unpredictable”).COVID-19-related background factors were assessed using self-developed items. Objective background factors were assessed by two items. One item assessed whether the respondent was working on the frontline (COVID-19 department irrespective of whether it was an ICU or non-ICU emergency department) or not. The other item assessed whether the HCW was relocated  during the pandemic or not. Subjective background factors were assessed using three items. Each item  is scored on a seven-item scale from 1  is scored on five-point scale from 0 (never) to 4 (very often), with positive items reverse scored .Perceived stress was assessed using the four-item version of Perceived Stress Scale (PSS)  (Hungarith version) (PQL STS), developed as part of tool assessing quality of life among caregiving professionals ).However, in a major difference to the hypothesized model, no direct effect of COVID-19-related objective factors  to stress, burnout, or depression was found. Based on the results, it appears that the difficulties caused by the pandemic only had a mediated effect. Because stressors exert their effect through subjective perception only, it underpins the importance of mental health support among HCWs in times of extreme crisis situations as suggested by Lee et al. . ConsistComparing physician HCWs and non-physician HCWs, no differences were found in the mechanisms of how COVID-19-related factors may cause stress, burnout, and depression. Therefore, in the model proposed, similar background factors may play a role in both HCW sub-populations. However, the study found that non-physician HCWs perceived a higher increase in work insecurity and in workload (COVID-19-related subjective factors) than physician HCWs and they also had higher mean depression scores compared to physician HCWs, although there were no significant differences between the two groups in the level of stress or burnout. These seemingly controversial results can be understood based on the model explained above. The differences in COVID-19-related subjective factors through direct and indirect paths only yielded a significant difference in the level of depression while the difference in the level of the partial mediator stress and burnout were not significant. Other researches comparing stress, burnout and depression among physician HCWs and non-physician HCWs were controversial. While Ruiz‐Fernández  reportedThe present study’s sample comprised high proportion of female HCWs. There could be additional care burdens in the case of female HCWs due to the impact of the COVID-19 pandemic within their own families . HoweverThe study has a number of limitations that should be considered when interpreting the findings. While the sample size was large and all members of the HMC and HCHP had the opportunity to participate in the survey, the participants were recruited using convenience sampling. Moreover, the data collected were self-report (which is subject to well established methods biases) and cross-sectional in nature . The findings were supported by both theoretical literature and previous research which decrease the possibility of misinterpretation of causality. The survey was administered online that which limited the length of the questionnaire. This limitation meant other important factors were not assessed such as resilience, social support, and more detailed questions concerning working conditions. Assessing and analyzing these factors in further research with a face-to-face study would help the in-depth understanding of the relationships examined in the present study. In-depth understanding of the psychological mechanisms underlying the findings could also be supported by further semi-structured interviews in future research.Based on the results reported here, in order to prevent subsequent mental health problems during crisis situations, such as the COVID-19 pandemic, it is extremely important to provide effective and accurate information to HCWs on safe patient care, to help create a predictable work environment in order to increase sense of security. The importance of greater sense of control and more accurate information concerning COVID-19 patient management was also emphasized by Ruiz‐Fernández et al. . The qua


Background: This study determined the effect of the COVID-19 pandemic on adherence to medication among children with congenital adrenal hyperplasia (CAH) living in the Kingdom of Saudi Arabia (KSA).Methods: Data were collected from April 2020 to April 2022 through face-to-face or telephonic interviews at a virtual paediatric endocrine clinic in Jeddah, KSA.Results: A total of 55 children, with a mean age of 12.9 ± 5.8 years, participated in the study. Most children  were administered treatment by their mother. Before the COVID-19 pandemic, 51 patients (93%) reported adhering to their CAH treatment. After the onset of the COVID-19 pandemic, this number decreased to 49 . The most common reasons for non-adherence before and after the pandemic included restricted access to medication  and challenges in obtaining new prescriptions and refills. These challenges increased after the onset of the pandemic. Before and after the onset of the pandemic, mothers with a university degree were significantly more likely to administer medication than mothers without a university degree, but fathers’ education level did not affect their role in medication administration, before or after the onset of the pandemic.Conclusion: This study confirms that the COVID-19 pandemic did not have a significant effect on medication adherence in children with CAH in Jeddah. Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive genetic disorders characterised by a deficiency of enzymes involved in the biosynthesis of corticosteroids and mineralocorticoids secreted by the adrenal glands. The disease has a variety of phenotypes . In SaudThe 2019 outbreak of Coronavirus disease (COVID-19) in Wuhan, China, led to a pandemic that was officially proclaimed in March 2020 and continues at the time of writing (July 2022). The virus is transmitted between humans via the droplet and faecal-oral routes . To prevMedication adherence among children and adolescents with chronic diseases is determined by several factors. These factors include medication accessibility and type; family and caregiver structure; healthcare system characteristics; and cultural, psychological, and socioeconomic factors . The COVTo the best of our knowledge, this is the first study to evaluate the effect of the COVID-19 pandemic on treatment adherence among patients with CAH.Study design and patientsA cross-sectional descriptive study was conducted at the King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia (KSA). Data on child/adolescent patients with CAH who are on medication were collected from their parents or guardians or from the adolescent patients themselves in Jeddah city via face-to-face or virtual interviews from April 2020 to April 2022. In this study, 55 patients were recruited according to the following inclusion criteria: aged 0-18 years, a diagnosis of CAH, and a prescription for hydrocortisone therapy. Patients were excluded from this study if they were aged >18 years, lived outside the country, had missing medical record data, or missed clinic appointments. This study was limited to 55 patients owing to the rarity of the disease.Variable assessmentsPatient data were anonymised and stored in the principal investigator’s office. Only the study co-authors had access to the dataset. The Research and Ethics Committee of the King Abdul-Aziz University Hospital approved the study protocol . All study procedures adhered to the provisions of the Helsinki Declaration. Written consent was obtained from adolescent patients (10-18 years) and their caregivers and from the primary caregivers of paediatric patients (0-9 years and 11 months) before the clinical interview. Face-to-face interviews were conducted at a paediatric endocrine clinic during the study period for children older than 10 years; data of younger children were obtained from their caregivers to assess adherence through structured interviews. The interviews were conducted in Arabic and consisted of three parts. The first part recorded information on demographic characteristics, such as socioeconomic status, gender, age, and the people responsible for medication administration and their level of education. The second and third parts recorded medication adherence and the regularity of clinic follow-up visits and laboratory tests, respectively. Treatment-related items included medication type and frequency (hydrocortisone and fludrocortisone), adherence, and reasons for non-compliance with clinic visits before and after the onset of the COVID-19 pandemic.Statistical analysisThe data were coded, tabulated, and analysed using SPSS version 20 . Categorical variables are presented as counts and percentages, and comparisons between groups were performed using the chi-square test. Continuous variables are presented as means and standard deviations. Non-normally distributed variables were tested using the Mann-Whitney U test and Kruskal-Wallis test. Correlation analysis was performed using Spearman’s rank correlation co-efficient. P-values <0.05 indicated statistical significance.The characteristics of the patients and their parents are presented in Table Before the COVID-19 pandemic, 51 patients (93%) reported adhering to their prescribed CAH treatment. However, after the onset of the COVID-19 pandemic, this number decreased to 49 . Reasons for non-adherence before and after the pandemic are shown in Table A total of 45 patients (82%) were prescribed hydrocortisone three times per day. The adherence rates before and after the onset of the COVID-19 pandemic were comparable. In addition, the number of patients who were prescribed hydrocortisone three times a day was comparable before and after the pandemic’s onset (p = 0.999).Before the pandemic, 41 patients (75%) underwent laboratory testing every three months. After the onset of the pandemic, this decreased to a total of 37 patients (67%). Similarly, before the pandemic, a total of 40 patients (73%) attended scheduled follow-up visits every three months. After the onset of the pandemic, this decreased to 37 patients (67%), primarily owing to the availability of virtual clinics.Before and after the onset of the pandemic, mothers with a university degree were significantly more likely to administer medication. The father’s level of education was not associated with medication administration before or after the pandemic’s onset.The patient characteristics associated with adherence to treatment with hydrocortisone and fludrocortisone before and after the pandemic’s onset are shown in Tables The COVID-19 pandemic has affected different aspects of the lives of children and adolescents with CAH, including but not limited to medication adherence and availability and follow-up in the clinic. This study assessed the effect of the COVID-19 pandemic on medication adherence in patients with CAH and showed that there was no significant difference in medication adherence before and after the onset of the COVID-19 pandemic. Several factors affect young people’s treatment compliance, including caregiver structure, treatment type, administration frequency, follow-up appointment scheduling, and medication sources.Several studies have been conducted on adults and children to assess medication adherence in Saudi Arabia. A study of adult diabetes patients showed reduced adherence to medication and a healthy lifestyle during the COVID-19 pandemic. Adherence was assessed by a questionnaire .Early diagnosis and treatment of CAH helps prevent poor outcomes. Treatment includes glucocorticoid replacement in the form of hydrocortisone at a dose of 10-15 mg/m2/day three times per day and mineralocorticoid replacement with 9α-fludrocortisone acetate at a dose of 100 µg once or twice daily. Sodium chloride replacement is recommended for infants . HydrocoIn previous studies conducted before the COVID-19 pandemic on pediatric patients with chronic diseases, 65-90% of patients did not adhere to treatment, with an average adherence rate of approximately 50% . In contMany factors have affected medication adherence in the paediatric population during the COVID-19 pandemic, including individual and family characteristics, as well as community and healthcare system factors. On an individual level, changes to daily routines may affect adherence by increasing forgetfulness; however, increasing parental responsibilities, including home-schooling and home-working, may have disrupted child treatment adherence. Conversely, increased caregiver supervision may increase medication adherence among children . In thisPatients with CAH require regular follow-up visits at the clinic. Patients aged ≤18 months require appointments every three months. Patients aged ≥18 months require appointments every three to six months with regular laboratory tests to evaluate serum electrolyte and plasma hormone levels and to make medication adjustments, as required. Outcomes associated with undertreatment can be monitored during these appointments, helping prevent failure to thrive, blood pressure abnormalities, and peripheral precocious puberty, leading to the early closure of the epiphyses ,8. This Paediatric treatment adherence is determined by many factors, including caregiver education level. Specifically, higher educational attainment of the parents is associated with higher treatment adherence rates of the children . A studyLimitationsThis study has some limitations. The sample size was small because of the rarity of the disease. This study used self-reporting for older children (aged over 10 years) and parental reporting for younger children, which may have introduced respondent bias. Other limitations include the limited geographic area covered (one clinic in one city) and loss-to-follow-up during the COVID-19 pandemic, either due to the pandemic or due to lack of access to technology for virtual clinic follow-up. Future research should evaluate the adherence of patients with CAH in several different cities in Saudi Arabia and should also evaluate the effect of virtual clinics on patients with other chronic diseases.The COVID-19 pandemic introduced physicians to the value of virtual follow-ups as a convenient alternative to hospital visits for stable patients with chronic diseases. The results of this study suggest that this approach helps maintain high adherence rates. Virtual clinics are a suitable model of care for the follow-up of patients with chronic diseases, even under non-epidemic conditions.


Concerns have grown that post-acute sequelae of COVID-19 may affect significant numbers of survivors. However, the analyses used to guide policy-making for Australia’s national and state re-opening plans have not incorporated non-acute illness in their modelling. We, therefore, develop a model by which to estimate the potential acute and post-acute COVID-19 burden using disability-adjusted life years (DALYs) associated with the re-opening of Australian borders and the easing of other public health measures, with particular attention to longer-term, post-acute consequences and the potential impact of permanent functional impairment following COVID-19.A model was developed based on the European Burden of Disease Network protocol guideline and consensus model to estimate the burden of COVID-19 using DALYs. Data inputs were based on publicly available sources. COVID-19 infection and different scenarios were drawn from the Doherty Institute’s modelling report to estimate the likely DALY losses under the Australian national re-opening plan. Long COVID prevalence, post-intensive care syndrome (PICS) and potential permanent functional impairment incidences were drawn from the literature. DALYs were calculated for the following health states: the symptomatic phase, Long COVID, PICS and potential permanent functional impairment . Uncertainty and sensitivity analysis were performed to examine the robustness of the results.Mortality was responsible for 72-74% of the total base case COVID-19 burden. Long COVID and post-intensive care syndrome accounted for at least 19 and 3% of the total base case DALYs respectively. When included in the analysis, potential permanent impairment could contribute to 51-55% of total DALYs lost.The impact of Long COVID and potential long-term post-COVID disabilities could contribute substantially to the COVID-19 burden in Australia’s post-vaccination setting. As vaccination coverage increases, the share of COVID-19 burden driven by longer-term morbidity rises relative to mortality. As Australia re-opens, better estimates of the COVID-19 burden can assist with decision-making on pandemic control measures and planning for the healthcare needs of COVID-19 survivors. Our estimates highlight the importance of valuing the morbidity of post-COVID-19 sequelae, above and beyond simple mortality and case statistics.The online version contains supplementary material available at 10.1186/s12889-022-13169-x. In response to the coronavirus disease 2019 (COVID-19) pandemic, Australian governments implemented a number of strict strategies, including international border closure, intermittent interstate border closure and lockdowns, effectively aiming to achieve COVID-19 zero .While these measures have been effective in reducing the number of COVID-19 cases and deaths compared to other nations, Australia has suffered significant economic losses as a result , and AusTo support the development of this plan, the Doherty Institute was commissioned by the National Cabinet to model the impact of different re-opening scenarios, based on vaccination coverage, public health and social measures (PHSM), the effectiveness of testing, trace, isolation, quarantine (TTIQ), with consideration of seeding infection growth . The DohTo better understand the dynamics and relative impact of COVID-19, the aim of our model is to supplement the Doherty modelling by estimating the full burden of COVID-19 in Australia’s border re-opening strategy using disability-adjusted life years (DALYs), paying particular attention to post-acute consequences and the potential impact of permanent functional impairment as a consequence of COVID-19. Readers should note that the authors of this paper were not involved in the Doherty Institute modelling exercise, and our modelling results should not be interpreted as bearing the endorsement of the Doherty Institute team.A decision tree was developed based on the European Burden of Disease Network (Burden-EU) protocol guideline and consensus model , 11 to eThe model in this study was developed in Microsoft Excel 2016  were estimated by summing the life years lost due to premature mortality (YLL) and the years lived with disability (YLD) primarily using an incidence-based approach , 11.\docYLL is calculated from the COVID-19 mortality statistics (M) and average life expectancy (LE), presented into a 10-age group band generated from public national data sources , 13.\docYLD for acute COVID-19, Long COVID and PICS (YLDinc) was calculated by multiplying the number of COVID-19 cases (N), the average duration of health state until recovery or death (D), and disability weight (DW). The disability weight accounts for the extent of health loss associated with the specific health outcomes, ranging from 0 to 1  .\documenSome COVID-19 survivors have developed permanent illness or disability (distinct from Long COVID) –9. Howevexcludes diabetes as a permanent impairment.The results of this model are presented in three scenarios. The base case DALYs consist of the mortality and morbidity impact of acute COVID-19, Long COVID and PICS. “Total Burden One” presents the base case result plus the potential impact of all listed permanent functional impairments. “Total Burden Two” The data were obtained from the literature, official statistics and Doherty’s modelling report , as updainitial number of daily cases present in the population at a given vaccination threshold”) were included in the Doherty analysis. Doherty model outputs over the first 180 days were reported in detail [Scenario 2C: Outbreaks seeded with 1000 to 4500 cases given partially effective TTIQ. The community has achieved COVID-19 vaccination coverage of 70% while maintaining low PHSM.medium PHSMs are overlaid between the 70 and 80% coverage thresholds with reversion to low PHSMs thereafter”.Scenario 2D: Outbreaks seeded with 1000 to 4500 cases given partially effective TTIQ. The “Scenario 3B: Outbreaks seeded with 300-1000 cases given partially effective TTIQ. The community has achieved COVID-19 vaccination coverage of 80% with baseline PHSM.Scenario 3C: Outbreaks seeded with 1000 to 4500 cases given partially effective TTIQ. The community has achieved COVID-19 vaccination coverage of 80% with baseline PHSM.The Doherty Institute COVID-19 model  was deven detail , enablinThe full definition of TTIQ and different levels of PHSM are reported elsewhere , 25. BriAccording to a systematic review and meta-analysis, approximately 17% (95%CI:14-20%) of total cases are asymptomatic . HoweverCOVID-19 cases were obtained from the Doherty Modelling Interim Report to the national Cabinet (17th September 2021) , and a pOur model assumed that Long COVID symptoms start directly after the symptomatic phase. Briefly, Long COVID refers to those patients experiencing any of the following symptoms: persistent fever, headache, muscle ache, weakness/tiredness/fatigue, nausea/vomiting, abdominal pain, diarrhoea, sore throat, cough, shortness of breath, loss or change of taste, loss or change of smell runny nose and chest pain post COVID-19 infection to reflect the symptoms observed in the studies of Liu et al. . Given tAccording to a large case-control study in the UK, fully vaccinated individuals appear less likely to experience Long COVID following “breakthrough” infection compared with their unvaccinated counterparts  . This OREvidence in the literature reported a wide range of permanent functional impairments after contracting COVID-19 –36. To qWe also included the debilitating effects often seen after ICU admission, commonly referred to as post-intensive care syndrome (PICS) . The morUncertainty analyses were undertaken to propagate parameter uncertainty (i.e. sampling error) from the input parameters to the final model outputs. Monte Carlo simulation with 2000 iterations via the add-in tool Ersatz  was used . EstimatThe pilot testing of the model was conducted using actual observed Australian COVID-19 cases, hospitalisations and deaths data from January 2020 to January 2021. In this pilot, we have conducted different sensitivity analyses on rates of acute health states, post-acute rates, and a 28-day recovery period from the acute health state to explore whether these input parameters have impacted the robustness of the results  and 89,958  respectively. Including the potential impact of permanent functional impairment, the total DALY Burden One was 197,534  for Scenario 3C and 185,174  for Scenario 3B. Doherty Scenarios 2C and 2D generate significantly lower DALY burden. The base case DALY burden for Scenarios 2C and 2D were 21,915  and 13,695 respectively. Total DALY Burden One including the potential burden of permanent function impairment was estimated as 49,046  for 2C and 30,705 for 2D. In all these scenarios, the total DALY burden is significantly higher in unvaccinated persons than in those vaccinated.  rate upon re-opening.To the best of our knowledge, this is the first study to illustrate the potential post-acute DALY losses arising from the hypothetical scenarios used by the Doherty Institute  to inforThe Doherty modelling accounts for the impacts of vaccination (and improved treatments) in reducing mortality from COVID-19. Our results show how this is reflected in a declining share of disease burden due to mortality compared with that seen in 2020 and how post-acute morbidity will drive an increasing share of COVID-19 disease burden in the future. Our study found that Long COVID was responsible for a large proportion of total YLDs (74-79%) in our base case DALY burden and accounted for 19-22% of the total DALYs lost across scenarios.A key advance in our study was to consider the possible impact of the potential burden of permanent impairment due to COVID-19, which contributed up to 80-82% of the total YLD or 51-55% of potential total DALY losses in our model. Thus, this is the first study that have estimated the burden of post-acute sequelae of COVID-19 by DALYs. Earlier models had only calculated the impact of the acute phase of COVID-19 and of Long COVID , 42–46. Our results emphasise the continuing importance of high levels of COVID-19 vaccination, not only to reduce mortality and severe acute illness but also to reduce the burden of Long COVID. At higher levels of vaccine coverage, the relative burden of longer-term morbidity increases, while that of mortality and acute illness decreases; healthcare system responses will increasingly need to deal with a larger post-acute burden of disease. Our results further emphasise a significant finding of the Doherty modelling – namely that, even with high vaccine coverage, specific choices of public health and social distancing measures still have significant impacts on case numbers. Overall COVID burden (acute and post-acute) is significantly higher under “baseline”  PHSMs than under low to medium settings. Data on the likely impacts on longer-term disease burden must therefore inform public health decision-making.Our results indicate that Australian health systems need to prepare to care for thousands of patients with Long COVID or PICS over the coming months. As discussed elsewhere , this reWe have used the Doherty modelling  where scKnowledge of post-COVID-19 sequelae is still evolving, and there are inevitable uncertainties around the estimates used in the model. Only the most cited permanent disabilities from COVID-19 with reported incidence rate was included to illustrate the potential additional morbidity from the impact of permanent functional impairment. Thus, the model might underestimate the burden of permanent functional impairment following COVID-19 infection given that only selected diseases were included based on the existing evidence. Also, international literature was used to inform the scale of permanent disability due to the scarcity of Australian data.The precise proportion of COVID-19 survivors who will experience Long COVID is still unknown and different studies reported a wide range of point estimates . We usedWe undertook uncertainty analysis to account for the unavoidable uncertainty in the total DALY estimation. Key inputs such as symptomatic recovery duration were tested using the COVID-19 2020 cases, and only a small variation was observed to total DALYs.This model assesses the likely magnitude of the overall burden of COVID-19 that can inform Australian and other policy-makers to prepare healthcare services and systems for the likely negative impacts beyond the acute phase of COVID-19 for Long COVID, PICS and permanent disability. A future COVID-19 burden of disease model could employ these health states to provide the likely impact of COVID-19 that goes beyond the acute phase of the pandemic.Our results emphasise that ongoing decisions on pandemic control measures and re-opening strategies need to incorporate more than simply numbers of expected infections and deaths. The burden of post-acute COVID-19 was already non-negligible during 2020. However, it becomes relatively more important as deaths fall with improved vaccination coverage. Emerging evidence of the potential for COVID survivors to develop significant long-term illness and disability – not to mention the impacts of Long COVID – means that policymakers in Australia and overseas will increasingly need to prepare for greater long-term demands for care and support. Our model provides a useful starting point for quantifying the burden involved, and can assist both planning and prioritisation efforts.In particular, we have demonstrated that even low rates of incidence of COVID-related permanent illness or disability could still lead to a very significant future burden of disease. Investing now in effective surveillance systems to understand the real incidence and burden of Long COVID and permanent illness or impairment after COVID is therefore essential, in Australia and other jurisdictions. Even more urgently, health services must act rapidly to meet the emerging needs of patients with Long COVID, PICS and longer-term illness, not only in the present Victorian and New South Wales outbreaks, but also for the new cases likely to accompany the progressive re-opening of Australia as envisaged in the National Plan . MoreoveAdditional file 1.Additional file 2.Additional file 3.Additional file 4.


Clozapine is an effective antipsychotic used in treatment-resistant schizophrenia. One of the serious complications of clozapine therapy is agranulocytosis, therefore regular monitoring of the level of white blood cells (WBC) in plasma is necessary. During acute inflammatory infections, including the COVID-19 infection, levels of clozapine may increase, by the CYP 450 system, leading to adverse effects such as sedation, hypersalivation and consequently to aspiration pneumonia.The aim of the study is to assess the validity of continuing clozapine treatment during the COVID-19 pandemic.Brief literature review, based on research of scientific articles published in PubMed, using as keywords the terms “clozapine” and “COVID-19”.Research studies indicate that SARS-COV2 infection in patients treated with clozapine does not significantly reduce the level of neutrophils, despite commonly observed leucopenia with lymphopenia. Due to pandemic, existing WBC scheme has been modified with a trend towards less frequent measurements. To minimize the side effects of clozapine during infection, it is recommended to reduce the dose of clozapine by half and continue lower dose until 3 days after fever has subsided. Additionally, there have been reports of psychosis recurrence after discontinuation of clozapine causing difficulties in treatment COVID-19 as also comorbid mental disease.Treatment of clozapine is associated with higher risk of COVID-19 complications and at the same time COVID-19 infection may increase clozapine toxicity. Therefore, the risks of COVID-19 infection present a challenge for safe clozapine use. Further research will be needed to assess these dependencies and strategies.No significant relationships.


With the onset of Coronavirus disease 2019 (COVID-19) pandemic, all attention was drawn to finding solutions to cure the coronavirus disease. Among all vaccination strategies, the nanoparticle vaccine has been shown to stimulate the immune system and provide optimal immunity to the virus in a single dose. Ferritin is a reliable self-assembled nanoparticle platform for vaccine production that has already been used in experimental studies. Furthermore, glycosylation plays a crucial role in the design of antibodies and vaccines and is an essential element in developing effective subunit vaccines. In this computational study, ferritin nanoparticles and glycosylation, which are two unique facets of vaccine design, were used to model improved nanoparticle vaccines for the first time. In this regard, molecular modeling and molecular dynamics simulation were carried out to construct three atomistic models of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor binding domain (RBD)-ferritin nanoparticle vaccine, including unglycosylated, glycosylated, and modified with additional O-glycans at the ferritin–RBD interface. It was shown that the ferritin–RBD complex becomes more stable when glycans are added to the ferritin–RBD interface and optimal performance of this nanoparticle can be achieved. If validated experimentally, these findings could improve the design of nanoparticles against all microbial infections. Coronavirus disease 2019 (COVID-19), a highly contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has infected more than 281 million people worldwide and caused more than 5.4 million deaths as of 29 December 2021 . The COVID-19 pandemic caused by the SARS-CoV-2 virus causes enormous distress to millions of people worldwide and has long-term effects on all aspects of people’s lives.Coronaviruses are large enveloped RNA-positive-stranded viruses, and the SARS-CoV-2 consists of a large RNA genome, four structural proteins, 16 nonstructural proteins, and nine to 11 accessory proteins . The fouCoronaviruses are a diverse group of viruses that includes the Middle East respiratory syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome coronavirus (SARS-CoV), infecting different animal species, and they can cause diseases of the upper respiratory tract, gastrointestinal tract, and central nervous system in humans and other animals . In 2002The spike protein with a functional polynucleotide furin cleavage site at its S1–S2 subdomain boundary plays an essential role in the infectivity of SARS-CoV-2 . The actThe receptor binding domain of the spike protein binds to angiotensin-converting enzyme 2 (ACE2) ectodomain, creating significant immunogenicity among the other spike proteins, accounting for up to 90% of neutralizing antibodies (nAbs) obtained from convalescent serum . ImportaSince the outbreak, several strategies have emerged to combat this deadly virus . HoweverOver the last few years, there have been tremendous advances in the field of protein-based nanomaterials, and among the various protein-based nanomaterials, protein nanocages are probably the most sophisticated in protein subunit vaccines . Self-orProtein subunit vaccines and genetically encoded nucleic acid vaccines are most effective for SARS-CoV-2 treatment . AlthougThe ferritins are a superfamily of well-studied proteins that self-assemble into hollow cage-like structures, which are ubiquitously found in prokaryotes and eukaryotes . One of Several former studies reported that the ferritin SARS-CoV-2 nanoparticle vaccines are promising in clinical trials . Also, tThe use of glycans in drug design has a long history, and an essential element in developing effective subunit vaccines is the characterization of the glycosylation of viral proteins . GlycosyConsidering that the immunogenicity of the nanoparticle vaccine would be the most efficient by adding adjuvants, it can be the best candidate vaccine platform to fight the pandemic. Promoting this vaccine is of great importance in treating and managing COVID-19 and might be practical for similar viral diseases.in silico study, two unique facets of vaccine design were used to model improved nanoparticle vaccines. Ferritin nanoparticles were used to stimulate further the immune system attached to the RBD. Each of these ferritin units has an attached RBD that, when aggregated, greatly stimulates the immune system. In this design, the capabilities of glycans were used to bind two proteins that had been previously studied but had not been used for therapeutic purposes.In this The atomic model of glycosylated ferritin-RBD nanoparticle vaccine is modeled for the first time, and their interactions are studied at the atomic level . Then, tin vitro and in vivo.As this modified nanoparticle vaccine is designed computationally, this construct’s features and general stability are yet to be certified Experimental validation and the use of these findings in vivo can significantly contribute to the ongoing research around viral infections.The crystal structure of the SARS-CoV-2 spike receptor-binding domain in complex with ACE2 (PDB ID: 7lo4)  was chosThe selected structures of RBD and ferritin were used for molecular docking with the haddock server . SeveralThe RBD sequence selection is based on the experimentally constructed nanocages . They usThe modified RBD model was glycosylated with GLYCAM builder  at the AThree systems were set up, including the unglycosylated RBD-ferritin , glycosyAll molecular dynamics simulations were carried out with the AMBER16 package . The parvia the reference pressure set to 1 bar and maintained with 1-ps relaxation time. Langevin dynamics  for 100 ps, followed by equilibration of the whole complex for 250 ps Three replicates of ns production runs were performed on each system utilizing the isothermal-isobaric ensemble (NPT) scheme. A weak-coupling algorithm  was utildynamics  with a cRMSD, RMSF, PCA, and cross-correlations of the CA atoms were calculated in the Bio3D package  in R forVisual molecular dynamics (VMD)  was usedin silico injections were given at the time steps of 1, 84, and 168 with no LPS and maintained a minimum of 30 days of the time interval between two injections.The C-IMMSIM server  was usedHenceforth, the RBD-ferritin nanoparticle, glycosylated RBD-ferritin nanoparticle, and glycosylated modified RBD-ferritin nanoparticle systems will be referred to as RBDfN, gRBDfN, and gmRBDfN, respectively.The overall RMSD plot shows that the gmRBDfN model is the most stable of the three systems, while the gRBDfN model shows a comparable RMSD range to the gmRBDfN model, and the RBDfN model is the least stable system .Average RMSD values for the RBDfN, gRBDfN, and gmRBDfN are 4 (Å), 3.5 (Å), and 3 (Å), respectively. The average RMSD values also show that the gmRBDfN system is the most stable. This observation was expected as several other experimental, computational, and structural studies have reported that glycosylation contributes to increasing the stability of protein structures .The histogram of the overall RMSD shows that the lowest RMSD belongs to the gmRBDfN system, while the RMSD of the gRBDfN system is more persistent. Among these models, the RBDfN model has the most dispersed RMSD values. Furthermore, the gRBDfN and gmRBDfN plots are quite comparable. While their RMSD peaks are 0.5 (Å) different, the gRBDfN model has a smaller RMSD value .The RMSF was calculated to explore the fluctuations of the CA atoms in all systems . AverageThere are two clear peaks in the RMSF plots of the glycosylated systems (gRBDfN and gmRBDfN). One in residues 480–482 of RBD includes cysteine, asparagine, and glycine amino acids, corresponding to a flexible loop region on the protein surface . VisualiTo clarify the effect of glycans in the conformation of the structures in the three existing models, the principal component analysis was studied . The perTo better understand the RBD interactions with ferritin, RMSD and RMSF plots were calculated separately for the RBD and ferritin in the complex. The general trend is in good agreement with the overall RMSD plots. The gmRBDfN is the most stabilized system with the smallest RMSD values along with the RBD , while tIn the RMSF plot of RBD , high peRMSD plots of ferritin show that the ferritin structure is more stable in the gRBDfN and gmRBDfN systems as opposed to the RBDfN system . The aveThe RMSF plots of ferritin show two noticeable peaks at residues 73–91, the RBD–ferritin interface, and at 153–160 residue position, which is located in the C-terminal of ferritin .A secondary structure timeline was calculated for the RBD–ferritin protein structure . The secIn general, the stability of the ferritin in all three systems is very high, and in none of them do its dynamics undergo profound changes. All of these investigations are supported by the RBD and ferritin RMSF plots . By tracing the flexible loop in the secondary structure timeline, it could be observed that its stability increases by increasing the number of the attached glycans to the nanoparticle. With gmRBDfN, gRBDfN and RBDfN show the highest stability. These observations give us another piece of evidence of the role of glycans in increasing the stability of the ferritin nanoparticle vaccines.The presence of the O-glycan at S494 of the RBD interface with ACE2  increaseAt the atomic level, the gRBDfN model has an N-glycan attached to the Asn343 and O-glycan attached to the Ser494 . The gmRO-glycan inter-hydrogen bonds were formed between GalNAc1-Gal6 and GlcNAc4-Gal3 . Intra-hTo specifically show the effect of stabilized RBD–ferritin interactions in the gmRBDfN system, the cross-correlation between the fluctuations of the CA atoms was mapped for the dynamics of all systems . The posHowever, the most interesting alteration has occurred between the RBD and ferritin in the gmRBDfN system . Anti-co+ T cell are shown, respectively, which shows the increase in cell population after each vaccine dose. Panel A3 shows the CD8+ T cell population per cell state, showing the active cell population is higher than the anergic cells, and panel A4 shows the plasma cell population, which reaches a higher cell concentration (85 cells per mm) after the third dose. Panel B shows that the secondary and tertiary immune responses eliminate the antigen on a shorter timescale due to the presence of memory cells ready to react. An increasing trend of IgM and IgG antibody titer was observed after the third injection, while the antigen level was decreased. It was also shown that levels of cytokines such as IFN-γ and IL-2, which are essential for inhibition of viral replication and T-cell-mediated immunity, are elevated. Antigenic molecules were found to be cleared off after three doses of vaccination; at the same time, the B and T memory cell population increased to the maximum of 800 cells/mm3 and 11,000 cells/mm3, respectively. This makes the construct RBD-ferritin a suitable nanoparticle vaccine candidate.The immunogenic profile of the refined RBD-ferritin vaccine candidate was obtained from the C-IMMSIM server. The vaccine is injected in three doses over a period of 2 months and 30 days of time intervals between two injections. It found that our vaccine candidates could elicit both humoral and cellular-mediated immune responses . In plotCOVID-19 is a severe and dangerous infectious disease with symptoms similar to SARS, including fever, cough, and fatigue. It is a significant threat to the health and safety of the world and must be prevented from spreading. Ever since the pandemic of COVID-19 began, many efforts have been made to find a cure for this deadly virus. Vaccines have been more effective among all approaches against coronavirus, especially nanoparticle vaccines that produce long-lasting immune responses. The RBD of infusion spike protein contains multiple conformation-dependent epitopes and is the main domain that induces neutralizing antibody and T-cell immune responses against SARS-CoV-2 infection , making Ferritin nanoparticles are of significant interest for developing new vaccines because they self-assemble into stable structures that display RBD protein on their surface . CoronavThis work is based on existing glycosylation and nanoparticle vaccine experimental and computational works . Herein,RBD-ferritin nanoparticles are one of the most effective vaccines that provide optimal immunity to the virus in a single dose. In this work, molecular modeling and MD simulations combined the self-assemble ferritin nanoparticle scaffold with glycosylation to improve the currently available ferritin-RBD vaccine. Three states of the ferritin–RBD nanoparticle vaccines specific to SARS-CoV-2 were modeled, including the unglycosylated, glycosylated, and modified with additional O-glycans at the ferritin–RBD interface. It was shown that glycosylation generally maintains the nanoparticle’s stability. The stability increases significantly by introducing a modified loop that includes additional glycosylation sites. If experimentally validated, these findings could be essential for improving the currently available ferritin–RBD nanoparticle vaccine and future nanoparticle vaccine designs against all sorts of Coronaviridae family.


The ongoing COVID-19 pandemic is caused by an RNA virus, SARS-CoV-2. The genome of SARS-CoV-2 lacks a nuclear phase in its life cycle and is replicated in the cytoplasm. However, interfering with nuclear trafficking using pharmacological inhibitors greatly reduces virus infection and virus replication of other coronaviruses is blocked in enucleated cells, suggesting a critical role of the nucleus in virus infection. Here, we summarize the alternations of nuclear pathways caused by SARS-CoV-2, including nuclear translocation pathways, innate immune responses, mRNA metabolism, epigenetic mechanisms, DNA damage response, cytoskeleton regulation, and nuclear rupture. We consider how these alternations contribute to virus replication and discuss therapeutic treatments that target these pathways, focusing on small molecule drugs that are being used in clinical studies. Weekly epidemiological update on COVID-19, retrieved from https://www.who.int on 24 June 2022). COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the Coronaviridae family of enveloped RNA viruses Coronaviridae family includes the Letovirinae and Orthocoronavirinae subfamilies and members of the latter are commonly known as coronaviruses Alphacoronavirus, Betacoronavirus, Gammacoronavirus, and Deltacoronavirus Betacoronavirus. Betacoronavirus can be further divided into four lineages, or subgroups The ongoing coronavirus disease 2019 (COVID-19) is one of the deadliest infectious diseases in history. To date, it has caused more than 536 million confirmed cases and over 6.31 million deaths  for SARS-CoV-2, triggers membrane fusion and the viral genome is released into the cytosol. S protein contains an RGD tripeptide which can facilitate its binding to multiple integrins and viral entry into ACE2-negative cells Although coronavirus genome replication and transcription occur in the cytoplasm, the nucleus is important for their replication The life cycle of coronavirus doesn't show clear dependency on the nucleus, but virus clearance is accelerated by blocking nuclear entry and virus infection is reduced by inhibiting nuclear export The nucleus hosts almost all the cell's genomic material  and contains nucleolus and a number of nuclear bodies involved in RNA synthesis, RNA processing, and ribosome assembly. It is the site of gene regulation, as transcription factors must enter the nucleus to activate or inhibit gene expression. The nucleus is bounded by the nuclear envelope consisting of the outer nuclear membrane (ONM), the inner nuclear membrane (INM), and the nuclear lamina. Between the ONM and the INM is the nuclear lumen, or the perinuclear space. Because the ONM is continuous with the endoplasmic reticulum (ER), the nuclear lumen is connected to the ER lumen. The INM and ONM are also continuous, but they contain different sets of proteins Nuclear transportation relies on the NPC and the gradient of Ran (Ras-related nuclear protein) small GTPase. The NPCs are giant pore complexes with eightfold rotational symmetry Active nuclear transport requires the Ran system. Ran is a member of the Ras family of small GTPases Upon membrane fusion, the coronavirus genomic RNA is uncoated and released into the cytosol. The released RNA first serves as an mRNA and is translated into polypeptides that are processed to form the replication and transcription complexes (RTC) The genomic RNA contains a nested set of subgenomic mRNAs, which encode the M, E, S, and N structural proteins and additional accessory proteins The nucleus may contribute to virus production due to its connection to the replication organelles. Notably, the replication organelles are usually located in the perinuclear region of the cells. These organelles are interconnected and connect to the ER, so, in principle, material exchange can occur between the nuclear lumen and the intermembrane space of the DMVs. However, given that synthesized RNAs are protected by the inner membrane and enter the cytosol through the pore complex, it is unlikely that luminal factors can considerably affect virus replication. Similarly, transmembrane proteins synthesized in the ER can diffuse to the ONM. The E protein of SARS-CoV-2, when overexpressed alone, was indeed shown to localize to the nucleus (and the cytoplasm) The nucleus is also in close proximity to the ERGIC and the Golgi complexes. Two proteins involved in nuclear transportation, RanBP1 and importin-α, regulate the dynamics of the Golgi complexes Supporting a role of the nucleus in viral production, several viral proteins were shown to contain NLS and/or NES and localize to the nucleus. The SARS-CoV N protein, which is 90% identical to SARS-CoV-2 N protein, contains multiple NLSs and a signal for nucleolar localization Because viral assembly occurs in the cytoplasm, nuclear localization of some of the viral proteins may not be desirable and they need to be exported from the nucleus. Pharmacological inhibition of nuclear export leads to nuclear accumulation of viral proteins and significantly decreases viral infection Pathogenic coronaviruses commonly interfere with the interferon (IFN) pathway but trigger an aberrant immune response by producing excessive cytokines and chemokines (cytokine storm) The mechanisms of IFN antagonism have been extensively studied for type I IFNs SARS-CoV-2 antagonizes IFN with many, likely redundant, mechanisms targeting both the pre-IFN IRF3 pathway and the downstream JAK-STAT pathway Table . RegulatThe underlying mechanism of IFN downregulation is best understood for ORF6. SARS-CoV-2 ORF6 was shown to interact with importin α2 and inhibit importin-dependent nuclear translocation of both IRF3 and ISGF3 Pro) can downregulate IFN signaling by cleaving a ubiquitin-like protein, ISG15 Pro can also occur The protease domain of Nsp3  of SARS-CoV-2 were shown to inhibit STING Upstream of IFN and NF-κB, the cyclic GMP-AMP synthase-stimulator of interferon genes (cGAS-STING) pathway has a direct connection to the nucleus. Damage to the nuclear envelope or mitochondria releases DNA to the cytoplasm Fig . CytoplaSARS-CoV-2 cuts down cellular protein synthesis to inhibit immune responses and optimize viral replication. This is in part achieved by targeting host mRNAs, including inhibiting mRNA release after transcription, blocking nuclear trafficking of mRNAs, and accelerating degradation of mRNAs Cilia are microtubule-dependent organelles projected from the cell body The machinery of nuclear trafficking has a surprising role in ciliogenesis and translocation of cilia proteins In a SARS‐CoV‐2-human protein interactomic study, Nsp13 is found to interact with 12 centrosomal components Epigenetic mechanisms, such as DNA/RNA methylation and histone modification, are important regulators of gene expression. Differences in epigenetic modifications contribute greatly to the susceptibility to SARS-CoV-2 and the prevalence of comorbidities Not surprisingly, SARS-CoV-2 also induces epigenetic changes to optimize viral infection and limit immunity. First, mRNA methylation is affected by virus infection. Epitranscriptomic studies using blood samples of COVID-19 patients and healthy controls have revealed significant differences in their N6-methylation of adenosine (m6A) modification profiles Second, DNA methylation is altered by SARS-CoV-2 and shows significant differences between COVID-19 patients and healthy controls. Profiles of DNA methylation can be used to calculate epigenetic ages and aging in COVID-19 patients was shown to be accelerated Third, histone modification is altered by SARS-CoV-2. An interactomic study has identified direct interactions between viral proteins  and epigenetic regulators Lastly, chromatin organization contributes to viral susceptibility and is affected by the virus. Chromatin accessibility regulates the expression profiles of ACE2 and related genes and modulates differential virus entry across tissues One of the nuclear processes that is frequently triggered by virus infection is the DNA damage response, even for mRNA viruses i.e. the lack of accelerated telomere shortening and accelerated aging, have also been reported Besides DNA damage, SARS-CoV-2 was reported to affect two other aspects of the host genome. First, accelerated telomere shortening was found in infected Vero E6 cells and COVID-19 survivors In addition to gating nuclear trafficking and altering epigenetic mechanisms, several nuclear pathways can also play roles in the virus life cycle or host cell anti-viral activities.The nucleus may contribute to the virus life cycle indirectly through the cytoskeleton. All three classes of cytoskeletal elements  have been reported to involve in virus entry A recent study links the nucleus and the nuclear lamina to DNA-induced IFN response during SARS-CoV-2 infection Small molecule drugs targeting the above pathways have therapeutic potential and some are being used in clinical studies. Epigenetic drugs have been reviewed and are not discussed here Because the IFN-I response is down-regulated by coronaviruses, many studies have been conducted to evaluate the effects of interferon treatments Cytoplasmic DNAs can activate the cGAS-STING pathway and induce antiviral responses DNA damage repair pathways play poorly understood roles in SARS-CoV-2 replication in vivo and in vitro settings used in the studies. Or, it can be due to the differential effects of the virus on different cell types or different stages of infection. A better understanding of these roles of the nucleus requires more mechanistic studies.We have summarized the evidence demonstrating the importance of the nucleus in SARS-CoV-2 infection. The nucleus plays multiple roles in the virus life cycle, but these roles are complicated and sometimes counteract each other. Some of the apparent incompatibilities are due to the differences between the Nuclear biology is understudied in COVID-19 research. The importance of the nucleus and its many interactions with the virus merit more studies in this area and promise fruitful results. Further works are expected to uncover new roles of the nucleus in SARS-CoV-2 infection and COVID-19 pathogenesis. They will also provide mechanical details of the SARs-CoV-2-nucleus interactions and fuel the discovery of new treatments.


Further, the HDRS scores at the third follow-up were significantly lower in patients on combination therapy of omega-3 fatty acid supplement and antidepressants (arm-3) than the patients on the omega-3 fatty acid supplement alone (arm-1)  or the patients taking an antidepressant alone (arm 2) . The combination of an omega-3 fatty acid supplement and an antidepressant elicited significantly higher improvement in depressive symptoms than the supplement or the antidepressant alone.Depression is a common mood disorder characterized by persistent sadness and loss of interest. Research suggests an association between the inclusion of omega-3 fatty acids in the diet and a reduced risk for depression. The present study evaluated the effectiveness of omega-3 fatty acid supplements in alleviating depressive symptoms in patients with mild to moderate depression. A total of 165 patients suffering from mild to moderated depression were randomized to receive omega-3 fatty acid supplementation, an antidepressant (single agent), or a combination of an antidepressant and omega-3 fatty acid supplementation. The clinical features of depression were assessed using the Hamilton Depression Rating Scale (HDRS) during the follow-up period. A statistically significant improvement in depressive symptoms was observed from baseline to first, second and third follow-ups within each treatment arm as measured by HRDS scores ( Depression, also known as major depressive disorder (MDD), is characterized by persistently low or depressed mood, decreased interest, and pleasure in activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor agitation, sleep disturbances, or suicidal thoughts. According to the World Health Organization, clinical depression is a principal cause of debility worldwide, affecting 5% of the global adult population . The NatPharmacological intervention is commonly used to manage clinical depression. A recently conducted drug utilization study in depression patients revealed that escitalopram was the most commonly prescribed antidepressant as monotherapy or in combination . The stuRecent reports suggested that, the Hamilton scale for measuring depression symptoms showed a significant improvement when omega-3 fatty acids were added to a typical antidepressant regimen in the majority of patients with treatment-resistant depression, in this regard to improvise the treatment targets a “Neurobiological targeted” techniques, focused on the glutamate system, are being promoted with the objective of encouraging new lines of research aiming at creating therapies that cross the monoaminergic barriers to enhance the treatment of depression disorders ,8,9. Another study reported that, an add-on therapy of omega-3 has significantly improvized the clinical functioning of sertraline and in addition, Antidepressant effects were amplified by combining antidepressant drugs with dietary and physiological supplements. It is also reported that, when compared to antidepressants alone, adding omega-3 fatty acids in the management of depression was effective and successful with few negative effects ,11.Recent studies have demonstrated the usefulness of omega-3, and it has been suggested that taking omega 3 alongside other antidepressants may not be harmful. Another study suggested that combining omega-3 fatty acids with a selective serotonin uptake inhibitor may be beneficial for treating depression at the beginning, and a subsequent experiment found a trend favoring omega-3 supplementation over a placebo in terms of lowering depressed symptoms ,13,14.Research suggests that depression can be attributed to several factors, including genetics, abnormal brain chemistry, stressful life events, personality traits, use of certain medications, and due to certain medical conditions . Lifesty12, and a vegetarian and vegan diet may be low in long-chain omega-3 PUFAs, as both of these nutrients are critical for the brain health and brain function [Recent evidence suggests that consuming a vegetarian or vegan diet could be linked to an increased risk of depression since vegan diets lack vitamin Bfunction . The preA prospective observational study was conducted in the psychiatry department’s outpatient unit in a tertiary care hospital in South India for 2 years. A total of 165 patients diagnosed with mild or moderate depression were included in our study after obtaining written consent. In the current study, Hamilton Depression Rating Scale (HDRS) was used to categorize the study participants into either mild or moderate depression. Accordingly, individuals were diagnosed to have mild depression if the total score on 17-item HDRS was between 8 and 13, whereas, moderate depression if the scores were between 14 and 18. In this study the patients; (a) with major depression (score ≥ 19) as per HDRS, (b) who were regularly consuming omega-3 fatty acids in any form (c) with any other co-morbid conditions were excluded.This study was approved by the Institutional Review Board of the study site (JSSCPM/IHEC/2019/016). Patients satisfying the study criteria were enrolled and categorized into one of the study arms following a simple randomization technique. Patients in Arm-1 consumed omega-3 fatty acid supplementation  but no antidepressants; those in Arm-2 took an antidepressant alone  but no omega-3 fatty acid supplementation; and the patients in Arm-3 took an antidepressant  along with omega-3 fatty acid supplementation . The Hamilton Depression Rating Scale (HDRS) was used to estimate baseline and periodic (once a month for three months) changes in clinical features of depression in study participants. Medication adherence to the prescribed antidepressant medications and omega-3 fatty acid supplements were assessed at first, second, and third follow-ups in all three study arms with the help of the Medication Adherence Rating Scale (MARS) score.The sample size was calculated to estimate the total number of patients required to compare HRDS scores between three treatment arms using the ANOVA test. Accordingly, the sample size estimations suggested that a minimum of 158 patients were needed to compare the HDRS scores in the different study arms to provide a medium effect, with an effect size of 0.25, power of study of 0.8, and significance level of 0.05.p-value of <0.05 was considered statistically significant. All the statistical analyses were carried out using Statistical Package for the Social Sciences (SPSS) version 24.0, IBM, Armonk, New York, USA. One-way ANOVA with Tukey HSD was used to assess the differences in the mean HDRS scores among the study participants in the different study arms. A n = 55) of participants. Patient demographics and clinical particulars of study participants are described in The study consisted of 165 patients with mild or moderate depression. All three study arms had an equal number  was observed between the arms at the second and third follow-ups. The details are presented in A statistically significant improvement was observed from baseline to first, second and third follow-ups within each treatment arm concerning HRDS scores. There was no significant difference in HDRS scores for the three arms at baseline and first follow-up. However, a statistically significant difference  in comparison to patients who were on the omega-3 fatty acid supplement alone (arm-1)  and the patients who were taking antidepressants alone (arm 2)  at third follow-up. The details are presented in The Tukey’s HSD test revealed a significant improvement in HDRS scores in patients who were on combination therapy of omega-3 fatty acid supplement and antidepressants (arm-3) in comparison to patients on the omega-3 fatty acid supplement alone (arm-1) [Q = 3.83; To check the confounding effect of different antidepressants on mean HRDS scores within the treatment arms 2 and 3, the mean HRDS scores among patients on different antidepressants in arm-2 and arm-3 at baseline, first, second and third follow-ups were compared. There was no significant difference concerning mean HRDS scores between the three-antidepressant treatment sub-groups in treatment arm-2 and arm-3 throughout treatment. The details are presented in In the present study population, more women (71%) than men (29%) had mild to moderate depression, which was in agreement with earlier studies which reported depression is twice as common in women than men . One posWith the growing interest in the benefits of veganism and vegetarianism, researchers have tried to establish if this particular way of life is truly all it claims to be. Devoid of vital nutrients like vitamin B12 and omega-3 fatty acids that are necessary for brain function, vegan diets could be associated with depression. Despite having potential advantages like lower rates of obesity, diabetes, heart disease, and cancer, some studies claim that individuals on vegetarian/vegan diets had a higher risk of depression .The adherence to prescribed medications and omega-3 fatty acid supplements in the study participants was assessed using MARS, a validated tool to identify medication adherence of participants, prepared after combining concise concepts from the Morisky Adherence Questionnaire and the Drug Attitude Inventory into the multidimensional self-reporting questionnaire . The tooThe MARS score was 7 and above in all three treatment arms during all three follow-up periods, indicating adequate medication adherence in our study population. In addition, when compared for the patients in different arms at each follow-up, MARS scores revealed no significant difference—indicating no adherence bias concerning treatment outcomes. The treatment outcomes were measured using HRDS scores, a scale that measures the severity of depressive symptoms and categorizes patients based on the score as normal or having mild, moderate, or severe depression .p = 0.00001 for each arm). This illustrated that administered antidepressants , and omega-3 fatty acid supplements were efficacious in treating depression alone as well as in combination. Fluoxetine, escitalopram, and sertraline belong to selective serotonin reuptake inhibitors (SSRIs), the antidepressant class considered to be the first line of management in individuals diagnosed with depression due to their better safety and efficacy profile than other antidepressants [A significant improvement in the depressive symptoms of the study subjects was observed post-therapy, as indicated by a significant decline in the HRDS score from baseline to follow-ups (ressants . Similarressants ,27. Simiressants . Furtherressants .Our study illustrated that the maximum decline in HRDS from baseline to follow-ups was observed in the third arm, where omega-3 supplements were combined with antidepressants, establishing the superiority over individual therapy. This was confirmed by comparing inter-arm HRDS scores, which revealed a significant decline during the second and third follow-ups in the patients treated with the combination, compared to the patients administered with any therapy alone. Researchers hypothesize that the benefits of omega-3 fatty acids in depression could be multi-faceted . Omega-3Finally, the assessment of HRDS scores within arms 2 and 3 to evaluate the effect of the type of administered antidepressant revealed no statistical difference, confirming that the type of antidepressant administered did not influence the treatment outcome. The results were aligned with other clinical studies which established similar effectiveness of these SSRIs for depressive symptoms ,32.There were few reports that previously demonstrated no efficacy of omega-3 fatty acid in the treatment of Major Depression , hence tOmega-3 fatty acids, when combined with three different types of SSRI, resulted in a significant decline in the severity of depressive symptoms as assessed using HRDS scores, irrespective of the antidepressant used. Our study findings support the use of omega-3 fatty acids as an adjunct therapy along with antidepressants to reduce the severity of depression.