Epidemiological shift of paediatric fracture characteristics during COVID-19 in Hong Kong - a reflection on bone health crisis

Introduction: Since the beginning of Coronavirus disease 2019 (COVID-19) pandemic, schools in Hong Kong were suspended intermittently as part of the anti-epidemic measure. This study aims to investigate the impact of COVID-19 pandemic on the epidemiology of paediatric fracture and bone health of children. Method(s): We recruited patients aged 3-17 admitted to tertiary paediatric orthopaedic trauma centres for fractures from 1st February 2020 till 4th March 2021 during COVID-19 period as study group and compared with patients admitted from 1st February 2019 till 31st January 2020 before COVID-19 as control group. Result(s): Total number of admissions due to fracture was reduced by 49% (pre-COVID period: 345, COVID period: 177). Demographic data such as age, age group distribution, sex, location of fractures, energy of injury, prior history of fracture were comparable in the two groups. There was no statistically significant difference in the proportion of patients requiring operative treatment. Significant change was found in injury mechanisms, with injury related to body-powered vehicles (33.7%, n = 58) becoming the leading cause of injury during COVID period (p < 0.001). There was significant drop in proportion of patient with injury from level ground fall (p < 0.001) and sports (p < 0.001). The percentage of obese children increased significantly (p = 0.009) during the COVID period (32.7%, n = 48) than pre-COVID period (21.0%, n = 67). The proportion of patients with hypocalcaemia was found to be higher (p = 0.002) during COVID period. Conclusion(s): This study reflects paediatric bone health issues during COVID-19 pandemic. We postulate the reduction in fracture incidence, change in the distribution of injury mechanisms, and more obesity could be related to a more sedentary lifestyle during COVID period. Hypocalcaemia can be associated with reduced sunlight exposure, obesity, and lack of physical activities. If the problem is left neglected, it can lead to long-term bone health problems.Copyright © The Author(s) 2023.

An investigation into the aging of disposable face masks in landfill leachate

Due to the excessive use of disposable face masks during the COVID-19 pandemic, their accumulation has posed a great threat to the environment. In this study, we explored the fate of masks after being disposed in landfill. We simulated the possible process that masks would experience, including the exposure to sunlight before being covered and the contact with landfill leachate. After exposure to UV radiation, all three mask layers exhibited abrasions and fractures on the surface and became unstable with the increased UV radiation duration showed aging process. The alterations in chemical groups of masks as well as the lower mechanical strength of masks after UV weathering were detected to prove the happened aging process. Then it was found that the aging of masks in landfill leachate was further accelerated compared to these processes occurring in deionized water. Furthermore, the carbonyl index and isotacticity of the mask samples after aging for 30 days in leachate were higher than those of pristine materials, especially for those endured longer UV radiation. Similarly, the weight and tensile strength of the aged masks were also found lower than the original samples. Masks were likely to release more microparticles and high concentration of metal elements into leachate than deionized water after UV radiation and aging. After being exposed to UV radiation for 48 h, the concentration of released particles in leachate was 39.45 muL/L after 1 day and then grew to 309.45 muL/L after 30 days of aging. Seven elements (Al, Cr, Cu, Zn, Cd, Sb and Pb) were detected in leachate and the concentration of this metal elements increased with the longer aging time. The findings of this study can advance our understanding of the fate of disposable masks in the landfill and develop the strategy to address this challenge in waste management. Copyright © 2023 Elsevier B.V.

Association of Vitamin D Knowledge, Behavior and Attitude with BMI Status among Arab Adults.

This study aims to investigate the association of vitamin D (VD) knowledge, behavior, and attitude with BMI status among Saudi adults. This cross-sectional online survey included a total of 774 participants (M/F: 239/535). Knowledge about the overall sources of VD was highest in OB participants in correctly identifying sunlight (95.1%; p < 0.001) while significantly more OW participants answered food (83.1%; p = 0.04) and fortified food (66.5%; p = 0.02). However, 18.9% of OB participants also wrongly identified air as a VD source and this was significantly higher than in other groups (p = 0.03). OW participants were 50% less likely to identify salmon and fish oil (odds ratio, OR 0.5 (95% Confidence interval, CI 0.4-0.7); p < 0.01) and 40% more likely to identify chicken (OR 1.4 (1.0-1.9); p < 0.05) as dietary sources of VD than controls. On the other hand, OB participants were almost three times more likely to know that sunlight exposure is the main source of VD than controls (OR 2.65 (1.2-6.0); p < 0.05). In conclusion, while VD knowledge overall was apparently high in Saudi adults regardless of BMI status, the quality of knowledge among OB and OW individuals appear inconsistent, particularly in terms of identifying the right VD sources. Public health awareness campaigns should include the correction of VD misconceptions so that high-risk populations are able to make well-informed decisions in achieving optimal VD levels.

IMPACT of the SARS-COV 2 PANDEMIC and RELATED EPIDEMIOLOGICAL RESTRICTIONS on the CARE of PATIENTS with OSTEOPOROSIS-EXPERIENCES of A HUNGARIAN CENTRE

Background: Treatment of patients with osteoporosis was inadequate even before the COVID-19 pandemic. Not only patients without fracture, but only a small proportion of patients with osteoporotic fracture have treated. In Hungary only 30% of patients with osteoporosis received adequate antiporotic treatment before the pandemic. Almost 90% of whom were women, less than 10% of men. The incidence of fractures is increasing dramatically worldwide. In 2010, the vertebral fracture rate was 3.5 million in Europe but it is expected to reach 4.5 million by 2025. In 1990, osteoporosis caused 1.26 million hip fractures and by 2025 this is estimated at 2.6 million worldwide. The care for patients with osteoporosis was further aggravated by the restrictions necessarily imposed due to the coronavirus. Objectives: The aim of the study was to explore the extent and consequences of diagnostic and therapeutic failure in patients with osteoporosis. Methods: I determined the number of osteoporosis examinations performed in our centre in 2019-2021 from the medical database. I surveyed how many patients were discontinued the antiporotic treatment during the pandemic according to the different drug groups in Hungary and also in our centre as well as the prevalence of wrist and hip fractures due to minor trauma in our county in the pre-and post-pandemic period. Results: In our centre an average of 30 DEXA examinations were performed daily in the pre-pandemic period. From the end of October 2021 to the end of May 2021 there was not perform any ODM examinations. It means 3.980 missed exams and at least 1.000 missed osteoporosis diagnoses and therapy starts. More than 20% of patient were lost from the antiporotic care in Hungary. Drop-out was mainly seen in patients treated with bisphosphonates. There were 20730 bisphosphonate-treated patient in 2019, 19813 in 2020 and 17315 in 2021. Antiporotic treatment was discontinued in 30% of patients treated with bisphosphonate+vitamin-D (7849 in 2019, 6950 in 2020, 5484 in 2021) or bisphosphonate+calcium+vitamin-D fxed combination products (3256-2876-2289). In our centre, the prescribing of bisphosphonates has also decreased more than half. Patients treated with iv. bisphosphonates were interrupted or switched to oral formulations. Denosumab therapy was continuous: 581 injections were prescribed in the 12 months before and 579 during the pandemic. However, no new treatment started. In case of teriparatide, the initiated therapies were continued and even the number of prescriptions increased. As a consequence, an increase in the occurrence of fractures due to minor trauma is expected. Although epidemiological restrictions in this regard, the curfew has had some positive effects. According to international data, the number of wrist fractures has almost halved, while the data for hip fractures are controversial. The decrease of wrist fractures can also be verifed in our county. The number of wrist fractures was 598 in April-May 2019, 393 in the same period in 2020, and 372 in 2021. After a signifcant reduction in hip fractures in 2020, there is already an upward trend in 2021 (470 in 2019, 358 in 2020, 393 in 2021). The real consequences of failure to treat osteoporosis are expected only after years. Conclusion: Missed doctor-patient appointments were associated with missed diagnoses and interruptions of ongoing treatments. Fear of the virus, immobilisation due to home office and curfews, lack of exercise, sun exposure, caused depressive symptoms, increased alcohol consumption and caloric intake are all increase the risk of osteoporosis. Thus, traditional risk factors for osteoporosis expanded with the direct effects and the introduced restrictions because of the pandemic.

Prevalence of vitamin D deficiency in critically-ill COVID-19 patients

The role of vitamin D in supporting the body’s immune response to respiratory viruses has become a topic of significant interest during the COVID-19 pandemic, especially for critically-ill patients with severe respiratory failure. We therefore were interested in examining the prevalence of vitamin D deficiency in adult patients admitted to our critical care unit due to COVID-19 infection during the second surge of the virus in the UK. Due to vitamin D being a negative acute phase reactant and serum concentration falling in the presence of a systemic inflammatory response, and following local multidisciplinary discussion involving a Consultant Biochemist, a pragmatic recommendation was made to consider assessing for vitamin D deficiency in patients with (a) a deranged serum adjusted calcium, phosphate or alkaline phosphatase, or (b) evidence of vitamin D supplementation prior to hospital admission. Retrospective data was examined for 168 patients admitted to critical care from 04.10.20 to 04.04.21 and analysed using an excel spreadsheet. Local diagnostic cut-off values determined if serum vitamin D level was deficient, suboptimal or adequate. Table 1 below summarises the results for 33/168 patients (19.6%) who had a serum vitamin D result available. [Formula presented] Acknowledging the small number of tests within our patient population, our results demonstrate a high prevalence of patients (>50%) with a vitamin D level indicative of deficiency. If combined with those with suboptimal levels, this increases further to 75.8%. Interestingly, of the 134 patients (80.4%) with no serum vitamin D result, there was a high prevalence of recognised risk factors for deficiency such as age, presence of obesity and non-white ethnicity. It is also key to consider the impact of reduced sunlight exposure due to seasonality and COVID-19 lockdown restrictions on the vitamin D status of the whole UK population, which led to reissued government guidance1,2 that more people should consider taking a daily vitamin D supplement. Recent clinical guidance identifies that at present, there is little evidence available for vitamin D for preventing or treating COVID-19 but it acknowledges that a low vitamin D status is associated with more severe clinical outcomes3. We support the recommendation that further research is required in this area, including patient outcomes, and if routine vitamin D supplementation could benefit critically-ill COVID-19 patients. References 1. Vitamin D, National Health Service (NHS), 2020. (Accessed June 21, 2021 at ) 2. Scientific Advisory Committee on Nutrition (SACN) Rapid review on vitamin D and acute respiratory tract infections (ARTI), 2020. (Accessed June 21, 2021 at ) 3. National Institute for Health and Care Excellence (NICE) COVID-19 rapid guideline: vitamin D [NG187], 2020 (Accessed June 21, 2021 at )

KNOWLEDGE, ATTITUDES AND PRACTICE OF IRAQI ADULTS TOWARDS VITAMIN D

Vitamin D deficiency is a pandemic nutritional problem throughout the world. Many national data indicated a reverse association between vitamin D status and disease. Recently with COVID-19, which raises worries about vitamin D deficiency as a serious public health problem. Therefore, the present study designated to find out whether lack of knowledge towards vitamin D contribute to the prevalence of vitamin D deficiency among adults in Iraq. To the best of our knowledge, this is the first study that examine vitamin D-related knowledge, attitude and practice of adults across Iraq. This cross sectional study was conducted electronically among Iraqi adults (aged > 16 years), using a questionnaire designated by the research team. 1061 participants completed the questionnaire and data were subjected to statistical analysis. Participants were found to have a moderately good level of knowledge regarding vitamin D but have Poor specific knowledge of vitamin D dietary food sources. Poor practice regarding usage of vitamin D supplementations, negative attitudes towards sun exposure and mixed attitudes towards VD was identified. Effective educational campaigns targeting the general populations in Iraq may improve the Iraqi population’s knowledge towards the importance, sources, supplementations of vitamin D and could lead to positive health outcomes.

Mi Reloj Interno (My endogenous clock): an evidence-based mobile-app to improve sleep and circadian rhythms

Introduction: The human circadian clock is daily entrained by both light exposure and daily social schedules, which were severely affected during the pandemic-associated lockdown. In a previous work we found that after one month of lockdown, Argentinian residents exhibited later chronotypes compared with a pre-pandemic situation, despite they slept longer and showed less social jetlag (Leone M.J. et al, Current Biology). In this study, we collected an independent set of local data with the aim to develop an evidence-based mobile app that offers customized recommendations to improve and maintain healthy sleep and circadian rhythms. Materials and methods: Data was collected throughout a phone/website survey between July and September 2020 (n=4460, after 4-6 months into lockdown) in Argentina. The survey included questions about demographic factors, habits, and previously standardized and validated questionnaires (MEQ, MCTQ, PSQI). Data from Buenos Aires city and suburbs (n=3246) was calibrated to match the population distribution and it was used to run the main analyses. The rest of the database was used to validate results. We conducted a cross validation process using linear models, which included a feature selection process to find the most relevant regressors to fit each chronotype and sleep-related variable. For a given age and gender, each model predicted a set of optimal values for the regressors (e.g. sunlight exposure, regular activities) where the dependent variable is maximized (or minimized). Finally, the recommendation system is based on the comparison between optimal and actual values for each predictor, considering the most affected variables. Results: The final calibrated sample (age: 41.3±15.5, 67% female) shows late chronotypes (MSFsc: 06:00±11min, MEQ score: 49.42±11.3), low levels of social jetlag (0.99h±1.09) and considerable long sleep duration on weekdays (7.31h±1.43). The regressors which significantly affect at least one variable were light exposure, use of alarm, naps and regular activities (and its timing, i.e. work, study, dinner, other activities) as well as age and gender (and interactions). We found no effects of cohabitation, exercise timing and use of screens. The optimal levels of the selected regressors were used to build the recommendation system (i.e. algorithm) on which the mobile app MiRelojInterno is based (available for both Android and iOS platforms, www.mirelojinterno.org). Conclusions: We developed a mobile app based on local evidence that inquires about habits, chronotype and sleep, returns to its users an overview of their current state -including all variables and predictors- along with customized recommendations with the aim to create awareness and improve and maintain healthy sleep and circadian rhythms depending on the age, gender and habits. Acknowledgements: This research project was supported by CONICET and Agencia I+D+i (IP-COVID19-679).

Insufficient vitamin D scenario is associated with poor sleep quality during the pandemic: a population-based study, COVIDInconfidentes

Introduction: Hypovitaminosis D is a global health problem that affects more than one billion people worldwide, and this prevalence is expected to have increased during a pandemic with social restriction measures. Vitamin D has been implicated in extraskeletal functions in many physiological mechanisms, including sleep. Objective: To evaluate the association of vitamin D scenario with sleep quality during the COVID-19 pandemic. Methods: Cross-sectional, populationbased study, between October and December 2020 in two medium-sized cities in Minas Gerais. Sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI), with a global score from 0 to 21. Scores of 5-10 indicate poor sleep quality. We evaluated a possible scenario of vitamin D adequacy, considering the time of sun exposure and the consumption of food supplements that are sources of vitamin D. Thus, we classified the vitamin D scenario as sufficient when the average daily sun exposure was greater than or equal to 30 minutes/day or the individual reported consuming a food supplement that is a source of vitamin D. And insufficient individuals who expose themselves to the sun for less than 30 minutes/day or do not consume a food supplement that is a source of vitamin D. Multiple logistic regression was used to verify the association of insufficient vitamin D scenario with sleep quality. Results: Of the individuals evaluated, most were female (51.9%), black or brown (67.9%), with minimum high school education (56.5%), and family income below 5 minimum wages (60.4%). Regarding vitamin D, 35.0% had insufficient sun exposure (< 30min/day), 77.9% did not use vitamin D source supplements. Evaluating the vitamin D scenario, 27.1% were insufficient. The mean of PSQI score was 6.32 (95%CI: 6.03-6.62) e 52.5% had poor quality. In multivariate analysis, adjusted for sex, age, and income, subjects with insufficient vitamin D had 1.41 times the chance of having poor sleep quality (OR=1.41;95% CI: 1.01-1.98). Conclusion: Individuals with insufficient vitamin D scenario are more likely to have poor sleep quality during the pandemic of COVID-19. Thus, this study demonstrates the importance of evaluating the impact of the pandemic on health conditions like vitamin D, and how they relate to sleep.

Management of COVID-19-A Review

Coronavirus disease-2019 (COVID-19) has gained much popularity not only in the Wuhan city of China but internationally also;in January 2020, the corona rapidly spread to many countries like the USA, Italy, Russia, India, Singapore, Pakistan, Thailand, Canada, Australia, England, and so on through passengers traveling to other countries. Corona patients can be cured with synthetic drugs, traditional herbal medicines (THM), use of Vitamin D and the quarantine approach. Different allopathic medicines, herbal extracts, and vitamin D have been observed to be useful in the treatment of novel coronavirus, like Remdesivir, hydroxychloroquine, Teicoplanin, Lopinavir+ Ritonavir, Ribavirin + corticosteroids, Glycyrrhizin, Sanguisorbae radix, Acanthopanacis cortex, Sophorae radix, etc. Various antiviral drugs are used to treat COVID-19, alone or in combination with other medications like Interferon-α, Lopinavir + Ritonavir, Arbidol, corticosteroids, etc., and some herbal extracts;also quarantine approach and Vitamin D are used that not only cure the infection but also boost up our immunity. For this review article, different papers were searched on Google Scholar, Scopus, WHO’s website, PubMed, clinicaltrials.gov and other relevant scientific research websites. In this review article, we have discussed the current strategies that are being used to treat COVID-19. Along with allopathic drugs, some herbal extracts can also be used to treat this novel coronavirus, like Glycyrrhizin, Sanguisorbae radix, Acanthopanacis cortex, Sophorae radix, etc. and even vitamin D.

Sunlight Exposure on Sars-Cov-2 Samples;Descriptive Analysis

OBJECTIVE: To determine the association of sunlight exposure and PCR positivity of SARS-COV-2 samples. METHODOLOGY: This Quasi-Experimental Study was carried out at PAQSJIMS – Gambat, District Khairpur, Sindh, Pakistan. This experiment was conducted during the summer season from April-September 2020 with consecutive sampling techniques. The average temperature of the study during the given period was 41°C. Sample Size was 8 PCR positive Covid-19 Patients (Each sample divided into 12 portions) (6 controls and 6 test samples) and re-tested by PCR. Six control samples were kept in a laboratory environment. In contrast, six were kept in sunlight (each for a differing duration, i.e., 0, 5, 15, 30, 60, and 120 minutes), and the temperature and humidity levels were recorded. The experiment samples underwent a PCR test (along with its time-matched control), and SARS-COV-2 positivity was recorded. Following the experiment, the samples were discarded as per safety regulations. Both male and female covid-19 patients (PCR positive) aged 18 years and above were included, Patients enrolled in treatment trials were excluded. RESULTS: Among the eight samples (each tested in six different batches after exposure to sunlight for varying amounts of time), most, i.e., 45 (93.75%), tested positive for SARS-COV-2. However, there may be a relationship between the length of exposure to sunlight and PCR positivity of the samples since all three samples that tested negative were exposed to sunlight for more at least 30 minutes, all controls (placed in the laboratory and not exposed to sunlight, tested positive). CONCLUSION: There is no significant association between sunlight exposure and PCR positivity of SARS-COV-2 samples.

The Effects of Using the Sun Safe App on Sun Health Knowledge and Behaviors of Young Teenagers: Results of Pilot Intervention Studies

Background: A balanced approach toward sun exposure and protection is needed by young people. Excessive sun exposure increases their risk for skin cancers such as melanoma, whereas some exposure is necessary for vitamin D and healthy bones. We have developed a new iOS smartphone app—Sun Safe—through a co-design process, which aims to support healthy and balanced decision-making by young teenagers (aged 12-13 years). Objective: The aim of this study was to test the capacity of Sun Safe to improve sun health knowledge and behaviors of young teenagers in 3 pilot intervention studies completed in 2020. Methods: Young teenagers (aged 12-13 years;N=57) were recruited through the web or through a local school via an open-access website and given access to Sun Safe (29/57, 51%) or a placebo (SunDial) app (28/57, 49%). Participants completed sun health questionnaires and knowledge quizzes before and after the 6-week intervention (either on the web or in class) and rated the quality of the app they used via a survey. Results: Of the 57 participants, 51 (89%) participants (26, 51% for placebo arm and 25, 49% for the Sun Safe arm) completed these studies, with most (>50%) reporting that they used a smartphone to access their designated app either “once a fortnight” or “once/twice in total.” Improved sun health knowledge—particularly about the UV Index—was observed in participants who were given access to Sun Safe compared with those who used the placebo (−6.2 [percentage correct] difference in predicted means, 95% CI –12.4 to –0.03;P=.049;2-way ANOVA). Unexpectedly, there were significantly more sunburn events in the Sun Safe group (relative risk 1.7, 95% CI 1.1-1.8;P=.02;Fisher exact test), although no differences in time spent outdoors or sun-protective behaviors were reported. COVID-19 pandemic–related community-wide shutdowns during April 2020 (when schools were closed) reduced the time spent outdoors by >100 minutes per day (–105 minutes per day difference in predicted means, 95% CI –150 to –59 minutes per day;P=.002;paired 2-tailed Student t test). Sun Safe was well-rated by participants, particularly for information (mean 4.2, SD 0.6 out of 5). Conclusions: Access to the Sun Safe app increased sun health knowledge among young teenagers in these pilot intervention studies. Further investigations with larger sample sizes are required to confirm these observations and further test the effects of Sun Safe on sun-protective behaviors.

Changes in 25-(OH) Vitamin D Levels during the SARS-CoV-2 Outbreak: Lockdown-Related Effects and First-to-Second Wave Difference-An Observational Study from Northern Italy.

BACKGROUND: We investigated the changes in 25-hydroxy vitamin D [25-(OH)D] concentrations values, during the first and the second pandemic waves and the impact of the lockdown periods, with their different approaches to home confinement, among different age groups. METHODS: Daily cloud-modified vitamin D UV dose (UVDVC), for the area of interest (Milano, Italy), was obtained. Single-center 25-(OH)D determinations from 40,996 individuals in a 2019 (pre-pandemic), 32,355 individuals from 1 January to 31 August 2020 (containing the first pandemic wave) and 27,684 individuals from 1 June to 30 November 2020 (containing the second wave) were compared to investigate both the effect of the lockdown on vitamin D status and the association between 25-(OH)D and SARS-CoV-2 positivity. RESULTS: No direct association was found between UVDVC, 25-(OH)D status and SARS-CoV-2 infection. The stringent confinement implemented during the first wave lockdown has not had any effect on 25-(OH)D status, although some peculiar time-restricted profile behaviors can be deduced, possibly due to vitamin D supplementation habits and features of those patients who presented to the hospital during the lockdown period. CONCLUSIONS: Although our data do not suggest any direct relationship between 25-(OH)D status, sun exposure, and SARS-CoV-2 infection, an indirect protective role cannot be excluded.

Investigating the Potential for Ultraviolet Light to Modulate Morbidity and Mortality From COVID-19: A Narrative Review and Update.

During the COVID-19 (coronavirus disease of 2019) pandemic, researchers have been seeking low-cost and accessible means of providing protection from its harms, particularly for at-risk individuals such as those with cardiovascular disease, diabetes and obesity. One possible way is via safe sun exposure, and/or dietary supplementation with induced beneficial mediators (e.g., vitamin D). In this narrative review, we provide rationale and updated evidence on the potential benefits and harms of sun exposure and ultraviolet (UV) light that may impact COVID-19. We review recent studies that provide new evidence for any benefits (or otherwise) of UV light, sun exposure, and the induced mediators, vitamin D and nitric oxide, and their potential to modulate morbidity and mortality induced by infection with SARS-CoV-2 (severe acute respiratory disease coronavirus-2). We identified substantial interest in this research area, with many commentaries and reviews already published; however, most of these have focused on vitamin D, with less consideration of UV light (or sun exposure) or other mediators such as nitric oxide. Data collected to-date suggest that ambient levels of both UVA and UVB may be beneficial for reducing severity or mortality due to COVID-19, with some inconsistent findings. Currently unresolved are the nature of the associations between blood 25-hydroxyvitamin D and COVID-19 measures, with more prospective data needed that better consider lifestyle factors, such as physical activity and personal sun exposure levels. Another short-coming has been a lack of measurement of sun exposure, and its potential to influence COVID-19 outcomes. We also discuss possible mechanisms by which sun exposure, UV light and induced mediators could affect COVID-19 morbidity and mortality, by focusing on likely effects on viral pathogenesis, immunity and inflammation, and potential cardiometabolic protective mechanisms. Finally, we explore potential issues including the impacts of exposure to high dose UV radiation on COVID-19 and vaccination, and effective and safe doses for vitamin D supplementation.