COVID-19, immune system response, hyperinflammation and repurposing antirheumatic drugs

Early predictors of severe COVID-19 among hospitalized patients

BACKGROUND

Limited research has been conducted on early laboratory biomarkers to identify patients with severe coronavirus disease (COVID-19). This study fills this gap to ensure appropriate treatment delivery and optimal resource utilization.

METHODS

In this retrospective, multicentre, cohort study, 52 and 64 participants with severe and mild cases of COVID-19, respectively, were enrolled during January-March 2020. Least absolute shrinkage and selection operator and binary forward stepwise logistic regression were used to construct a predictive risk score. A prediction model was then developed and verified using data from four hospitals.

RESULTS

Of the 50 variables assessed, eight were independent predictors of COVID-19 and used to calculate risk scores for severe COVID-19: age (odds ratio (OR = 14.01, 95% confidence interval (CI) 2.1-22.7), number of comorbidities (OR = 7.8, 95% CI 1.4-15.5), abnormal bilateral chest computed tomography images (OR = 8.5, 95% CI 4.5-10), neutrophil count (OR = 10.1, 95% CI 1.88-21.1), lactate dehydrogenase (OR = 4.6, 95% CI 1.2-19.2), C-reactive protein OR = 16.7, 95% CI 2.9-18.9), haemoglobin (OR = 16.8, 95% CI 2.4-19.1) and D-dimer levels (OR = 5.2, 95% CI 1.2-23.1). The model was effective, with an area under the receiver-operating characteristic curve of 0.944 (95% CI 0.89-0.99, p < 0.001) in the derived cohort and 0.8152 (95% CI 0.803-0.97; p < 0.001) in the validation cohort.

CONCLUSION

Predictors based on the characteristics of patients with COVID-19 at hospital admission may help predict the risk of subsequent critical illness.

COVID-19 and Sepsis

The COVID-19 pandemic has created a major alteration in the medical literature including the sepsis discussion. From the outset of the pandemic, various reports have indicated that although there are some unique features pertinent to COVID-19, many of its acute manifestations are similar to sepsis caused by other pathogens. As a consequence, the old definitions now require consideration of this new etiologic agent, namely SARS-CoV-2. Although the pathogenesis of COVID-19 has not been fully explained, the data obtained so far in hospitalized patients has revealed that serum cytokine and chemokine levels are high in severe COVID-19 patients, similar to those found with sepsis. COVID-19 may involve multiple organ systems. In addition to the lungs, the virus has been isolated from blood, urine, faeces, liver, and gallbladder. Results from autopsy series in COVID-19 patients have demonstrated a wide range of findings, including vascular involvement, congestion, consolidation, and hemorrhage as well as diffuse alveolar damage in lung tissue consistent with acute respiratory distress syndrome (ARDS). The presence of viral cytopathic-like changes, infiltration of inflammatory cells (mononuclear cells and macrophages), and viral particles in histopathological samples are considered a consequence of both direct viral infection and immune hyperactivation. Thromboembolism and hyper-coagulopathy are other components in the pathogenesis of severe COVID-19. Although the pathogenesis of hypercoagulability is not fully understood, it has been pointed out that all three components of Virchow’s triad (endothelial injury, stasis, and hypercoagulable state) play a major role in contributing to clot formation in severe COVID-19 infection. In severe COVID-19 cases, laboratory parameters such as hematological findings, coagulation tests, liver function tests, D-dimer, ferritin, and acute phase reactants such as CRP show marked alterations, which are suggestive of a cytokine storm. Another key element of COVID-19 pathogenesis in severe cases is its similarity or association with hemophagocytic lymphohistiocytosis (HLH). SARS-CoV-2 induced cytokine storm has significant clinical and laboratory findings overlapping with HLH. Viral sepsis has some similarities but also some differences when compared to bacterial sepsis. In bacterial sepsis, systemic inflammation affecting multiple organs is more dominant than in COVID-19 sepsis. While bacterial sepsis causes an early and sudden onset clinical deterioration, viral diseases may exhibit a relatively late onset and chronic course. Consideration of severe COVID-19 disease as a sepsis syndrome has relevance and may assist in terms of determining treatments that will modulate the immune response, limit intrinsic damage to tissue and organs, and potentially improve outcome.

Achievements of the COVID-19 Turkey Platform in vaccine and drug development with an approach of "co-creation and succeeding together"

Mobilizing the research ecosystem for accelerating vaccine and drug development has been an important reality of the pandemic. This article reviews the scientific advances that are attained by the COVID-19 Turkey Platform for vaccine and drug development against the SARS-CoV-2 virus. The platform that is coordinated by the Scientific and Technological Research Council of Turkey is established with a "co-creation and succeeding together" approach, which involves 436 researchers across 49 different institutions working on 17 vaccine and drug development projects in total. Recent advances of the COVID-19 Turkey Platform include the fourth virus-like particle-based vaccine candidate in the world to enter clinical studies based on the World Health Organization COVID-19 vaccine tracker that is currently completing phase 2 clinical studies on the path towards initiating phase 3 clinical studies. Moreover, an adjuvanted inactivated vaccine candidate and two drug candidates that have been identified through the virtual scanning of more than 20,000 molecules are currently in clinical studies. Other vaccines and drug candidates involve additional innovative aspects, and a locally synthesized drug is found to have an impact on COVID-19. This review article discusses the advances that are achieved by the COVID-19 Turkey Platform from the ecosystem perspective, emphasizing the important scientific advances that have been achieved in the field of medical sciences.

Toward finding the difference between untreated celiac disease and COVID-19 infected patients in terms of CD4, CD25 (IL-2 Rα), FOXP3 and IL-6 expressions as genes affecting immune homeostasis

BACKGROUND

Coronavirus disease 2019 (COVID-19) is defined as an emerging infectious disease caused by severe acute respiratory syndrome coronavirus 2 and celiac disease (CD) is one of the autoimmune multiorgan diseases, which can be accompanied by an increased risk of viral infections. CD patients, especially untreated subjects, may be at greater risk of infections such as viral illnesses. Interleukin (IL)-6, CD4, CD25, and FOXP3 are known as genes affecting immune homeostasis and relate to the inflammation state. This study aimed to compare the expression levels of aforementioned genes in peripheral blood samples of CD and severe COVID-19 patients.

METHODS

Sixty newly diagnosed CD patients with median age (mean ± SD) of 35.40 ± 24.12 years; thirty confirmed severe COVID-19 patients with median age (mean ± SD) of 59.67 ± 17.22, and 60 healthy subjects with median age (mean ± SD) of 35.6 ± 13.02 years; were recruited from March to September 2020. Fresh whole blood samples were collected, total RNA was obtained and cDNA synthesis was carried out. RNA expression levels of IL-6, CD4, CD25, and FOXP3 genes were assessed using real-time quantitative RT-PCR according to the 2^-∆∆Ct formula. Statistical analysis was performed using SPSS (V.21) and GraphPad, Prism (V.6).

RESULTS

While increased expression of CD4, CD25, and FOXP3 was observed in CD patients compared to the control group (p = 0.02, p = 0.03, and p < 0.0001 respectively) and COVID-19 patients group (p < 0.0001 for all of them), their expression levels in COVID-19 patients decreased compared to controls (p < 0.0001, p = 0.01, p = 0.007, respectively). Increased IL-6 expression was observed in both groups of patients compared to controls (p < 0.0001 for both of them).

CONCLUSIONS

Although untreated CD patients may be at greater risk of developing into severe COVID-19 if they are infected by SARS-CoV-2 virus (due to their high expression of IL-6), increased expression of anti-inflammatory markers in these patients may be beneficial for them with the ability of reducing the severity of COVID-19 disease, which needs to be proven in future studies involving celiac patients infected with COVID-19.

Immunological evaluation of an inactivated SARS-CoV-2 vaccine in rhesus macaques

Because of the relatively limited understanding of coronavirus disease 2019 (COVID-19) pathogenesis, immunological analysis for vaccine development is needed. Mice and macaques were immunized with an inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine prepared by two inactivators. Various immunological indexes were tested, and viral challenges were performed on day 7 or 150 after booster immunization in monkeys. This inactivated SARS-CoV-2 vaccine was produced by sequential inactivation with formaldehyde followed by propiolactone. The various antibody responses and specific T cell responses to different viral antigens elicited in immunized animals were maintained for longer than 150 days. This comprehensive immune response could effectively protect vaccinated macaques by inhibiting viral replication in macaques and substantially alleviating immunopathological damage, and no clinical manifestation of immunopathogenicity was observed in immunized individuals during viral challenge. This candidate inactivated vaccine was identified as being effective against SARS-CoV-2 challenge in rhesus macaques.

Effects of β-Blockers on the Sympathetic and Cytokines Storms in Covid-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a causative virus in the development of coronavirus disease 2019 (Covid-19) pandemic. Respiratory manifestations of SARS-CoV-2 infection such as acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) leads to hypoxia, oxidative stress, and sympatho-activation and in severe cases leads to sympathetic storm (SS). On the other hand, an exaggerated immune response to the SARS-CoV-2 invasion may lead to uncontrolled release of pro-inflammatory cytokine development of cytokine storm (CS). In Covid-19, there are interactive interactions between CS and SS in the development of multi-organ failure (MOF). Interestingly, cutting the bridge between CS and SS by anti-inflammatory and anti-adrenergic agents may mitigate complications that are induced by SARS-CoV-2 infection in severely affected Covid-19 patients. The potential mechanisms of SS in Covid-19 are through different pathways such as hypoxia, which activate the central sympathetic center through carotid bodies chemosensory input and induced pro-inflammatory cytokines, which cross the blood-brain barrier and activation of the sympathetic center. β2-receptors signaling pathway play a crucial role in the production of pro-inflammatory cytokines, macrophage activation, and B-cells for the production of antibodies with inflammation exacerbation. β-blockers have anti-inflammatory effects through reduction release of pro-inflammatory cytokines with inhibition of NF-κB. In conclusion, β-blockers interrupt this interaction through inhibition of several mediators of CS and SS with prevention development of neural-cytokine loop in SARS-CoV-2 infection. Evidence from this study triggers an idea for future prospective studies to confirm the potential role of β-blockers in the management of Covid-19.

Rosemary and its protective potencies against COVID-19 and other cytokine storm associated infections: A molecular review

BACKGROUND: Nowadays, medicinal plants have attracted great interest in treatment of human diseases. Rosemary is a well-known medicinal plant which has been widely used for different therapeutic purposes. METHODS: This is a narrative review using databases including PubMed, ISI, Scopus, ScienceDirect, Cochrane, and google scholar, the most authoritative articles were searched, screened, and analyzed. RESULTS: Rosemary is a natural antioxidant which removes reactive oxygen species from tissues and increases expression on Nrf2 gene. Rosemary and its metabolites reduce inflammation by inhibiting production of pro-inflammatory cytokines, decreasing expression of NF-κB, inhibiting infiltration of immune cells to inflamed sites, and affecting gut microbiome. Besides, rosmarinic acid in rosemary extract has positive effects on renin-angiotensin-system. Rosemary affects respiratory system by reducing oxidative stress, inflammation, muscle spasm, and also through anti-fibrotic properties. Carnosic acid is able to penetrate blood-brain-barrier and act against free radicals, ischemia and neurodegeneration in brain. Cardioprotective effects include correcting lipid profile, controlling blood pressure by inhibition of ACE, prevention of atherosclerosis, and reduction of cardiac muscle hypertrophy. CONCLUSIONS: Accordingly, rosemary supplementation has potential protective effects against COVID-19 and other cytokine storm associated infections, a conclusion that needs more evaluations in the next clinical trials.

Glucocorticoid excess and COVID-19 disease

The pandemic of coronavirus disease (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing high and rapid morbidity and mortality. Immune system response plays a crucial role in controlling and resolving the viral infection. Exogenous or endogenous glucocorticoid excess is characterized by increased susceptibility to infections, due to impairment of the innate and adaptive immune system. In addition, diabetes, hypertension, obesity and thromboembolism are conditions overrepresented in patients with hypercortisolism. Thus patients with chronic glucocorticoid (GC) excess may be at high risk of developing COVID-19 infection with a severe clinical course. Care and control of all comorbidities should be one of the primary goals in patients with hypercortisolism requiring immediate and aggressive treatment. The European Society of Endocrinology (ESE), has recently commissioned an urgent clinical guidance document on management of Cushing's syndrome in a COVID-19 period. In this review, we aim to discuss and expand some clinical points related to GC excess that may have an impact on COVID-19 infection, in terms of both contagion risk and clinical outcome. This document is addressed to all specialists who approach patients with endogenous or exogenous GC excess and COVID-19 infection.

The Use of Extracorporeal Membrane Oxygenation in COVID-19 Patients with Severe Cardiorespiratory Failure: The Influence of Obesity on Outcomes

Extracorporeal membrane oxygenation (ECMO) in the management of severely ill patients with COVID-19 has been reported in more than 5,827 cases worldwide according to the Extracorporeal Life Support Organization (ELSO). Several pre-existing conditions have been linked to an increase in COVID-19 mortality risk including obesity. The purpose of this research is to review the clinical experience from a cohort of 342 COVID-19 patients treated with ECMO in which 61.7% (211/342) are confirmed obese. Following institutional review board approval, we reviewed all 342 COVID-19 patients supported with ECMO between March 17, 2020 and March 18, 2021, at 40 American institutions from a multi-institutional database. Descriptive statistics comparing survivors to non-survivors were calculated using chi-square, Welch's ANOVA, and Kruskal-Wallis rank sum test as appropriate. Multivariable logistic regression was used to estimate the effect of body mass index (BMI) on the odds of survival while adjusting for age, gender, chronic renal failure, diabetes, asthma, hypertension, and pre-ECMO P/F ratio. Descriptive analysis showed that obese patients were more likely to be hypertensive (58.1% vs. 32%, p < .001), diabetic (42% vs. 30%, p < .05), and female (35% vs. 21%, p < .05), and had longer median days from intubation to cannulation (4.0 vs. 2.0, p < .05). Obese patients appeared to also have a slightly lower median age (47.9 vs. 50.5, p = .07), higher incidence of asthma (17.8% vs. 10.2%, p = .09), and a slightly lower pre-ECMO PaO₂/FiO₂ ratio (67.5 vs. 77.5, p = .08) though these differences were slightly less statistically reliable. Results from the logistic regression model suggest no statistically reliable association between BMI and odds of survival. Age had a moderately large and statistically reliable negative association with survival; the relative odds of survival for a 59-year-old patient were approximately half those of a 41-year-old patient (OR = .53, 95% CI: .36-.77, p < .001). Obesity does not seem to be a major risk factor for poor outcomes in COVID-19 patients supported with ECMO; however, age was moderately negatively associated with survival. The potential influence of other comorbidities on odds of survival among these patients warrant further investigation.

COVID-19 from a rheumatology perspective: bibliometric and altmetric analysis

The Coronavirus disease 2019 (COVID-19) outbreak turned out the greatest pandemic for decades. It challenged enormously the global health system, forcing it to adjust to the new realities. We aimed to analyze articles covering COVID-19 papers in the rheumatological field and outline emerging topics raising within this frame. We applied the bibliometric database Scopus for our literature search and conducted it on the 5th of June using the following keywords: "rheumatic" OR "rheumatology" OR "rheumatoid arthritis" OR "systemic lupus erythematosus" OR "myositis" OR "systemic sclerosis" OR "vasculitis" OR "arthritis" OR "ankylosing spondylitis" AND "COVID-19". We analyzed all selected articles according to various aspects: type of document, authorship, journal, citations score, rheumatology field, country of origin, language, and keywords. With the help of the software tool VOSviewer version 1.6.15, we have built the visualizing network of authors and keywords co-occurrence. The measurement of the social impact of articles was made using Altmetric data. This study included 1430 retrieved articles with open access mostly. The top five journals in this field were Annals of the Rheumatic Diseases (n = 65), Rheumatology International (n = 51), Clinical Rheumatology (n = 50), Lancet Rheumatology (n = 50), and Frontiers In Immunology (n = 33). Most studies originate from countries with a high incidence of COVID-19 among the general population (the USA-387; Italy-268; UK-184; France-114; Germany-110; India-98 and Spain-96, China-94, Canada-73 Turkey-66). Original Articles (42.1%) were the most common articles' type, following by Letters (24.4%), Reviews (21.7%), Notes (6%), Editorials (4.8%), Erratum (1%). According to the citations scores, articles dedicated to the clinical course of COVID-19 in patients with rheumatic diseases were of the highest importance for the scientific rheumatologic community. Rheumatoid arthritis (n = 527), systemic lupus erythematosus (n = 393), vasculitis (n = 267), myositis (n = 71), systemic sclerosis (n = 68), and psoriatic arthritis (n = 68) were the most widely discussed rheumatic diseases in the view of COVID-19. The analysis of Altmetric and citations scores revealed a moderate correlation between them. This article provides a comprehensive bibliometric and altmetric analysis of COVID-19 related articles in the rheumatology field and summarizes data about features of rheumatology service in the time of the pandemic.

Prospect of 3D bioprinting over cardiac cell therapy and conventional tissue engineering in the treatment of COVID-19 patients with myocardial injury

Due to multiple mutations of SARS-CoV-2, the mystery of defeating the virus is still unknown. Cardiovascular complications are one of the most concerning effects of COVID-19 recently, originating from direct and indirect mechanisms. These complications are associated with long-term Cardio-vascular diseases and can induce sudden cardiac death in both infected and recovered COVID-19 patients. The purpose of this research is to do a competitive analysis between conventional techniques with the upgraded alternative 3D bioprinting to replace the damaged portion of the myocardium. Additionally, this study focuses on the potential of 3D bioprinting to be a novel alternative. Finally, current challenges and future perspective of 3D bioprinting technique is briefly discussed.

Immune response in acute respiratory syndrome induced by the new coronavirus

Coronaviruses (CoVs) belong to the family Coronaviridae, which are enveloped and have a single-stranded RNA genome. The new coronavirus (SARS-CoV-2) is the seventh known coronavirus that can infect humans and cause serious illness, such as acute respiratory syndrome. The coronaviruses already identified have contributed to the understanding of the clinical manifestations caused by SARS-CoV-2, as well as their associations with the immune system. The aim of the present study was to carry out a narrative review of the literature on the host's immune response to infection by the new coronavirus. The review contains basic and summarized information on the main mechanisms involved in the immune response to SARS-CoV-2. The characteristics of the infection were considered according to the following: from the initial contact with the host through binding to angiotensin-converting enzyme 2 (ACE-2); the recognition of the pathogen by innate immunity cells; its containment mechanisms, including the production of effector cytokines and chemokines important in the development of the inflammatory process; and the participation of the complement system until the activation of the adaptive immune response. The probable occurrence of a host dysfunctional immune response and the escape mechanisms of the virus were also addressed. Despite numerous studies on the pathogenesis of SARS-CoV-2 infection, knowledge about the host's immune response in COVID-19 is not fully understood. The present work established the relationship between the new coronavirus and the immune system, but further studies are needed for all the mechanisms of the process to be elucidated.

Effects of statins and steroids on coronary artery disease and stroke in patients with interstitial lung disease and pulmonary fibrosis: A general population study

Purpose

To determine the effects of statins and steroids on the risk of coronary artery disease (CAD) and stroke in patients with interstitial lung disease and pulmonary fibrosis (ILD-PF).

Methods

We retrospectively enrolled patients with ILD-PF who were using statins (statin cohort, N = 11,567) and not using statins (nonstatin cohort, N = 26,159). Cox proportional regression was performed to analyze the cumulative incidence of CAD and stroke. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of CAD and stroke were determined after sex, age, and comorbidities, as well as the use of inhaler corticosteroids (ICSs), oral steroids (OSs), and statins, were controlled for.

Results

Compared with those of patients without statin use, the aHRs (95% CIs) of patients with statin use for CAD and ischemic stroke were 0.72 (0.65–0.79) and 0.52 (0.38–0.72), respectively. For patients taking single-use statins but not ICSs/OSs, the aHRs (95% CIs) for CAD and ischemic stroke were 0.72 (0.65–0.79)/0.69 (0.61–0.79) and 0.54 (0.39–0.74)/0.50 (0.32–0.79), respectively. For patients using ICSs/OSs, the aHRs (95% CIs) for CAD and ischemic stroke were 0.71 (0.42–1.18)/0.74 (0.64–0.85) and 0.23 (0.03–1.59)/0.54 (0.35–0.85), respectively.

Conclusions

The findings demonstrate that statin use, either alone or in combination with OS use, plays an auxiliary role in the management of CAD and ischemic stroke in patients with ILD-PF.

Neurological Manifestations of Hospitalized Patients with Covid-19: A Case Series Study

There are some reports about the neurological manifestations and complications of COVID-19. We present neurological manifestations in 6 hospitalized patients with COVID-19. The patients presented with common symptoms of COVID-19 along with common findings from high-resolution computed tomography (HRCT) scan such as ground-glass opacities (GGOs). Though, RT-PCR testing of SARS-CoV-2 was negative for all 6 cases. In the current report, acute cerebrovascular diseases affected older patients, while dementia, seizure and encephalopathy affected younger ones. Three of the 6 patients had proven strokes based on their neuroimaging. Four of the 6 patients had high d-dimer levels. Two of the cases experienced convulsion. The third patient presented with typical symptoms and signs of neuroleptic malignant syndrome. The sixth case was interesting for transient dementia. Unfortunately, four out of six patients died. The recent case series report the association between neurological involvements and COVID-19 infection. Clinicians should be alert of the neurologic symptoms in the setting of COVID-19, which might even be the first presentations of this infection.

New-Onset Insulin Allergy After COVID-19 Infection in an Insulin-Dependent Type-2 Diabetic Patient: A Rare Complication

Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease caused by the novel coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Initially, it was reported in December 2019 and became a global pandemic in March 2020, with many presentations and after-effects. We report the case of a 68-year-old female patient who presented to the emergency room with the chief complaint of a skin rash and itching all over her body, developing within a few minutes of insulin injection. The patient had tested positive for COVID-19 almost eight days ago and was self-quarantined. She was a known diabetic for the past 28 years. Her blood glucose levels were maintained within the normal range by a combination regimen of oral anti-diabetic drugs and subcutaneous humulin 70/30 (70% neutral protamine Hagedorn (NPH) insulin and 30% regular human insulin) injections. After careful examination and thorough history taking, a newly acquired insulin allergy was diagnosed in the patient, attributed to her disrupted immune system due to the recent COVID-19 infection.

Within Host Dynamics of SARS-CoV-2 in Humans: Modeling Immune Responses and Antiviral Treatments

In December 2019, a newly discovered SARS-CoV-2 virus was emerged from China and propagated worldwide as a pandemic, resulting in about 3-5% mortality. Mathematical models can provide useful scientific insights about transmission patterns and targets for drug development. In this study, we propose a within-host mathematical model of SARS-CoV-2 infection considering innate and adaptive immune responses. We analyze the equilibrium points of the proposed model and obtain an expression of the basic reproduction number. We then numerically show the existence of a transcritical bifurcation. The proposed model is calibrated to real viral load data of two COVID-19 patients. Using the estimated parameters, we perform global sensitivity analysis with respect to the peak of viral load. Finally, we study the efficacy of antiviral drugs and vaccination on the dynamics of SARS-CoV-2 infection. Results suggest that blocking the virus production from infected cells can be an effective target for antiviral drug development. Finally, it is found that vaccination is more effective intervention as compared to the antiviral treatments.

Rheumatologic aspects of the COVID-19 pandemic: a practical resource for physicians in Kuwait and the Gulf region based on recommendations by the Kuwait Association of Rheumatology (KAR)

The Kuwait Association of Rheumatology members met three times in April 2020 to quickly address and support the local practitioners treating rheumatic disease in Kuwait and the Gulf region during the COVID-19 pandemic. As patients with rheumatic and musculoskeletal disease (RMD) may need modifications to their therapy during the COVID-19 pandemic, we voted online for general guidance that local practitioners needed. In this review, we have addressed the vulnerability of rheumatic patients and issues surrounding their optimum management. We base our recommendations on a synthesis of national/international guidelines and expert consensus among KAR members in the context of the Kuwaiti healthcare system caring for the patient population with RMD. The most recent reports from the World Health Organization, the Center for Disease Control, the National Institutes of Health - National Medical Library, and the COVID-19 educational website of the United Kingdom National Health Service have been incorporated. We discuss the management of RMD in various clinical scenarios: screening protocols in an infusion clinic, medication protocols for stable patients and care for suspected or confirmed COVID infection and whether they are stable, in a disease flare or newly diagnosed. Besides, we also outline the conditions for the hospital admission. This guidance is for the specialist and non-specialist readership and should be regarded as interim as the virus is relatively new and we rely on experience and necessity more than evidence collection. The guidance presented should be supplemented with recent scientific evidence wherever applicable.

Effect of ORF7 of SARS-CoV-2 on the Chemotaxis of Monocytes and Neutrophils In Vitro

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently the most significant public health threat worldwide. Patients with severe COVID-19 usually have pneumonia concomitant with local inflammation and sometimes a cytokine storm. Specific components of the SARS-CoV-2 virus trigger lung inflammation, and recruitment of immune cells to the lungs exacerbates this process, although much remains unknown about the pathogenesis of COVID-19. Our study of lung type II pneumocyte cells (A549) demonstrated that ORF7, an open reading frame (ORF) in the genome of SARS-CoV-2, induced the production of CCL2, a chemokine that promotes the chemotaxis of monocytes, and decreased the expression of IL-8, a chemokine that recruits neutrophils. A549 cells also had an increased level of IL-6. The results of our chemotaxis Transwell assay suggested that ORF7 augmented monocyte infiltration and reduced the number of neutrophils. We conclude that the ORF7 of SARS-CoV-2 may have specific effects on the immunological changes in tissues after infection. These results suggest that the functions of other ORFs of SARS-CoV-2 should also be comprehensively examined.

Recent advances in antibody-based immunotherapy strategies for COVID-19

The emergence of a new acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), the cause of the 2019-nCOV disease (COVID-19), has caused a pandemic and a global health crisis. Rapid human-to-human transmission, even from asymptomatic individuals, has led to the quick spread of the virus worldwide, causing a wide range of clinical manifestations from cold-like symptoms to severe pneumonia, acute respiratory distress syndrome (ARDS), multiorgan injury, and even death. Therefore, using rapid and accurate diagnostic methods to identify the virus and subsequently select appropriate and effective treatments can help improvement of patients and control the pandemic. So far, various treatment regimens along with prophylactic vaccines have been developed to manage COVID-19-infected patients. Among these, antibody-based therapies, including neutralizing antibodies (against different parts of the virus), polyclonal and monoclonal antibodies, plasma therapy, and high-dose intravenous immunoglobulin (IVIG) have shown promising outcomes in accelerating and improving the treatment process of patients, avoiding the viral spreading widely, and managing the pandemic. In the current review paper, different types and applications of therapeutic antibodies in the COVID-19 treatment are comprehensively discussed.

Multiplex NanoSPR Molecular Biosensor for Blood Cytokine Monitoring

Cytokines, as protein biomarkers, have essential functions in the diagnosis, identification, and healing of a broad range of syndromes. For the specific and accurate monitoring of immune conditions, which change rapidly throughout the duration of disease, sophisticated sensors for detecting cytokines are essential and will assist in clinical testing and studies of various diseases. The present manuscript briefly discusses fundamental principles applied to the development of tools for cytokine detection and new biomarker development. The latest developments in the technologies for highly sensitive and multiplexed cytokine quantification, with current detection capabilities across a broad, vibrant array, are also discussed. Finally, nanomaterial-based cytokine sensors, currently considered new approaches, are presented from the perspective of optimizing the sensitivity and multiplexity of cytokine detection.

Can Anakinra and corticosteroid treatment be an effective option in pregnant women with severe Covid-19?

Anakinra, which is an Interleukin-1 (IL-1) receptor antagonist with the advancing disease process, has started to be considered as an alternative treatment for Covid-19 patients with cytokine storms. We evaluated the effect of corticosteroids and IL-1 receptor blockage with anakinra on pregnant patients with Covid-19 at high risk for respiratory distress, ongoing fever, deterioration in their general condition and consequently maternal and fetal complications. Fourteen pregnant women who received anakinra (median dosage: 400 mg) and corticosteroid (methylprednisolone-median dosage: 80 mg) treatment were evaluated retrospectively. Patients were assessed according to the World Health Organization (WHO) scale. The mortality rate of the cohort was 7.1%, the median hospitalization period of the patients was 15 days and 2 patients had premature births. Covid-19 was found to have a similar spectrum of symptoms in pregnant and non-pregnant women, such as dyspnea, cough and fever. Our study was the first to analyze the combined treatment of corticosteroid and anakinra in pregnant patients with pneumonia from Covid-19 based on the WHO scoring system. Due to the obscurity in the treatment process in pregnant patients, studies are ongoing on managing Covid-19 infection in these patients. We presume that the early use of anakinra and corticosteroid treatments in patients severely infected with Covid-19 may have positive effects on disease progression and survival.

Targeting purinergic receptors to suppress the cytokine storm induced by SARS-CoV-2 infection in pulmonary tissue

The etiological agent of coronavirus disease (COVID-19) is the new member of the Coronaviridae family, a severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2), responsible for the pandemic that is plaguing the world. The single-stranded RNA virus is capable of infecting the respiratory tract, by binding the spike (S) protein on its viral surface to receptors for the angiotensin II-converting enzyme (ACE2), highly expressed in the pulmonary tissue, enabling the interaction of the virus with alveolar epithelial cells promoting endocytosis and replication of viral material. The infection triggers the activation of the immune system, increased purinergic signaling, and the release of cytokines as a defense mechanism, but the response can become exaggerated and prompt the so-called “cytokine storm”, developing cases such as severe acute respiratory syndrome (SARS). This is characterized by fever, cough, and difficulty breathing, which can progress to pneumonia, failure of different organs and death. Thus, the present review aims to compile and correlate the mechanisms involved between the immune and purinergic systems with COVID-19, since the modulation of purinergic receptors, such as A2A, A2B, and P2X7 expressed by immune cells, seems to be effective as a promising therapy, to reduce the severity of the disease, as well as aid in the treatment of acute lung diseases and other cases of generalized inflammation.

SARS-CoV-2 infection of the central nervous system in a 14-month-old child: A case report of a complete autopsy

Background

Neurological and other systemic complications occur in adults with severe COVID-19. Here we describe SARS-CoV-2 infection complicated by neuroinvasion in the post-mortem tissues of a child.

Methods

We performed a complete autopsy of a 14-month-old child who died of COVID-19 pneumonitis. Histological sections of multiple organs were stained with haematoxylin and eosin. Luxol fast blue staining for myelin and immunohistochemistry were performed in selected areas of the brain. The presence of SARS-CoV-2 was investigated by immunostaining with anti-spike protein antibody and by RT-qPCR.

Findings

Lesions included microthrombosis, pulmonary congestion, interstitial oedema, lymphocytic infiltrates, bronchiolar injury, collapsed alveolar spaces, cortical atrophy, and severe neuronal loss. SARS-CoV-2 staining was observed along the apical region of the choroid plexus (ChP) epithelium and in ependymal cells of the lateral ventricle, but was restricted to ChP capillaries and vessels in some regions. SARS-CoV-2 infection of brain tissue was confirmed by RT-qPCR in fragments of the ChP, lateral ventricle, and cortex.

Interpretation

Our results show multisystemic histopathological alterations caused by SARS-CoV-2 infection and contribute to knowledge regarding the course of fatal COVID-19 in children. Furthermore, our findings of ChP infection and viral neurotropism suggest that SARS-CoV-2 may invade the central nervous system by blood-cerebrospinal fluid barrier disruption.

Funding

Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ); the National Council for Scientific and Technological Development (CNPq) and Coordination for the Improvement of Higher Education Personnel (CAPES), in addition to intramural grants from D'Or Institute for Research and Education.

Editor's Note

This translation in Portuguese was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript.

Resumo

Complicações sistêmicas e neurológicas foram descritas em adultos com COVID-19 grave. Neste trabalho, descrevemos a infecção por SARS-CoV-2, incluindo sua neuroinvasão, nos tecidos post-mortem de uma criança.

Métodos

Realizamos a autópsia completa de uma criança de 14 meses que morreu de pneumonite por COVID-19. Cortes histológicos de múltiplos órgãos foram corados com Hematoxilina e Eosina. A coloração de Luxol Fast Blue para mielina e imuno-histoquímica foram realizadas em áreas selecionadas do cérebro. A presença de SARS-CoV-2 foi investigada por imunomarcação com anticorpo anti-proteína spike e por RT-qPCR.

Achados

As lesões incluíram microtrombose, congestão pulmonar, edema intersticial, infiltrados linfocíticos, lesão bronquiolar, colapso dos espaços alveolares, atrofia cortical e perda neuronal grave. A presença de SARS-CoV-2 foi observada ao longo da região apical do epitélio do plexo coróide (PC) e nas células ependimárias do ventrículo lateral, mas ficou restrita aos capilares e vasos do PC em outras regiões. A infecção do tecido cerebral por SARS-CoV-2 foi confirmada por RT-qPCR em fragmentos do PC, ventrículo lateral e cortex cerebral.

Interpretação

Nossos resultados mostram alterações histopatológicas multissistêmicas causadas pela infecção por SARS-CoV-2 e contribuem para ampliar o conhecimento sobre a evolução da COVID-19 fatal em crianças. Além disso, nossos achados sobre a infecção no PC e neurotropismo viral sugerem que o SARS-CoV-2 pode invadir o sistema nervoso central pela ruptura da barreira sangue-líquido cefalorraquidiano.

Financiamento

Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ); Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ) e Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), além de financiamento intramural do Instituto D'Or de Pesquisa e Educação.

Drug repurposing against coronavirus disease 2019 (COVID-19): A review

Since December 2019, severe acute respiratory syndrome coronavirus 2 has been found to be the culprit in the coronavirus disease 2019 (COVID-19), causing a global pandemic. Despite the existence of many vaccine programs, the number of confirmed cases and fatalities due to COVID-19 is still increasing. Furthermore, a number of variants have been reported. Because of the absence of approved anti-coronavirus drugs, the treatment and management of COVID-19 has become a global challenge. Under these circumstances, drug repurposing is an effective method to identify candidate drugs with a shorter cycle of clinical trials. Here, we summarize the current status of the application of drug repurposing in COVID-19, including drug repurposing based on virtual computer screening, network pharmacology, and bioactivity, which may be a beneficial COVID-19 treatment.

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Mechanism of SARS-CoV-2 infection and drug targets were reviewed.

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Drug repurposing against COVID-19 based on computer virtual screening, network pharmacology, bioactivity were summarized.

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The use of drug repurposing in COVID-19 was addressed.

The role of type I interferon in the treatment of COVID-19

Although significant research has been done to find effective drugs against coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), no definite effective drug exists. Thus, research has now shifted towards immunomodulatory agents other than antivirals. In this review, we aim to describe the latest findings on the role of type I interferon (IFN)‐mediated innate antiviral response against SARS‐CoV‐2 and discuss the use of IFNs as a medication for COVID‐19. A growing body of evidence has indicated a promoting active but delayed IFNs response to SARS‐CoV‐2 and Middle East respiratory syndrome coronavirus in infected bronchial epithelial cells. Studies have demonstrated that IFNs' administration before the viral peak and the inflammatory phase of disease could offer a highly protective effect. However, IFNs' treatment during the inflammatory and severe stages of the disease causes immunopathology and long‐lasting harm for patients. Therefore, it is critical to note the best time window for IFNs' administration. Further investigation of the clinical effectiveness of interferon for patients with mild to severe COVID‐19 and its optimal timing and route of administration can be beneficial in finding a safe and effective antiviral therapy for the COVID‐19 disease.

1‐IFNs have many antiviral actions including; the activation of cytotoxic T‐cell responses, the inhibition of the viral mRNA translation, the degradation of the viral RNA, RNA editing and modulating the synthesis of Nitric Oxide.

2‐IFNS are two‐edged immunomodulatory agents; as they can provide a protective effect if administered in the early phases of the disease before the viral peak, whereas a harming effect is observed when administered in the inflammatory phase.

3‐More human trials are needed to find the best time window for administrating type I IFN for patients with various COVID‐19 modalities.

Rised sudden sensorineural hearing loss during COVID-19 widespread

BACKGROUND

Sudden sensorineural hearing loss (SSNHL) is commonly encountered in otolaryngologic practice. SARS-CoV-2 infection is typically marked by respiratory symptoms although neurologic manifestations of the disease have also been described.

OBJECTIVE

We want to measure the incidence and clinical aspects of persons exhibiting in otolaryngology clinic (OC) with SSNHL during the COVID-19 widespread and in the constant interval of previous year.

METHODS

We retrospectively inspected the medical information for admissions to OC in Eskisehir, Turkey, during the COVID-19 widespread to describe the patients SSNHL. Clinical knowledge was saved for each subject and corresponded with that of SSNHL subjects demonstrating in 2019.

RESULT

Between 1 April and 30 September 2020, 68 patients admitted to OC for SSNHL; in 2019, there were 41 subjects, for an incidence rate ratio of 8.5 per 100.000 (95% CI 1.02-2.92) for the 2020 cohort. Of the 2020 group, forty-one patients (60.3%) presented with active or recent symptoms consistent with COVID-19 infection, compared with four (9.8%) in 2019 (p < 0.001). Furthermore, subjects in 2020 group were younger (-15.5 years, p = 0.0141) than 2019 group and demonstrated prolonged interim (+1.7 days, p < 0.001) between SSNHL initiation and OC petition.

CONCLUSION

We detected increased incidence of SSNHL during the COVID-19 widespread compared to the same interval of the prior year; 60.3% of subjects confronting with SSNHL had signs that were harmonious with COVID-19.

In-depth review of cardiopulmonary support in COVID-19 patients with heart failure

Coronavirus disease 2019 infection has spread worldwide and causing massive burden to our healthcare system. Recent studies show multiorgan involvement during infection, with direct insult to the heart. Worsening of the heart function serves as a predictor of an adverse outcome. This finding raises a particular concern in high risk population, such as those with history of preexisting heart failure with or without implantable device. Lower baseline and different clinical characteristic might raise some challenge in managing either exacerbation or new onset heart failure that might occur as a consequence of the infection. A close look of the inflammatory markers gives an invaluable clue in managing this condition. Rapid deterioration might occur anytime in this setting and the need of cardiopulmonary support seems inevitable. However, the use of cardiopulmonary support in this patient is not without risk. Severe inflammatory response triggered by the infection in combination with the preexisting condition of the worsening heart and implantable device might cause a hypercoagulability state that should not be overlooked. Moreover, careful selection and consideration have to be met before selecting cardiopulmonary support as a last resort due to limited resource and personnel. By knowing the nature of the disease, the interaction between the inflammatory response and different baseline profile in heart failure patient might help clinician to salvage and preserve the remaining function of the heart.

Evaluation of adalimumab effects in managing severe cases of COVID-19: A randomized controlled trial

Background

COVID-19, which is a disease caused by the SARS-CoV-2 virus, has spread around the world since late 2019. Studies have found associations between the rising levels of TNF-α and severe COVID-19 cases. Hence, TNF-α blocking can possibly be a favorable intervention in modifying COVID-19. To this end, in order to manage pneumonia caused by COVID-19, adalimumab may potentially be considered as a potential therapeutic agent. The present study aimed to investigate the potential therapeutic role of adalimumab in treating COVID-19 cases in combination therapy with remdesivir and dexamethasone.

Methods

Among the 68 patients who were included in the current randomized controlled trial, 34 were assigned to the adalimumab group and the remaining 34 were assigned to the control group. Adalimumab at a dose of 40 mg, subcutaneous for once, was used for the intervention group. Both the intervention and control groups received remdesivir, dexamethasone, and supportive care. The data gathered to make comparisons of the groups included demographic information, the rate of mortality, mechanical ventilation requirement, length of stay in hospital and Intensive Care Unit (ICU), and imaging findings.

Results

There was no significant difference between the two groups in the terms of mortality rate (P-value = 1) and mechanical ventilation requirement (P-value = 1). The length of hospital and ICU stay as well as radiologic changes were not affected either (P-value = 1, 0.27, and 0.53, respectively).

Conclusions

Our findings did not support the use of adalimumab in combination with remdesivir and dexamethasone in the treatment of severe COVID-19 cases.

Co-expression of the SARS-CoV-2 entry molecules ACE2 and TMPRSS2 in human ovaries: Identification of cell types and trends with age

The high rate of SARS-CoV-2 infection poses a serious threat to public health. Previous studies have suggested that SARS-CoV-2 can infect human ovary, the core organ of the female reproductive system. However, it remains unclear which type of ovarian cells are easily infected by SARS-CoV-2 and whether ovarian infectivity differs from puberty to menopause. In this study, public datasets containing bulk and single-cell RNA-Seq data derived from ovarian tissues were analyzed to demonstrate the mRNA expression and protein distribution of the two key entry receptors for SARS-CoV-2—angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2). Furthermore, an immunohistochemical study of ACE2 and TMPRSS2 in human ovaries of different ages was conducted. Differentially expressed gene (DEG) analysis of ovaries of different ages and with varying ovarian reserves was conducted to explore the potential functions of ACE2 and TMPRSS2 in the ovary. The analysis of the public datasets indicated that the co-expression of ACE2 and TMPRSS2 was observed mostly in oocytes and partially in granulosa cells. However, no marked difference was observed in ACE2 or TMPRSS2 expression between young and old ovaries and ovaries with low and high reserves. Correspondingly, ACE2 and TMPRSS2 were detected in the human ovarian cortex and medulla, especially in oocytes of different stages, with no observed variations in their expression level in ovaries of different ages, which was consistent with the results of bioinformatic analyses. Remarkably, DEG analysis showed that a series of viral infection-related pathways were more enriched in ACE2-positive ovarian cells than in ACE2-negative ovarian cells, suggesting that SARS-CoV-2 may potentially target specific ovarian cells and affect ovarian function. However, further fundamental and clinical research is still needed to monitor the process of SARS-CoV-2 entry into ovarian cells and the long-term effects of SARS-CoV-2 infection on the ovarian function in recovered females.

Identification of COVID-19 prognostic markers and therapeutic targets through meta-analysis and validation of Omics data from nasopharyngeal samples

Background

While our battle with the COVID-19 pandemic continues, a multitude of Omics data have been generated from patient samples in various studies. Translation of these data into clinical interventions against COVID-19 remains to be accomplished. Exploring host response to COVID-19 in the upper respiratory tract can unveil prognostic markers and therapeutic targets.

Methods

We conducted a meta-analysis of published transcriptome and proteome profiles of respiratory samples of COVID-19 patients to shortlist high confidence upregulated host factors. Subsequently, mRNA overexpression of selected genes was validated in nasal swabs from a cohort of COVID-19 positive/negative, symptomatic/asymptomatic individuals. Guided by this analysis, we sought to check for potential drug targets. An FDA-approved drug, Auranofin, was tested against SARS-CoV-2 replication in cell culture and Syrian hamster challenge model.

Findings

The meta-analysis and validation in the COVID-19 cohort revealed S100 family genes (S100A6, S100A8, S100A9, and S100P) as prognostic markers of severe COVID-19. Furthermore, Thioredoxin (TXN) was found to be consistently upregulated. Auranofin, which targets Thioredoxin reductase, was found to mitigate SARS-CoV-2 replication in vitro. Furthermore, oral administration of Auranofin in Syrian hamsters in therapeutic as well as prophylactic regimen reduced viral replication, IL-6 production, and inflammation in the lungs.

Interpretation

Elevated mRNA level of S100s in the nasal swabs indicate severe COVID-19 disease, and FDA-approved drug Auranofin mitigated SARS-CoV-2 replication in preclinical hamster model.

Funding

This study was supported by the DBT-IISc partnership program (DBT (IED/4/2020-MED/DBT)), the Infosys Young Investigator award (YI/2019/1106), DBT-BIRAC grant (BT/CS0007/CS/02/20) and the DBT-Wellcome Trust India Alliance Intermediate Fellowship (IA/I/18/1/503613) to ST lab.

Nanotechnology against COVID-19: Immunization, diagnostic and therapeutic studies

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early 2020 soon led to the global pandemic of Coronavirus Disease 2019 (COVID-19). Since then, the clinical and scientific communities have been closely collaborating to develop effective strategies for controlling the ongoing pandemic. The game-changing fields of recent years, nanotechnology and nanomedicine have the potential to not only design new approaches, but also to improve existing methods for the fight against COVID-19. Nanomaterials can be used in the development of highly efficient, reusable personal protective equipment, and antiviral nano-coatings in public settings could prevent the spread of SARS-CoV-2. Smart nanocarriers have accelerated the design of several therapeutic, prophylactic, or immune-mediated approaches against COVID-19. Some nanovaccines have even entered Phase IΙ/IIΙ clinical trials. Several rapid and cost-effective COVID-19 diagnostic techniques have also been devised based on nanobiosensors, lab-on-a-chip systems, or nanopore technology. Here, we provide an overview of the emerging role of nanotechnology in the prevention, diagnosis, and treatment of COVID-19.

COVID-19 and Progesterone: Part 2. Unraveling High Severity, Immunity Patterns, Immunity grading, Progesterone and its potential clinical use

Severely ill COVID–19 (Corona Virus Disease of 2019) patients have a hyperinflammatory condition with a high concentration of pro-inflammatory cytokines termed the cytokine storm. This milieu is reported to cause acute lung injury, oxygen deprivation, multiorgan damage, critical illness, and often death. Post SARS–CoV–2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection, the fight between the invading virus and the host's immune system would either terminate in recovery, with eradication of the infection and regulation of the immune system; or there would be a continuation of immune attacks even after the virus has been cleared, leading to immune dysregulation and disease. This outcome is chiefly dependent on two factors: (1) the patient's immune response, and (2) sufficiency plus efficiency of the regulator(s). Concerning the first, the present research introduces a framework based on different types of immune responses to SARS–CoV–2 along with known disease examples, and how this relates to varying clinical outcomes and treatment needs for COVID–19 patients. About the second factor of ‘regulator(s)’, part 1 of the manuscript described in depth the regulatory role of progesterone in COVID–19. The present study investigates five immunity patterns and the status of the regulatory hormone progesterone with respect to the two established demographic risk factors for COVID–19 high-severity: male sex, and old age. The study evaluates the status of progesterone as a credible determinant of immune regulation and dysregulation. It duly relates the immunity patterns to clinical outcomes and evinces indications for clinical use of progesterone in COVID–19. It proposes a clear answer to the question: "why are males and old patients most likely to have critical illness due to COVID–19?" The study highlights clinical domains for the use of progesterone in COVID–19. Part 2 of this research introduces the concept of immunity patterns and immunity grading. These concepts herewith provided for the clinical course of COVID–19 also apply to other hyperinflammatory conditions. Possible clinical applications of progesterone to treat critically ill COVID–19 patients will open an avenue for hormonal treatments of infections and other immune-related diseases.

Metatranscriptomic Characterization of Coronavirus Disease 2019 Identified a Host Transcriptional Classifier Associated With Immune Signaling

BACKGROUND

The recent identification of a novel coronavirus, also known as SARS-CoV-2, has caused a global outbreak of respiratory illnesses. The rapidly developing pandemic has posed great challenges to diagnosis of this novel infection. However, little is known about the metatranscriptomic characteristics of patients with Coronavirus Disease 2019 (COVID-19).

METHODS

We analyzed metatranscriptomics in 187 patients (62 cases with COVID-19 and 125 with non-COVID-19 pneumonia). Transcriptional aspects of three core elements – pathogens, the microbiome, and host responses – were interrogated. Based on the host transcriptional signature, we built a host gene classifier and examined its potential for diagnosing COVID-19 and indicating disease severity.

RESULTS

The airway microbiome in COVID-19 patients had reduced alpha diversity, with 18 taxa of differential abundance. Potentially pathogenic microbes were also detected in 47% of the COVID-19 cases, 58% of which were respiratory viruses. Host gene analysis revealed a transcriptional signature of 36 differentially expressed genes significantly associated with immune pathways such as cytokine signaling. The host gene classifier built on such a signature exhibited potential for diagnosing COVID-19 (AUC of 0.75-0.89) and indicating disease severity.

CONCLUSIONS

Compared to those with non-COVID-19 pneumonias, COVID-19 patients appeared to have a more disrupted airway microbiome with frequent potential concurrent infections, and a special trigger host immune response in certain pathways such as interferon gamma signaling. The immune-associated host transcriptional signatures of COVID-19 hold promise as a tool for improving COVID-19 diagnosis and indicating disease severity.

What cellular mechanisms are related to thromboembolic events in patients with COVID-19?

SARS-CoV-2 is the virus responsible for the COVID-19 pandemic. This disease is beginning to be better understood in terms of its other, non-respiratory, clinical manifestations. Over the course of months caring for patients infected by the virus, clinical and laboratory changes have been identified that have prompted researchers to debate the potential that SARS-CoV-2 has to trigger an exacerbated immune response that is capable of changing endothelial homeostasis through both direct and indirect mechanisms. With the intention of contributing to this debate, a review was conducted of the possible mechanisms that could trigger these phenomena in patients with COVID-19. It is important to understand the pathophysiology of the immunological mechanisms related to this disease in order to understand the potential endothelial damage that COVID-19 can provoke.

Does inflammation link stress to poor COVID-19 outcome?

Coronavirus disease 2019 (COVID-19) continues to ravage communities across the world. Despite its primary effect on the respiratory system, the virus does not solely impact those with underlying lung conditions as initially predicted. Indeed, prognosis is worsened (often fatal) in patients with pre-existing hyperinflammatory responses (e.g., hypertension, obesity and diabetes), yet the mechanisms by which this occurs are unknown. A number of psychological conditions are associated with inflammation, suggesting that these may also be significant risk factors for negative outcomes of COVID-19. In this review, we evaluate preclinical and clinical literature suggesting that chronic stress-induced hyperinflammation interacts synergistically with COVID-19-related inflammation, contributing to a potentially fatal cytokine storm syndrome. In particular, we hypothesize that both chronic stress and COVID-19-related hyperinflammation are a product of glucocorticoid insufficiency. We discuss the devastating effects of SARS-CoV-2 on structural and functional aspects of the biological stress response and how these induce exaggerated inflammatory responses, particularly interleukin (IL)-6 hypersecretion. We postulate that chronic stress should be considered a significant risk factor for adverse COVID-19-related health outcomes, given overlapping peripheral and central immune dysregulation in both conditions. We conclude by discussing how people with a history of chronic stress could mitigate their risk for COVID-19 complications, identifying specific strategies that can be implemented during self-isolation.

Knowledge, attitude, and utilization of drugs toward COVID-19 pandemic among Bale Zone residents, Southeast Ethiopia

Background:

Coronavirus disease is a highly transmittable and pathogenic viral infection caused by severe acute respiratory syndrome coronavirus 2, which poses therapeutic dilemmas. Some suggestions for drug treatment seem problematic. Beliefs about the causes of health problems are determinants of treatment seeking decisions. Hence, one of the alternatives for the solution of health problems is employing traditional medicine to prevent coronavirus disease 19.

Objective:

To assess the knowledge, attitude, and utilization of drugs toward the coronavirus disease 19 pandemic among Bale zone residents.

Methods:

Community-based cross-sectional study was conducted among the Bale Zone population from May 30 to June 30, 2020. Eight hundred fifty-four participants were selected using a single population formula, and a multistage sampling technique was employed. Data were analyzed using SPSS version 25.0. Descriptive and binary logistic regression was used to analyze the outcomes. A p value ⩽ 0.05 was considered statistically significant.

Results:

Out of the total 854 respondents, about 534 (62.5%) got information about coronavirus disease 19 from TV/radio. More than two-thirds (71.9%) of the respondents have known that severe acute respiratory syndrome coronavirus 2 has no curative drugs, and 65.4% had a more appropriate attitude toward overall drug use in coronavirus disease 19. Level of education and, attitude towards drug use were singnificantly associated with knowledge of drugs, source of information about coronavirus disease 19 and having good practice were significantly associated with atittude toward drug utilization.

Conclusion:

One out of two study participants have good knowledge regarding drugs to the coronavirus disease 19 pandemic. Illiterate people in the community were identified to have poor knowledge about drugs, hence community educuation program is important to improve the knowledge about drugs towards the coronavirus disease 19 pandemic.

Work Stress, Dysbiosis, and Immune Dysregulation: The Interconnected Triad in COVID-19 Infection in the Medical Team Staff - A Mini-Review

The COVID-19 pandemic has hit most of the communities around the globe. Earlier researches have reported the psychological effects of pandemics either on the general populations or on specific communities such as students and health professionals. A scanty number of papers have focused on the interaction among complex factors underlying the pathogenesis of the disease. In this review, we aimed to integrate the accessible data about the possible mechanistic processes predisposing to COVID-19 infection in the health professions. We summarized these factors as "stress, microbiota, and immunity triad." We utilized the PubMed database, Google, and Google Scholar search engines to search the literature related to combinations of these keywords: "pandemics, COVID-19, coronavirus, SARS-CoV2;" "gut microbiota, gut-lung axis, dysbiosis, nutrition;" "work stress, workload, health workers, health professions, and medical team;" and "immunity, cytokine storm, and viral load." We detected no discussions combining the suggested triad concerning the medical team personnel. We cast light, for the first time to our knowledge, on the potential pathogenic role of "stress, microbiota, and immunity triad" in COVID-19-infected health workers.

Reactivation of Acute Retinal Necrosis following SARS-CoV-2 Infection

Purpose

To report on a case of reactivation of acute retinal necrosis following SARS-CoV-2 infection.

Methods

Observational case report. Observations. A 32-year-old female with a distant history of left retinal detachment secondary to necrotizing herpetic retinitis complained of right-eye vision loss, pain, redness, and photophobia. An ophthalmological examination revealed findings consistent with acute retinal necrosis of the right eye. A polymerase chain reaction (PCR) analysis of the right vitreous was positive for herpes simplex virus type 2 (HSV-2). A coronavirus disease 2019 (COVID-19) screening test using reverse transcriptase- (RT-) PCR was positive for SARS-CoV-2 RNA.

Conclusions

Our case suggests that COVID-19 may cause a latent HSV infection to reactivate, causing contralateral involvement in patients with a prior history of HSV-associated acute retinal necrosis.

The signal pathways and treatment of cytokine storm in COVID-19

The Coronavirus Disease 2019 (COVID-19) pandemic has become a global crisis and is more devastating than any other previous infectious disease. It has affected a significant proportion of the global population both physically and mentally, and destroyed businesses and societies. Current evidence suggested that immunopathology may be responsible for COVID-19 pathogenesis, including lymphopenia, neutrophilia, dysregulation of monocytes and macrophages, reduced or delayed type I interferon (IFN-I) response, antibody-dependent enhancement, and especially, cytokine storm (CS). The CS is characterized by hyperproduction of an array of pro-inflammatory cytokines and is closely associated with poor prognosis. These excessively secreted pro-inflammatory cytokines initiate different inflammatory signaling pathways via their receptors on immune and tissue cells, resulting in complicated medical symptoms including fever, capillary leak syndrome, disseminated intravascular coagulation, acute respiratory distress syndrome, and multiorgan failure, ultimately leading to death in the most severe cases. Therefore, it is clinically important to understand the initiation and signaling pathways of CS to develop more effective treatment strategies for COVID-19. Herein, we discuss the latest developments in the immunopathological characteristics of COVID-19 and focus on CS including the current research status of the different cytokines involved. We also discuss the induction, function, downstream signaling, and existing and potential interventions for targeting these cytokines or related signal pathways. We believe that a comprehensive understanding of CS in COVID-19 will help to develop better strategies to effectively control immunopathology in this disease and other infectious and inflammatory diseases.

Does chronic inflammation cause acute inflammation to spiral into hyper-inflammation in a manner modulated by diet and the gut microbiome, in severe Covid-19?

We propose that hyper-inflammation (HYPi) is a ''runaway'' consequence of acute inflammation (ACUi) that arises more easily (and also abates less easily) in those who host a pre-existing chronic inflammation (CHRi), because (i) most factors involved in generating an ACUi to limit viral proliferation are already present when there is an underlying CHRi, and also because (ii) anti-inflammatory (AI) mechanisms for the abatement of ACUi (following containment of viral proliferation) are suppressed and desensitized where there is an underlying CHRi, with this causing the ACUi to spiral into a HYPi. Stress, pollution, diet, and gut microbiomes (alterable in weeks through dietary changes) have an intimate and bidirectional cause-effect relationship with CHRi. We propose that avoidance of CHRi-promoting foods and adoption of CHRi-suppressing foods could reduce susceptibility to HYPi, in Covid-19 and in other viral diseases, such as influenza, which are characterized by episodic and unpredictable HYPi.

Drug-induced organ injury in coronavirus disease 2019 pharmacotherapy: Mechanisms and challenges in differential diagnosis and potential protective strategies

The world is currently facing an unprecedented pandemic caused by a newly recognized and highly pathogenic coronavirus disease 2019 (COVID-19; induced by SARS-CoV-2 virus), which is a severe and ongoing threat to global public health. Since COVID-19 was officially declared a pandemic by the World Health Organization in March 2020, several drug regimens have rapidly undergone clinical trials for the management of COVID-19. However, one of the major issues is drug-induced organ injury, which is a prominent clinical challenge. Unfortunately, most drugs used against COVID-19 are associated with adverse effects in different organs, such as the kidney, heart, and liver. These side effects are dangerous and, in some cases, they can be lethal. More importantly, organ injury is also a clinical manifestation of COVID-19 infection. These adverse reactions are increasingly recognized as outcomes of COVID-19 infection. Therefore, the differential diagnosis of drug-induced adverse effects from COVID-19-induced organ injury is a clinical complication. This review highlights the importance of drug-induced organ injury, its known mechanisms, and the potential therapeutic strategies in COVID-19 pharmacotherapy. We review the potential strategies for the differential diagnosis of drug-induced organ injury. This information can facilitate the development of therapeutic strategies, not only against COVID-19 but also for future outbreaks of other emerging infectious diseases.

Pathophysiology and Clinical Manifestations of COVID-19-Related Acute Kidney Injury-The Current State of Knowledge and Future Perspectives

The continually evolving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in a vast number of either acute or chronic medical impairments of a pathophysiology that is not yet fully understood. SARS-CoV-2 tropism for the organs is associated with bilateral organ cross-talks as well as targeted dysfunctions, among which acute kidney injury (AKI) seems to be highly prevalent in infected patients. The need for efficient management of COVID-related AKI patients is an aspect that is still being investigated by nephrologists; however, another reason for concern is a disturbingly high proportion of various types of kidney dysfunctions in patients who have recovered from COVID-19. Even though the clinical picture of AKI and COVID-related AKI seems to be quite similar, it must be considered that regarding the latter, little is known about both the optimal management and long-term consequences. These discrepancies raise an urgent need for further research aimed at evaluating the molecular mechanisms associated with SARS-CoV-2-induced kidney damage as well as standardized management of COVID-related AKI patients. The following review presents a comprehensive and most-recent insight into the pathophysiology, clinical manifestations, recommended patient management, treatment strategies, and post-mortem findings in patients with COVID-related AKI.

SARS-CoV-2 Infection: Differences in Hematological Parameters Between Adults and Children

Since December 2019, corona virus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic, posing a huge threat to human health, and the current epidemic prevention situation is still severe. Hematological parameters directly reflect the damage of SARS-CoV-2 to human blood cells, which can better assess the severity and prognosis of patients infected with COVID-19, but hematological parameters have some differences between adults and children. This article comprehensively reviews the differences in hematological parameters between adults and children after SARS-CoV-2 infection, and provides a reference for the diagnosis and treatment of COVID-19.

Immunological Approaches to the Treatment of New Coronavirus Infection (Review)

The pandemic of the new coronavirus infection (COVID-19) caused by the SARS-CoV-2 virus has spread all over the world. The large amount of information that appears every day requires comprehension and systematization. The immunological aspects of the virus-host interaction are the core issues in the effective treatment and prevention of COVID-19' development. The review analyzes the known pathways of the viral invasion and evasion, the mechanisms of the cytokine storm, endothelial damage, and hypercoagulability associated with SARS-CoV-2 infection. Clinical data from previous SARS and MERS epidemics is discussed here. We also address the therapeutic approaches based on the basic knowledge of immune response and the blood cells' immune functions, as well as the ways to reduce their hyperactivation. The use of interferon therapy, anti-inflammatory therapy, anti-cytokine therapy, neutralizing antibodies, convalescent plasma, and mesenchymal stem cells, as well as prophylactic vaccines, is discussed.

Dual inhibition of COVID-19 spike glycoprotein and main protease 3CLpro by Withanone from Withania somnifera

Objective

To identify the safe and effective natural inhibitors of spike glycoprotein and main protease 3CLpro using potential natural antiviral compounds which are studied under various animal models and viral cell lines.

Methods

First, compounds were retrieved from the PubChem database and predicted for their druggability using the MolSoft web server, and compounds having drug-like property were predicted for major adverse drug reactions like cardiotoxicity, hepatotoxicity, arrhythmia, myocardial infarction, and nephrotoxicity using ADVERpred. Docking of nontoxic antiviral compounds with spike glycoprotein and main protease 3CLpro was performed using AutoDock vina by PyRx 0.8 version. The stability of compound-protein interactions was checked by molecular dynamic (MD) simulation using Schrodinger Desmond software.

Results

Based on the druggable and nontoxic profile, nine compounds were selected. Among them, Withanone from Withania somnifera showed the highest binding affinity and best fit at active sites 1 of spike glycoprotein (glycosylation site) and main protease 3CLpro via interacting with active site amino acid residues before and after MD simulation at 50 ns. Withanone, which may reduce the glycosylation of SARS-CoV-2 via interacting with Asn343 and inhibit viral replication.

Conclusion

The current study reports Withanone as a non-toxic antiviral against SARS-CoV-2 and serve as a potential lead hit for further experimental validation.

Potential Use of Exosomes as Diagnostic Biomarkers and in Targeted Drug Delivery: Progress in Clinical and Preclinical Applications

Exosomes are cell-derived vesicles containing heterogeneous active biomolecules such as proteins, lipids, mRNAs, receptors, immune regulatory molecules, and nucleic acids. They typically range in size from 30 to 150 nm in diameter. An exosome's surfaces can be bioengineered with antibodies, fluorescent dye, peptides, and tailored for small molecule and large active biologics. Exosomes have enormous potential as a drug delivery vehicle due to enhanced biocompatibility, excellent payload capability, and reduced immunogenicity compared to alternative polymeric-based carriers. Because of active targeting and specificity, exosomes are capable of delivering their cargo to exosome-recipient cells. Additionally, exosomes can potentially act as early stage disease diagnostic tools as the exosome carries various protein biomarkers associated with a specific disease. In this review, we summarize recent progress on exosome composition, biological characterization, and isolation techniques. Finally, we outline the exosome's clinical applications and preclinical advancement to provide an outlook on the importance of exosomes for use in targeted drug delivery, biomarker study, and vaccine development.

Exploring the room for repurposed hydroxychloroquine to impede COVID-19: toxicities and multipronged combination approaches with pharmaceutical insights

Introduction: SARS-CoV-2 has fatally affected the whole world with millions of deaths. Amidst the dilemma of a breakthrough in vaccine development, hydroxychloroquine (HCQ) was looked upon as a prospective repurposed candidate. It has confronted numerous controversies in the past few months as a chemoprophylactic and treatment option for COVID-19. Recently, it has been withdrawn by the World Health Organization for its use in an ongoing pandemic. However, its benefit/risk ratio regarding its use in COVID-19 disease remains poorly justified. An extensive literature search was done using Scopus, PubMed, Google Scholar, www.cdc.gov, www.fda.gov, and who.int.Areas covered: Toxicity vexations of HCQ; pharmaceutical perspectives on new advances in drug delivery approaches; computational modeling (PBPK and PD modeling) overtures; multipronged combination approaches for enhanced synergism with antiviral and anti-inflammatory agents; immuno-boosting effects.Expert commentary: Harnessing the multipronged pharmaceutical perspectives will optimistically help the researchers, scientists, biotech, and pharmaceutical companies to bring new horizons in the safe and efficacious utilization of HCQ alone or in combination with remdesivir and immunomodulatory molecules like bovine lactoferrin in a fight against COVID-19. Combinational therapies with free forms or nanomedicine based targeted approaches can act synergistically to boost host immunity and stop SARS-CoV-2 replication and invasion to impede the infection.