Abstract
Behavior and cognitive functions are results of a fine tuning of multiple neuronal synapsisand a myriad of biochemical reactions whose number, location, components, sequence, and logicare unknown.
In entirely theoretical terms deleterious effects of reactive oxygen species (ROS) productionduring aerobic metabolism are neutralized by the antioxidant systems and in this manner the brain effectively regulates its oxygen consumption and redox generation capacity.
The knowledge about the metabolic processes of the CNS is so elementary, so theoretical,that only in the previous paragraph we find two notable errors: aerobic metabolism and oxygenconsumption.
The phrase aerobic metabolism refers to the fact that the oxygen contained in any tissue of thehuman organism, such as the CNS, comes from the air that surrounds us, since it is supposedly absorbed through the lungs and reaches the bloodstream to be distributed to all the cells of theorganism.
However, since 1850 researchers of the stature of Christian Bohr, Carl Ludwig, and Halender,published works in which, according to their experiments, the diffusion of atmospheric oxygen through the pulmonary alveoli could not explain the enormous difference between the concentration of atmospheric oxygen, which ranges between 19 and 21%, and the % SpO2 in the blood that reaches values of 98 and 99% [1].
It was precisely the search for the mechanism that would explain such a difference betweenoxygen in the atmosphere and blood oxygen, which led these researchers to publish that therewas no such thing, and that diffusion alone did not explain such a difference.
Unfortunately, at that time, the work of Krogh appeared [2] who, by means of a theoretical mathematical model, apparently simple, explained the unlikely passage of atmospheric oxygento the bloodstream through the pulmonary alveoli. Krogh’s lung gas exchange model has beenthe foundation of respiratory physiology for the past 100 years even though the mathematicalconcepts it handles are so far-fetched that they cannot even be experimentally contrasted.
Krogh’s original model has been modified and something like 100 equations have been added to try to explain the supposedpassage of atmospheric oxygen to the bloodstream through the pulmonary alveoli, but even so, the experimental results do not
square with the predictions of such a model. So, research and care for patients during the past 100 years has been based on eminentlytheoretical models.
So, returning to the phrase “aerobic metabolism of the CNS”, we have the surprise that it is wrong because the oxygen we have inside the body does not come from the air that surrounds us but from the water that contains inside each cell that conforms us.
Keywords: Oxygen; aerobic; Krogh´s model; energy; combustion; CSF
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An important element to consider is that people with dementia may have limited access to information on COVID-19 and experience difficulties in applying safety strategies (social isolation, self-quarantine measures, wearing masks, and personal hygiene). Therefore, people with dementia may be more dependent on family members and social caregivers to support them [7] to live within government guidelines. This is further impounded by the provision of information through social media and the implementation of digital health technologies. Older people with dementia living in residential settings have not been able to engage with their family members due to the banning of visitors and with the cessation of group activities [8], older people, and those with dementia, are becoming further isolated [9].
The consideration of the impact of COVID-19 on older people and those with dementia is essential due to the aging global population [10]. The global population of those over 65 years of age was estimated to be over 562 million in 2012, and the population of older adults rose by 55 million in 2015, which is projected to be double by 2050 [11]. Cognitive impairment is common in the older population, although is not a natural part of ageing [12]. The cognitive function of an individual may decrease with age, but mild cognitive impairment and dementia impacts on the person’s ability to independently complete their own activities of daily living, as well as impacting on their memory, language, and orientation. Recent studies showed that the use of computer helped in cognitive stimulation and improved cognitive function with mild cognitive impairment of elderly people [45]. The combined intervention of digital inclusion and physical exercise helped to prevent cognitive and functional loss with elderly [46]. Cognitive decline is a significant issue in aging and it is associated of dementia patients and increases independence, quality of life and falls. Thus, dementia can negatively impact on a person’s quality of life and life expectancy [13]. Dementia poses a challenge to the long-term financial sustainability of health systems worldwide [14]. Likewise, the number of people living with dementia in the developing countries will reach to 71% by 2040 [15] in developed countries such as Western Europe 9.9%, in North America 9.2%, and in America 9.1% of the population by 2040 [16] furthermore, older adults with dementia require further care services such as; care delivery, medication management, education and training for family members and informal caregivers, cognitive interventions, but also leisure activities to support a person with dementia to remain independent, all of which are currently extremely limited [17].
Interventions to support people with dementia at home, have begun to use video telehealth, which has been found to be feasible to deliver cognitive rehabilitation [18] and improve cognitive performance [19, 20]. Face to face videoconference [21], pharmacological interventions [22], technology-based behavioral interventions [23] and cognitive assessments [24]. These approaches demonstrate that technology-based interventions for older people and those with dementia appears both affordable [25] and reliable [26]. COVID-19 has forced and enabled the adoption of technology in dementia support and care in the form of prevention, early detection, care, management and diagnosis [27]. The applications of these technologies could support older people and those living with dementia in rural areas, and those who have migrated and may have linguistically diverse languages. The COVID-19 crisis has provided the opportunity to embrace technology, to support older people, and those with dementia to maintain their connections with the outside world during self-isolation. Health policy makers, service providers and clinicians need to consider these innovative opportunities and support the technological transformation of dementia practice in the coming years [28].
Digital health technologies can support a reduction in the provision of care in hospital settings, and support the management of infections [29]. Considering a significant contribution of digital technologies, the American Academy of Neurology has developed guidelines to implement telemedicine services for clinicians to assess and examine their patients, although some limitations have been acknowledged, such as the follow-up appointments [30]. However, this has not been converted into clinical practice as yet. COVID-19 has forced nations to consider the use of digital health, such as telehealth and e-health, which can contribute to the management of communicable diseases during the pandemic and possibly slow the infection rate of COVID-19 through supporting social distancing [31]. Digital health technologies provide and improve patients’ health, and reduces expenses and as well as the need for care facilities [32]. Telemedicine and mobile care tele-mentoring, tele critical care were significantly useful to offer care facilities during COVID-19 [33]. Within the specialist field of dementia memory screening tools, care, management of behavioral and psychological symptoms in dementia and consultations [34], have occurred through the use of remote technology. This approach has supported the difficult balance of maintaining social distancing and continuing to support people living with dementia, and those caring for them, but has also enable a significant cost reduction to the health system and decreased the risk of infections [35]. Furthermore, these processes have enabled clinical decisions, diagnoses and outcomes to be supported in a timelier manner, supporting earlier intervention opportunities [36] to support and improve mental health.
Technology can also contribute to the reduction of the burden on healthcare institutions and professionals [37]. Technology has also been applied through satellite monitoring, health sensors and apps, Drones (drones were applied in carrying medicine), spraying disinfectants and 3D Printing which was deployed to mitigate shocks to the supply chain and export bans on personal protective equipment [38]. Digital health technologies have not only supported older people and those with dementia, through remote screening and the facilitation of care during a pandemic [39]. Telehealth played directly and indirectly in reducing the contamination by enabling physical distancing, tracking symptoms and detecting timely using interventions [40]. Further, telehealth supported to bring out put with patients’ safety, reliable and flexible regulatory [41]. Virtual care using technologies in home patients and out patients care in health institution, initial COVID-19 hospital surge, and post pandemic recovery was most effective for the care of the dementia patients [42].
Emerging technologies are changing our daily lives under lockdown. The COVID-19 crisis has shown a further way that emerging technologies like the internet and artificial intelligence are not just tools, they are essential to the functioning of our society and economy in this 21st century. Thus, such digital tools must adapt as essential developmental procedure as the time progress. It is not only for COVID-19 issues but also should be implemented to make our daily life easiest than before to fight with communicable disease. Digital technology enables to educate from remote to health workers and populations to follow better care in limited resources and accurately using the Chatbots information getting update of current health systems and patients care home location of their activities and protect from the spread of the virus. Also, saved time, money and to all the sectors and will be cost effective [43].
However, is still a gap in the research regarding how and which digital health (DH) technologies can be effective to support older people and those with dementia patients. But the reality is we are seeking more reliable proof to apply and implement the full potential of this growing area in health science [44]. Therefore, supporting older adults with dementia and maintaining their well-being during COVID-19 has become an urgent to apply digital health technology.
Full Text Description
The author of the article owns a series of publications highlighting the features of the pathogenesis of a new disease: "COVID - 19 - POSTCOVID SYNDROME", as well as a method of treatment and prevention of this disease based on the scientifically proven healing properties of Hirudo medicinalis medical leeches [3-13]. At the same time, the editors of three scientific medical journals have already adopted the author's concept of the name of the disease - "COVID - 19 - POST-COVID SYNDROME" [11-13], which reflects the understanding that this is a single disease that has two phases: the first phase is an acute process, which usually lasts 2-3 weeks - ("COVID - 19") and the next phase is the development of a chronic process - ("POSTCOVID]. The team of MGNOT doctors, represented by its Chairman - Professor A.P. Vorobyov, offers the following treatment for "Post-Covid syndrome": 1. Apply direct oral anticoagulants, twice a day; 2. Plasmapheresis - at least 900 ml, for 1 procedure, at least 5 procedures, daily, with plasma replacement with saline to reduce intoxication [6]. It should be noted that the use of direct anticoagulants has a number of limitations and significant complications with damage to the central nervous system, they can cause nasal, throat and renal bleeding. Plasmapheresis is applicable only if there is special equipment and trained personnel in the clinics. Given the huge masses of the population affected by the pandemic, the proposed treatment technology has no chance of large-scale application. SYNDROME"), which can last for 18-24 months.
Such a definition of the new pandemic is important not only from a taxonomic point of view, but, above all, from a mental point of view, so it gives the doctor an understanding of the complexity of the course of the disease and requires monitoring patients during the entire specified period, for example, monitoring the dynamics: D-dimers, prothrombin time, platelet count and the level of fibrinogen in the blood of convalescents. These are the recommendations of the International Society on Thrombosis and Hemostasis (ISTH) [15]. Now these are the most informative markers of the danger of thrombosis. The term "Long COVID" does not reflect the essence of the disease process [13].
It should be clearly distinguished that the cause of the disease is the virus "COVID-19" (Beta-coronavirus SARS-CoV-2), and the disease itself, for these reasons, should be called "COVID-19 - POSTCOVID SYNDROME".
Analyzing the pathogenesis of this disease, we will dwell on the analysis of the pathogenesis and treatment offered by two scientific schools of Russia. One of them is the analysis and opinion of doctors united in the Moscow City Scientific Society of Therapists (MCSST) named after Professor S.P. Botkin. After examination and treatment of a significant number of patients (more than 2,000 people), with a confirmed diagnosis of “COVID-19”, during 2020-2021, the diagnosis of «POSTCOVID SYNDROME" was formulated. According to MCSST " POSTCOVID SYNDROME " is: “Chronically occurring thrombovasculitis with a predominant lesion of the nervous system (Central, autonomous and peripheral) and skin” [14].
The team of MCSST doctors, represented by its Chairman - Professor A.P. Vorobyov, offers the following treatment for "POSTCOVID SYNDROME":
- Apply direct oral anticoagulants, twice a day;
- Plasmapheresis - at least 900 ml, for 1 procedure, at least 5 procedures, daily, with plasma replacement with saline to reduce intoxication [6].
It should be noted that the use of direct anticoagulants has a number of limitations and significant complications with damage to the central nervous system; they can cause nasal, throat and renal bleeding. Plasmapheresis is applicable only if there is special equipment and trained personnel in the clinics.
Given the huge masses of the population affected by the pandemic, the proposed treatment technology has no chance of large-scale application.
Another clinical school, headed by academician Makatsaria A.D., believes that the leading pathological sign of this disease is the "Syndrome of disseminated intravascular coagulation - (DIC) syndrome [15]. The most unfavorable prognostic sign, according to the authors of this school, is coagulopathy.
If the parameters of the main markers of coagulopathy (D-dimers, prothrombin platelet time, count and fibrinogen levels) worsen, more "aggressive" resuscitation care should be carried out: Low molecular weight heparin (LMWH) should be prescribed to all patients with diagnosed “COVID-19” infection (including non-critical patients) who require hospitalization, in the absence of contraindications to LMWH in these patients. The use of LMWH drugs by this school (Enaxiparin, Nadroparin, Dalteparin) in a prophylactic dose is also justified, which does not require special control. It is recommended to take these drugs to all patients, even with a mild course of the disease, excluding active bleeding, platelet count < 25x109/l, intolerance to LMWH, severe renal failure.
At the same time, it is not known how these drugs will behave with prolonged use, except for the above limitations for them.
The author of this article spoke at the 11th European Congress for Integrative Medicine in 2018 in Ljubljana (Slovenia) [1] and at the 5th International Meeting on Traditional and Alternative Medicine in Rome (Italy) April 2019 with a report: "The Renaissance of hirudotherapy in Russia: The end of XX and the beginning XXI century [2]. These speeches and publications were positively received by the medical community, which served as an incentive for a more complete coverage of the topic of the current state of hirudotherapy in Russia [11-13].
Without reducing the importance of the recommendations of the MCSST therapy of "POSTCOVID SYNDROME"), we offer an alternative way to solve the problem of reducing mortality from pneumonia and other complications caused by “COVID-19”. Previously, we expressed the same point of view in the treatment of elderly people with multi-organ pathology, namely, they become primarily victims of this pneumonia [4].
This is the application of the "System Method of Leeching" (SML) - (hirudotherapy). The method is based on a combination of the principles of homeopathy and acupuncture (hirudopuncture, our definition). The proposed solution is based on the almost 30-year use of SML in elderly people with multi-organ pathology and children treated at the Academy of Hirudotherapy of St. - Petersburg [16]. The preventive and therapeutic plan for anticoagulant and antiplatelet therapy for the prevention of DIC- syndrome, distress syndrome is considered step by step from the standpoint of the “System Method of Leeching” (SML) in recent publications [4, 17].
We remind readers about some unknown properties of leech.
Over the past 30 years, the Academy of Hirudotherapy in St.- Petersburg has obtained a number of new fundamental facts when applying the “System Method of Leeching (SML), which can significantly enhance the clinical effect of its use, and will reduce the mortality of patients with pneumonia caused by the “COVID-19” virus.
In addition to the already known properties of hirudotherapy - antithrombic and thrombolytic, anti-inflammatory, countercurrent, new properties of medical leeches were discovered at the department:
- Discovery of the energy effect (information-entropic);
- Discovery of the neurostimulating effect of the medical leech;
- Discovery of the acoustic effect of leeching (hirudotherapy);
- Discovery of the detoxification effect of leeching (hirudotherapy);
- Discovery of the phenomenon of local hyperthermia in the body of a benign brain tumor - neurinoma;
- Discovery of the negentropic effect of leeching (hirudotherapy);
- The role of autohemogyrudotherapy in the formation of the immunomodulatory effect of leeching (hirudotherapy) is shown;
- Discovery of the aquastructuring effect of leeching (hirudotherapy);
- Discovery of the "Resonance-wave effect" of leech on the state of the human aquasystem.
Descriptions of all these discoveries are detailed in the author's publications [3-13, 17].
Therefore, as soon as the pandemic caused by the “COVID-19” virus was pumped up in Russia, our doctors, trained in the SML technology, began to actively apply this method in the treatment of the disease "COVID-19 - POST-COVID SYNDROME".
At the same time, it was shown that SML is a pathogenetic method of treating this disease, including well-known signs of damage to the central and peripheral nervous system, (restoring smell, hearing and vision loss, manifesting antidepressant syndrome) preventing the development of DIC - syndrome.
It should be noted that the use of SML has no restrictions on the timing of use, so a patient with a brain tumor - a neurinoma (schwanoma) received treatment for 23 years, demonstrating a positive result of treatment (Clinical case
described [18]).
Why do we refer to hirudotherapy as a “Method of information medicine”?
Not only because this method has about 20 types of therapeutic effect. But also because in the process of treatment with medical leeches, which is first shown in our studies, there is an impact on the information-entropy processes in the aqua system of patients, which leads to a process of harmony between the indicators of the chaos criterion (Cc) and the order criterion (Co), with access to the harmony parameters - "Golden Proportion" or "Golden Ratio", which is characteristic of a high level of health [5, 19].
Known for many centuries, the method of hirudotherapy, as part of Ayurveda or Ayurvedic medicine, is still revered and used in India and the countries of South-East Asia.
At present, thanks to new knowledge in the field of hirudology and hirudotherapy, reflected in the "System Method of Hirudotherapy", the Ayurveda method has acquired a new image, content and capabilities.
Conclusion
The SML method has no complications and can be used as monotherapy in both the acute and chronic stages of the disease "COVID - 19 - POSTCOVID SYNDROME".
Abstract
Aim: To define and evaluate the role of Apulian General Practitioners in regarding the prescribing appropriateness of antibiotics and the importance of counseling for patients, to identify and manage the problem of ABR, particularly in the context of upper respiratory tract infections.
Materials and methods: the survey was conducted through the administration of a questionnaire consisting of 10 items addressed to the GPs of the Apulian territory, in the period from January to April 2024, by email, instant messaging and social media.
Results: 180 General Practitioners were interviewed, (58% women 42% men) of which 45% GPs with >1500 patients, 32% urgent care doctors, 16% GPs with 1200-1500 patients, 3% GPs with 1000- 1200 patients and 5% GPs with 800-1000 patients.
65% of GPs (n:117) prescribe an average of 5 antibiotics per week, 22% of GPs (n:39) prescribe 6-10 antibiotics and 13% (n:24) more than 10 antibiotics. Patients ask for antibiotics for the following reasons: pharyngitis (68%), urinary tract infections (69%), cough (40%), acute bronchitis (44%), otitis (23%), sinusitis (18%), cold (16%), other flu symptoms (15%). General Practitioners report that every day on average at least one patient requires a prescription for an antibiotic for a pharyngitis. In 33% of cases it is a woman (33%), very insistent (52%), arguing the need to resume her work activity as soon as possible (34%), for self-diagnosis (32%) for comparison with family members with similar symptoms who would have been prescribed an antibiotic (32%), for having started home therapies, residues of previous therapies.
GPs report a patients’ poor awareness about side effects, compared to the deep-rooted belief that the antibiotic guarantees a quicker and better resolution of symptoms.The proposals to stem the phenomenon from the GPs interviewed suggest patient education to limit improper requests (79%), counseling not to use antibiotics in viral infections (77%), information on individual adverse events linked to abuse (56%), empowerment regarding the impact on the global health of the planet and the growing difficulty in treating infections caused by resistant germs (52%), synergistic action with pharmacists (48%), greater diffusion and training for the application of treatment guidelines in primary care (19%) and more frequent updating on the issue of AMR (15%).
Regarding the use of diagnostic tests such as the rapid test for beta hemolytic streptococcus, although little used in general practice, the majority of participants (80%) consider it strategic to avoid inappropriate antibiotic therapies and guide the patient towards its use of symptomatic. 83% of GPs recommend the use of anti- inflammatory-analgesics for the management of "sore throats" and confirm the need to combat the abuse of antibiotic therapy requests.
Conclusions: Antibiotic resistance is a multifactorial public health issue that requires urgent prevention and control actions at global and cross-sectoral. General Practitioners in Apuglia have a fundamental role on the correct use of antibiotics. It is necessary to promote health education and patient counseling, citizen empowerment about good hygiene practices (use of DPI, hand washing, etc.), attention to environmental contamination (e.g. waste disposal); to encourage adherence to vaccination and the appropriate use of antibiotic or symptomatic therapies for themselves and for the community; to reduce the tendency to self- prescribe antibiotics and the adverse events related to it, such as the percentage of treatment failures and healthcare costs; to apply the guidelines in pharmaceutical prescriptions; to join collaborative, research and innovation initiatives to combat ABR.
A possible helpful tool may be the use of rapid diagnostic tests to reduce the inappropriate prescription of antibiotics. We need to move from a simple idea of appropriateness in prescription to an overall cultural appropriateness of a healthcare nature.
In fact, General Practitioners can act effectively only with other stakeholders, to trigger virtuous processes, respecting the skills and responsibilities of each individual, in order to always be able to operate for the best clinical outcome, in the absence of ethical conflicts. At the same time, we hope for more training opportunities for healthcare workers, pharmacists and veterinarians, in integrated multi-sectoral events, according to the principles of One Health.
Keywords: antibiotic resistance; General Practitioners; sore throat
