Alcohol use disorder: A pre-existing condition for COVID-19?

Community responses to corona virus disease (COVID-19) in Africa in the face of "Infodemic": A scoping review

Globally, Corona Virus Disease (COVID-19) has significantly affected communities in various aspects. The World Health Organization proposed different measures to prevent the pandemic. However, these measures in some instances have not effectively minimized the impacts of COVID-19, due to innumerable factors, inter alia, considerable "infodemic" related to myths, misinformation, and misconceptions. Knowledge of the "infodemic" on COVID -19 can lead to effective interventions to rid societies of COVID-19, hence reduction of COVID-19-related risks and outcomes. This article explores the "COVID-19 infodemic" that affected community responses to COVID-19 in Africa. The study employed a scoping review approach involving peer-reviewed articles from numerous search engines and databases. The keywords involved in the search query were: "COVID-19 infodemic, COVID-19 false news, COVID-19 in Africa, 'knowledge of COVID-19, 'myths, misinformation, and misconceptions on COVID-19, 'history of COVID-19', 'community responses to COVID-19 in Africa". Findings show that 5G technology transferred coronavirus, high temperature and alcohol can kill coronavirus, blacks are immune to COVID-19, COVID-19 vaccine development has been rushed hence not very effective and safe and also causes infertility. Diverse community responses have been registered which in some ways frustrated efforts in combating the pandemic. Therefore, the "infodemic" consisting of myths, misconceptions, and misinformation have been resulting from the history of COVID-19 which first affected white people more than blacks. Also, low knowledge of how the virus is transmitted and affect human being; and the notion that COVID-19 affects richer than poor people, hence since white people are richer than black people then they were the first to be affected by the pandemic. Obviously in presence of such myths, misconceptions, and misinformation; community responses in combating COVID-19 have not been very effective in Africa. For these interventions to be effective, collective efforts involving various stakeholders to raise awareness of COVID-19 are needed.

COVID-19, Possible Hepatic Pathways and Alcohol Abuse-What Do We Know up to 2023?

The pandemic period due to coronavirus disease 2019 (COVID-19) revolutionized all possible areas of global health. Significant consequences were also related to diverse extrapulmonary manifestations of this pathology. The liver was found to be a relatively common organ, beyond the respiratory tract, affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Multiple studies revealed the essential role of chronic liver disease (CLD) in the general outcome of coronavirus infection. Present concerns in this field are related to the direct hepatic consequences caused by COVID-19 and pre-existing liver disorders as risk factors for the severe course of the infection. Which mechanism has a key role in this phenomenon-previously existing hepatic disorder or acute liver failure due to SARS-CoV-2-is still not fully clarified. Alcoholic liver disease (ALD) constitutes another not fully elucidated context of coronavirus infection. Should the toxic effects of ethanol or already developed liver cirrhosis and its consequences be perceived as a causative or triggering factor of hepatic impairment in COVID-19 patients? In the face of these discrepancies, we decided to summarize the role of the liver in the whole picture of coronavirus infection, paying special attention to ALD and focusing on the pathological pathways related to COVID-19, ethanol toxicity and liver cirrhosis.

Chronic alcohol use primes bronchial cells for altered inflammatory response and barrier dysfunction during SARS-CoV-2 infection

Alcohol use disorder (AUD) is a significant public health concern and people with AUD are more likely to develop severe acute respiratory distress syndrome (ARDS) in response to respiratory infections. To examine whether AUD was a risk factor for more severe outcome in response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we examined early responses to infection using cultured differentiated bronchial epithelial cells derived from brushings obtained from people with AUD or without AUD. RNA-seq analysis of uninfected cells determined that AUD cells were enriched for expression of epidermal genes as compared with non-AUD cells. Bronchial epithelial cells from patients with AUD showed a significant decrease in barrier function 72 h postinfection, as determined by transepithelial electrical resistance. In contrast, barrier function of non-AUD cells was enhanced 72 h after SARS-CoV-2 infection. AUD cells showed claudin-7 that did not colocalize with zonula occludens-1 (ZO-1), indicative of disorganized tight junctions. However, both AUD and non-AUD cells showed decreased β-catenin expression following SARS-CoV-2 infection. To determine the impact of AUD on the inflammatory response to SARS-CoV-2 infection, cytokine secretion was measured by multiplex analysis. SARS-CoV-2-infected AUD bronchial cells had enhanced secretion of multiple proinflammatory cytokines including TNFα, IL-1β, and IFNγ as opposed to non-AUD cells. In contrast, secretion of the barrier-protective cytokines epidermal growth factor (EGF) and granulocyte macrophage-colony stimulating factor (GM-CSF) was enhanced for non-AUD bronchial cells. Taken together, these data support the hypothesis that AUD is a risk factor for COVID-19, where alcohol primes airway epithelial cells for increased inflammation and increased barrier dysfunction and increased inflammation in response to infection by SARS-CoV-2.NEW & NOTEWORTHY Alcohol use disorder (AUD) is a significant risk factor for severe acute respiratory distress syndrome. We found that AUD causes a phenotypic shift in gene expression in human bronchial epithelial cells, enhancing expression of epidermal genes. AUD cells infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had higher levels of proinflammatory cytokine secretion and barrier dysfunction not present in infected non-AUD cells, consistent with increased early COVID-19 severity due to AUD.

Substances of abuse and their effect on SAR-CoV-2 pathogenesis

Following the emergence of SARS-CoV-2, various reports suggest that there has been a significant increase in substance abuse due to social distancing and related issues. Several reports have suggested the impact of chronic substance use on individuals' physiological and psychological health. Therefore, there is a need to know the impact of SARS-CoV-2 on persons with substance use disorders. Individuals with substance use disorders are the most vulnerable groups and are at a high risk of SARS-CoV-2 infection due to their already existing health issues associated with substance use. This review discusses some of the molecular and systemic/organic effects chronic substance use such as alcohol, nicotine, marijuana (cannabis), opioids, methamphetamine, and cocaine have on SARS-CoV-2 infectivity and its potential cause for worsened disease outcomes in persons with substance use disorder. This will provide healthcare providers, public health policies, and researchers with the needed knowledge to address some of the many challenges faced during the Covid-19 pandemic to facilitate treatment strategies for persons with substance use disorders.

COVID-19 and alcohol consumption: recommendations in the Omicron era

In the early stages of the pandemic, the first reports began that alcohol consumption could increase the risk of becoming infected and worsening the prognosis disease. This is for two reasons: behavioral and socio-economic factors that characterize a part of this population can be the cause of viral spread and a direct or indirect negative action of ethanol on the immune system. The data used for the preparation of these recommendations are based on a detailed analysis of the scientific literature published before March 31, 2022 (Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted the guidelines/position papers of the Italian Society on Alcohol and of the World Health Organization. It has been confirmed that AC is in COVID-19 era a risky behavior and that AUD and substance use disorder (SUD) patients are certainly at greater risk of contracting infection and also of having a worse course. In light of what has been said, some recommendations can be made: correctly inform the general population that AC negatively interacts with COVID-19 infection; reducing the COVID-19 risk by advocating healthy lifestyle habits (smoke, diet, physical exercise, etc.) and preferential policies in population with comorbidities; implement actions that reduce the average consumption of alcohol by avoiding hazardous/harmful consumption. Abstention is better; identify alcohol consumption through a more in-depth alcohol history, using the AUDIT; AUDs patients are frail patients deserving a complete vaccination course; suggest a period of alcoholic abstention of at least thirty days before vaccination to be maintained for the following fifteen days; promoting health education campaigns for young people in order to promote vaccination culture and correct lifestyles.

Chronic ethanol exposure impairs alveolar leukocyte infiltration during pneumococcal pneumonia, leading to an increased bacterial burden despite increased CXCL1 and nitric oxide levels

Ethanol abuse is a risk factor for the development of pneumonia caused by Streptococcus pneumoniae, a critical pathogen for public health. The aim of this article was to investigate the inflammatory mechanisms involved in pneumococcal pneumonia that may be associated with chronic ethanol exposure. Male C57BL6/J-Unib mice were exposed to 20% (v/v) ethanol for twelve weeks and intranasally infected with 5x10⁴ CFU of S. pneumoniae. Twenty-four hours after infection, lungs, bronchoalveolar lavage and blood samples were obtained to assess the consequences of chronic ethanol exposure during infection. Alcohol-fed mice showed increased production of nitric oxide and CXCL1 in alveoli and plasma during pneumococcal pneumonia. Beside this, ethanol-treated mice exhibited a decrease in leukocyte infiltration into the alveoli and reduced frequency of severe lung inflammation, which was associated with an increase in bacterial load. Curiously, no changes were observed in survival after infection. Taken together, these results demonstrate that chronic ethanol exposure alters the inflammatory response during S. pneumoniae lung infection in mice with a reduction in the inflammatory infiltrate even in the presence of higher levels of the chemoattractant CXCL1.

Development and validation of the alcohol-related content poster prototype scale: Exploring the impact of social media prototypes on college students' drinking

BACKGROUND

Drinking is a public health concern among college students. Viewing and posting alcohol-related content (ARC) on social media may influence students' favorable prototypes of people who post, thereby impacting their drinking. This study created a measure to explore students' ARC poster prototypes. We validated our measure by examining the prototypes as mediators of the associations between viewing and posting ARC and drinking behaviors.

METHODS

Students (N = 8065) were asked to complete measures related to viewing and posting ARC, drinking behaviors, and adjectives that described their perceptions of the prototypical college student who posts ARC on social media.

RESULTS

Exploratory and confirmatory factor analysis yielded three prototypical images of students who post ARC on social media: hedonistic, despondent, and sociable. There were significant pathways between viewing and posting ARC and drinking. The sociable prototype emerged as a significant mediator of the association between ARC viewing and posting and drinking.

CONCLUSIONS

Understanding the role of students' poster prototypes may be important for informing targeted interventions. Our results indicate that the underlying reason for increased drinking among students with greater ARC engagement is that they perceived other ARC viewers and posters as being more sociable. Future research may focus on modifying these perceptions.

A person-centered approach to capture health disparities and multidimensional impact of COVID-related stressors

The COVID-19 pandemic has influenced people's lives in diverse ways. The authors utilized latent class analysis (LCA), a person-centered approach, to examine distinct patterns of COVID-related stressors and their associations with alcohol-related, mental health, and quality of life outcomes. Participants were 463 adults who completed the baseline assessment of the National Institute on Alcohol Abuse and Alcoholism COVID-19 Pandemic Impact on Alcohol Study from June 2020 to January 2022. Using cross-sectional data, three analytic methods (continuous sum score, categorical grouping, and LCA) were applied to model 17 COVID-related stressors. Regression analyses indicated higher COVID-related stress and endorsement of four or more COVID-related stressors were generally associated with worse health-related outcomes. LCA revealed four classes: Class 1: Minimal COVID-Related Impact (51.6%); Class 2: Work Interruptions (24.8%); Class 3: Family/Friends Affected by COVID (14.5%); and Class 4: Serious Financial Stress (9.1%). Racial/ethnic minorities were more likely to be in Class 3, whereas individuals with more years of education and higher income were less likely to be in Class 4. Individuals with a history of alcohol use disorder were more likely to be in Classes 2 and 4. Compared with Class 1, Class 4 reported highest levels of perceived stress, problematic alcohol use, anxiety symptoms, depressive symptoms, alcohol craving, loneliness, drinking to cope, and lowest levels of physical, psychological, social, and environment quality of life. COVID-related stressors disproportionately affected minority and vulnerable groups. Individuals who experienced multiple financial stressors had the greatest risk for negative health-related outcomes and may benefit from holistic interventions and community outreach. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

COVID-19 Spotlights Connections between Disease and Multiple Lifestyle Factors

The SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2), and the disease it causes (COVID-19), have had a profound impact on global human society and threaten to continue to have such an impact with newly emerging variants. Because of the widespread effects of SARS-CoV-2, understanding how lifestyle choices impact the severity of disease is imperative. This review summarizes evidence for an involvement of chronic, non-resolving inflammation, gut microbiome disruption (dysbiosis with loss of beneficial microorganisms), and impaired viral defenses, all of which are associated with an imbalanced lifestyle, in severe disease manifestations and post-acute sequelae of SARS-CoV-2 (PASC). Humans' physiological propensity for uncontrolled inflammation and severe COVID-19 are briefly contrasted with bats' low propensity for inflammation and their resistance to viral disease. This insight is used to identify positive lifestyle factors with the potential to act in synergy for restoring balance to the immune response and gut microbiome, and thereby protect individuals against severe COVID-19 and PASC. It is proposed that clinicians should consider recommending lifestyle factors, such as stress management, balanced nutrition and physical activity, as preventative measures against severe viral disease and PASC.

Modifiable contributing factors to COVID-19: A comprehensive review

The devastating complications of coronavirus disease 2019 (COVID-19) result from an individual's dysfunctional immune response following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events ultimately leading to COVID-19. The current study identifies eighty immune system dysfunction-enabling toxic stressors and behaviors (hereafter called modifiable contributing factors (CFs)) that also link directly to COVID-19. Each CF is assigned to one of the five categories in the CF taxonomy shown in Section 3.3.: Lifestyle (e.g., diet, substance abuse); Iatrogenic (e.g., drugs, surgery); Biotoxins (e.g., micro-organisms, mycotoxins); Occupational/Environmental (e.g., heavy metals, pesticides); Psychosocial/Socioeconomic (e.g., chronic stress, lower education). The current study shows how each modifiable factor contributes to decreased immune system capability, increased inflammation and coagulation, and increased neural damage and neurodegeneration. It is unclear how real progress can be made in combatting COVID-19 and other similar diseases caused by viral variants without addressing and eliminating these modifiable CFs.

COVID-19: Reducing the risk via diet and lifestyle

This review shows that relatively simple changes to diet and lifestyle can significantly, and rapidly, reduce the risks associated with coronavirus disease 2019 (COVID-19) in terms of infection risk, severity of disease, and even disease-related mortality. A wide range of interventions including regular exercise, adequate sleep, plant-based diets, maintenance of healthy weight, dietary supplementation, and time in nature have each been shown to have beneficial effects for supporting more positive health outcomes with COVID-19, in addition to promoting better overall health. This paper brings together literature from these areas and presents the argument that non-pharmaceutical approaches should not be overlooked in our response to COVID-19. It is noted that, in several cases, interventions discussed result in risk reductions equivalent to, or even greater than, those associated with currently available vaccines. Where the balance of evidence suggests benefits, and the risk is minimal to none, it is suggested that communicating the power of individual actions to the public becomes morally imperative. Further, many lives could be saved, and many harms from the vaccine mandates avoided, if we were willing to embrace this lifestyle-centred approach in our efforts to deal with COVID-19.

Alcohol use disorder as a potential risk factor for COVID-19 severity: A narrative review

In Dec. 2019-January 2020, a pneumonia illness originating in Wuhan, China, designated as coronavirus disease 2019 (COVID-19) was shown to be caused by a novel RNA coronavirus designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). People with advanced age, male sex, and/or underlying health conditions (obesity, type 2 diabetes, cardiovascular disease, hypertension, chronic kidney disease, and chronic lung disease) are especially vulnerable to severe COVID-19 symptoms and death. These risk factors impact the immune system and are also associated with poor health, chronic illness, and shortened longevity. However, a large percent of patients without these known risk factors also develops severe COVID-19 disease that can result in death. Thus, there must exist risk factors that promote exaggerated inflammatory and immune response to the SARS-CoV-2 virus leading to death. One such risk factor may be alcohol misuse and alcohol use disorder because these can exacerbate viral lung infections like SARS, influenza, and pneumonia. Thus, it is highly plausible that alcohol misuse is a risk factor for either increased infection rate when individuals are exposed to SARS-CoV-2 virus and/or more severe COVID-19 in infected patients. Alcohol use is a well-known risk factor for lung diseases and ARDS in SARS patients. We propose that alcohol has three key pathogenic elements in common with other COVID-19 severity risk factors: namely, inflammatory microbiota dysbiosis, leaky gut, and systemic activation of the NLRP3 inflammasome. We also propose that these three elements represent targets for therapy for severe COVID-19.

Forecasting Model Based on Lifestyle Risk and Health Factors to Predict COVID-19 Severity

The COVID-19 pandemic has now spread worldwide, becoming a real global health emergency. The main goal of this work is to present a framework for studying the impact of COVID-19 on Italian territory during the first year of the pandemic. Our study was based on different kinds of health features and lifestyle risk factors and exploited the capabilities of machine learning techniques. Furthermore, we verified through our model how these factors influenced the severity of the pandemics. Using publicly available datasets provided by the Italian Civil Protection, Italian Ministry of Health and Italian National Statistical Institute, we cross-validated the regression performance of a Random Forest model over 21 Italian regions. The robustness of the predictions was assessed by comparison with two other state-of-the-art regression tools. Our results showed that the proposed models reached a good agreement with data. We found that the features strongly associated with the severity of COVID-19 in Italy are the people aged over 65 flu vaccinated (24.6%) together with individual lifestyle behaviors. These findings could shed more light on the clinical and physiological aspects of the disease.

Relationship between high-risk alcohol consumption and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroconversion: a prospective sero-epidemiological cohort study among American college students

AIMS

To estimate the associations between high-risk alcohol consumption and (1) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroconversion, (2) self-reported new SARS-CoV-2 infection and (3) symptomatic COVID-19.

DESIGN

Prospective cohort study.

SETTING

Indiana University Bloomington (IUB), IN, USA.

PARTICIPANTS

A total of 1027 IUB undergraduate students (64% female), aged 18 years or older, residing in Monroe County, Indiana, seronegative for SARS-CoV-2 at study baseline.

MEASUREMENTS

Primary exposure was high-risk alcohol consumption measured with an Alcohol Use Disorders Identification Test (AUDIT) questionnaire score of 8 or more. Primary outcome was SARS-CoV-2 seroconversion since baseline, assessed with two SARS-CoV-2 antibody tests, at baseline (September 2020) and end-line (November 2020). Secondary outcomes were (a) self-reported new SARS-CoV-2 infection at the study end-line and (b) self-reported symptomatic COVID-19 at baseline.

FINDINGS

Prevalence of high-risk alcohol consumption was 32 %. In models adjusted for demographics, students with high-risk alcohol consumption status had 2.44 [95% confidence interval (CI) = 1.35, 4.25] times the risk of SARS-CoV-2 seroconversion and 1.84 (95% CI = 1.04, 3.28) times the risk of self-reporting a positive SARS-CoV-2 infection, compared with students with no such risk. We did not identify any association between high-risk alcohol consumption and symptomatic COVID-19 (prevalence ratio = 1.17, 95% CI = 0.93, 1.47). Findings from sensitivity analyses corroborated these results and suggested potential for a dose-response relationship.

CONCLUSIONS

Among American college students, high-risk alcohol consumption appears to be associated with higher risk for severe acute respiratory syndrome coronavirus 2 seroconversion/infection.

COVID-19 and alcohol use disorder: putative differential gene expression patterns that might be associated with neurological complications

BACKGROUND

Several lines of evidence suggest that SARS-CoV-2 invasion of the central nervous system leads to meningitis and encephalopathy syndromes. Additionally, chronic alcoholics were found to be at a higher risk of developing mental health problems and serious neurological manifestations, if exposed to SARS-CoV-2 infection.

METHODS

Herein, we studied RNA seq data from alcoholics' brain tissue and COVID-19 patient's brain tissue to identify the common differentially expressed genes.

RESULTS

Overlap analysis depicted the expression of seven genes (GHRL, SLN, VGF, IL1RL1, NPTX2, PDYN, and RPRML) that were significantly upregulated in both groups. Along with these, protein-protein interaction analysis revealed 10 other key molecules with strong interactions with the aforementioned genes.

CONCLUSIONS

Taken together with the functional effect of these genes, we suggest a strong molecular link between COVID-19-induced severities and neurological impairment in patients suffering from alcohol abuse disorder. These findings emphasize the importance of identifying chronic alcoholism as a risk factor for developing cognitive and memory impairment in COVID-19 patients.

COVID-19 patients with documented alcohol use disorder or alcohol-related complications are more likely to be hospitalized and have higher all-cause mortality

BACKGROUND

Coronavirus Disease 2019 (COVID-19) has affected every country globally, with hundreds of millions of people infected with the SARS-CoV-2 virus and over 6 million deaths to date. It is unknown how alcohol use disorder (AUD) affects the severity and mortality of COVID-19. AUD is known to increase the severity and mortality of bacterial pneumonia and the risk of developing acute respiratory distress syndrome. Our objective is to determine whether individuals with AUD have increased severity and mortality from COVID-19.

METHODS

We utilized a retrospective cohort study of inpatients and outpatients from 44 centers participating in the National COVID Cohort Collaborative. All were adult COVID-19 patients with and without documented AUDs.

RESULTS

We identified 25,583 COVID-19 patients with an AUD and 1,309,445 without. In unadjusted comparisons, those with AUD had higher odds of hospitalization (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.94 to 2.06, p < 0.001). After adjustment for age, sex, race/ethnicity, smoking, body mass index, and comorbidities, individuals with an AUD still had higher odds of requiring hospitalization (adjusted OR [aOR] 1.51, CI 1.46 to 1.56, p < 0.001). In unadjusted comparisons, individuals with AUD had higher odds of all-cause mortality (OR 2.18, CI 2.05 to 2.31, p < 0.001). After adjustment as above, individuals with an AUD still had higher odds of all-cause mortality (aOR 1.55, CI 1.46 to 1.65, p < 0.001).

CONCLUSION

This work suggests that AUD can increase the severity and mortality of COVID-19 infection. This reinforces the need for clinicians to obtain an accurate alcohol history from patients hospitalized with COVID-19. For this study, our results are limited by an inability to quantify the daily drinking habits of the participants. Studies are needed to determine the mechanisms by which AUD increases the severity and mortality of COVID-19.

COVID-19 and Preexisting Comorbidities: Risks, Synergies, and Clinical Outcomes

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated symptoms, named coronavirus disease 2019 (COVID-19), have rapidly spread worldwide, resulting in the declaration of a pandemic. When several countries began enacting quarantine and lockdown policies, the pandemic as it is now known truly began. While most patients have minimal symptoms, approximately 20% of verified subjects are suffering from serious medical consequences. Co-existing diseases, such as cardiovascular disease, cancer, diabetes, and others, have been shown to make patients more vulnerable to severe outcomes from COVID-19 by modulating host-viral interactions and immune responses, causing severe infection and mortality. In this review, we outline the putative signaling pathways at the interface of COVID-19 and several diseases, emphasizing the clinical and molecular implications of concurring diseases in COVID-19 clinical outcomes. As evidence is limited on co-existing diseases and COVID-19, most findings are preliminary, and further research is required for optimal management of patients with comorbidities.

Chronic and Binge Alcohol Ingestion Increases Truncated Oxidized Phosphatidylcholines in Mice Lungs Due to Increased Oxidative Stress

Heavy alcohol drinking has negative health effects in multiple organs. It predisposes lungs to inflammatory conditions associated with acute lung injury and increased incidence of pneumonia and sepsis, which may lead to death due to acute respiratory distress syndrome in some individuals with alcohol use disorder (AUD). In general, rodent models of alcohol exposure either do not recapitulate multiple organ injuries as seen in humans or require longer duration to establish tissue injury and inflammation. The recently introduced NIAAA model of alcohol-induced liver injury, characterized by a marked increase in steatosis and liver damage with 10 days of a liquid diet containing 5% ethanol followed by a single ethanol binge (5 g/kg). Therefore, we employed this model to explore the status of surfactant phospholipids, oxidative stress, tissue injury markers and inflammatory cytokines in lungs. In lungs of C57BL/6J mice, the alcohol feeding significantly increased levels of the surfactant phospholipid dipalmitoyl phosphatidylcholine (DPPC) as well as the truncated oxidized phosphatidylcholines palmitoyl oxovaleryl phosphatidyl-choline (POVPC), palmitoyl glutaryl phosphatidyl-choline (PGPC), palmitoyl oxo-nonanoyl phosphatidyl-choline (ALDO-PC), and palmitoyl azelaoyl phosphatidyl-choline (PAzePC) at 9 h post-binge. Additionally, gene expression of the enzymes catalyzing lipid oxidation, such as arachidonate 15-lipoxygenase (Alox15), prostaglandin synthase 2 (Ptgs2), Cytochrome P450 2E1 (Cyp2E1) and NADPH oxidase 1 (Nox1) were significantly increased. Furthermore, ethanol increased levels of the inflammatory cytokine Interleukin-17 in bronchoalveolar lavage fluid. In conclusion, the NIAAA alcohol feeding model might be suitable to study alcohol-induced lung injury and inflammation.

Malondialdehyde Acetaldehyde-Adduction Changes Surfactant Protein D Structure and Function

Alcohol consumption with concurrent cigarette smoking produces malondialdehyde acetaldehyde (MAA)-adducted lung proteins. Lung surfactant protein D (SPD) supports innate immunity via bacterial aggregation and lysis, as well as by enhancing macrophage-binding and phagocytosis. MAA-adducted SPD (SPD-MAA) has negative effects on lung cilia beating, macrophage function, and epithelial cell injury repair. Because changes in SPD multimer structure are known to impact SPD function, we hypothesized that MAA-adduction changes both SPD structure and function. Purified human SPD and SPD-MAA (1 mg/mL) were resolved by gel filtration using Sephadex G-200 and protein concentration of each fraction determined by Bradford assay. Fractions were immobilized onto nitrocellulose by slot blot and assayed by Western blot using antibodies to SPD and to MAA. Binding of SPD and SPD-MAA was determined fluorometrically using GFP-labeled Streptococcus pneumoniae (GFP-SP). Anti-bacterial aggregation of GFP-SP and macrophage bacterial phagocytosis were assayed by microscopy and permeability determined by bacterial phosphatase release. Viral injury was measured as LDH release in RSV-treated airway epithelial cells. Three sizes of SPD were resolved by gel chromatography as monomeric, trimeric, and multimeric forms. SPD multimer was the most prevalent, while the majority of SPD-MAA eluted as trimer and monomer. SPD dose-dependently bound to GFP-SP, but SPD-MAA binding to bacteria was significantly reduced. SPD enhanced, but MAA adduction of SPD prevented, both aggregation and macrophage phagocytosis of GFP-SP. Likewise, SPD increased bacterial permeability while SPD-MAA did not. In the presence of RSV, BEAS-2B cell viability was enhanced by SPD, but not protected by SPD-MAA. Our results demonstrate that MAA adduction changes the quaternary structure of SPD from multimer to trimer and monomer leading to a decrease in the native anti-microbial function of SPD. These findings suggest one mechanism for increased pneumonia observed in alcohol use disorders.

Delirium Tremens and Central Pontine Myelinolysis in a Patient with Alcohol Use Disorder and Pneumonia: a Case Report and a Narrative Review

INTRODUCTION

Delirium tremens (DT) is a serious condition occurring in alcohol withdrawal syndrome. Alcohol consumption may also cause additional health problems, such as respiratory infections or neuropsychiatric conditions such as central pontine myelinolysis. In this clinical scenario, managing DT can be expected to be more compelling and complex. Alcohol decreases coughing and mucociliary clearance and disrupts the immunity of the respiratory system.

CASE

Here we report on a middle-aged man with alcohol use disorder who had developed DT due to alcohol withdrawal and comorbid pneumonia.

DISCUSSION AND CONCLUSION

In this paper, DT, the relation between respiratory infections and alcohol intake, and the correlation of alcohol consumption and central pontine myelinolysis (CPM) are discussed. Also, the literature on alcohol consumption and the additional respiratory and neurologic problems resulting from it are presented.

Alcohol intake and mortality risk of COVID-19, pneumonia, and other infectious diseases: An analysis of 437191 UK biobank participants

This study aims to investigate the association between alcohol consumption and COVID-19, infectious diseases, and pneumonia mortality. This is a prospective analysis of 437,191 UK Biobank participants (age 56.3 years, 54% female). The main exposure was self-reported alcohol consumption. In addition to never and previous drinkers, we applied quartiles-based and UK guidelines-based criteria to divide current drinkers by weekly consumption into four groups. Outcomes included COVID-19, infectious diseases, and pneumonia mortality, obtained from the national death registries until May 2020. After an 11-year follow-up, compared to never drinkers, previous drinkers had higher mortality risks of infectious diseases and pneumonia (adjusted HR: 1.29 [95% CI 1.06-1.57] and 1.35 [1.07-1.70], respectively), but not COVID-19. There was a curvilinear association of alcohol consumption with infectious diseases and pneumonia mortality. Drinking within-guidelines (<14 UK units/wk) and amounts up to double the recommendation (14 to < 28 UK units/wk) was associated with the lowest mortality risks of infectious diseases (0.70 [0.59-0.83] and 0.70 [0.59-0.83], respectively) and pneumonia (0.71 [0.58-0.87] and 0.72 [0.58-0.88], respectively). Alcohol consumption was associated with lower risks of COVID-19 mortality (e.g., drinking within-guidelines: 0.53 [0.33-0.86]). Drinkers reporting multiples of the recommended alcohol drinking amounts did not have higher mortality risks of COVID-19 and other infectious diseases than never drinkers. Despite the well-established unfavorable effects on general health, we found no deleterious associations between alcohol consumption and the risk of infectious diseases, including COVID-19. Future research with other study designs is needed to confirm the causality.

Premorbid traumatic stress and veteran responses to the COVID-19 pandemic

The COVID-19 pandemic has had unprecedented effects on lifestyle stability and physical and mental health. We examined the impact of preexisting posttraumatic stress disorder (PTSD), alcohol use disorder (AUD), and depression on biopsychosocial responses to the pandemic, including psychiatric symptoms, COVID-19 exposure, and housing/financial stability, among 101 U.S. military veterans enrolled in a longitudinal study of PTSD, a population of particular interest given veterans' trauma histories and defense-readiness training. Participants (83.2% male, 79.2% White, M_age  = 59.28 years) completed prepandemic, clinician-administered psychiatric diagnostic interviews and a phone-based assessment between May and September 2020 using a new measure, the Rapid Assessment of COVID-19-Related Experiences (RACE), which was used to assess pandemic responses and its effects on mental and physical health; COVID-19 diagnosis and testing were also extracted from electronic medical records. Multivariate regressions showed that, controlling for demographic characteristics, prepandemic PTSD, β = .332; p = .003, and AUD symptoms, β = .228; p = .028, were associated with increased pandemic-related PTSD symptoms. Prepandemic AUD was associated with increased substance use during the pandemic, β = .391; p < .001, and higher rates of self-reported or medical record-based COVID-19 diagnosis, β = .264; p = .019. Minority race was associated with pandemic-related housing/financial instability, β = -.372; p < .001, raising concerns of population inequities. The results suggest that preexisting PTSD and AUD are markers for adverse pandemic-related psychiatric outcomes and COVID-19 illness. These findings carry implications for the importance of targeting prevention and treatment efforts for the highest-risk individuals.

Aldehyde Trapping by ADX-102 Is Protective against Cigarette Smoke and Alcohol Mediated Lung Cell Injury

Most individuals diagnosed with alcohol use disorders smoke cigarettes. Large concentrations of malondialdehyde and acetaldehyde are found in lungs co-exposed to cigarette smoke and alcohol. Aldehydes directly injure lungs and form aldehyde protein adducts, impacting epithelial functions. Recently, 2-(3-Amino-6-chloroquinolin-2-yl)propan-2-ol (ADX-102) was developed as an aldehyde-trapping drug. We hypothesized that aldehyde-trapping compounds are protective against lung injury derived from cigarette smoke and alcohol co-exposure. To test this hypothesis, we pretreated mouse ciliated tracheal epithelial cells with 0-100 µM of ADX-102 followed by co-exposure to 5% cigarette smoke extract and 50 mM of ethanol. Pretreatment with ADX-102 dose-dependently protected against smoke and alcohol induced cilia-slowing, decreases in bronchial epithelial cell wound repair, decreases in epithelial monolayer resistance, and the formation of MAA adducts. ADX-102 concentrations up to 100 µM showed no cellular toxicity. As protein kinase C (PKC) activation is a known mechanism for slowing cilia and wound repair, we examined the effects of ADX-102 on smoke and alcohol induced PKC epsilon activity. ADX-102 prevented early (3 h) activation and late (24 h) autodownregulation of PKC epsilon in response to smoke and alcohol. These data suggest that reactive aldehydes generated from cigarette smoke and alcohol metabolism may be potential targets for therapeutic intervention to reduce lung injury.

Molecular and Physiological Aspects of SARS-CoV-2 Infection in Women and Pregnancy

Whilst scientific knowledge about SARS-CoV-2 and COVID-19 is rapidly increasing, much of the effects on pregnant women is still unknown. To accommodate pregnancy, the human endometrium must undergo a physiological transformation called decidualization. These changes encompass the remodeling of endometrial immune cells leading to immunotolerance of the semi-allogenic conceptus as well as defense against pathogens. The angiotensin converting enzyme 2 (ACE2) plays an important regulatory role in the renin-angiotensin-system (RAS) and has been shown to be protective against comorbidities known to worsen COVID-19 outcomes. Furthermore, ACE2 is also crucial for decidualization and thus for early gestation. An astounding gender difference has been found in COVID-19 with male patients presenting with more severe cases and higher mortality rates. This could be attributed to differences in sex chromosomes, hormone levels and behavior patterns. Despite profound changes in the female body during pregnancy, expectant mothers do not face worse outcomes compared with non-pregnant women. Whereas mother-to-child transmission through respiratory droplets during labor or in the postnatal period is known, another question of in utero transmission remains unanswered. Evidence of placental SARS-CoV-2 infection and expression of viral entry receptors at the maternal-fetal interface suggests the possibility of in utero transmission. SARS-CoV-2 can cause further harm through placental damage, maternal systemic inflammation, and hindered access to health care during the pandemic. More research on the effects of COVID-19 during early pregnancy as well as vaccination and treatment options for gravid patients is urgently needed.

Results of the Adult COVID-19 Lifestyle Matching Study

Objective: The aim of our case-control study was to find the influence of lifestyle and comorbidities on COVID-19 susceptibility, identify risk factors and protective factors, and identify ways to encourage people to adopt a healthy lifestyle.

Methods: Patients with COVID-19 were matched with non-COVID-19 participants in a ratio of 1:2. Univariate analysis was performed using the chi-square test, and multivariate analysis was performed using conditional logistic regression.

Results: Multivariate analysis using conditional logistic regression found that alcohol consumption (AC) and a bland diet increased the risk of COVID-19, while college degrees and above, smoking, drinking tea, and exercise, especially walking, significantly reduced the risk of COVID-19.

Conclusion: After removing the effects of demographic factors, the study demonstrated that AC significantly reduced the ability of the body to resist COVID-19 infection. Moreover, following a bland diet increased the susceptibility to COVID-19. Notably, people who drank tea and performed regular exercises, especially walking, were significantly less likely to be infected with COVID-19. College degree or above relative illiteracy is COVID-19 protective factors of infection.

A quantitative and qualitative examination of the impacts of the COVID-19 pandemic on U.S. veterans with self-reported anxiety and alcohol use disorder

INTRODUCTION

The COVID-19 pandemic generated concerns about rising stress and alcohol use, especially in U.S. veterans who experience high rates of anxiety disorders (ADs), alcohol use disorder (AUD), and dual AD+AUD diagnoses. This study investigated differences among these diagnostic groups in a veteran population related to their concern about COVID-19, impacts of COVID-19 on quality of life, and self-reported changes to urge to drink and drinking frequency.

METHODS

A nationally administered online survey was given to a sample of U.S. veterans reporting substance use issues during the pandemic. Differences in the level of concern about COVID-19, impacts of COVID-19 on quality of life, and drinking behaviors were examined in those self-reporting AD (n = 98), AUD (n = 46), or AD+AUD (n = 67). Consensual qualitative research was used to analyze an open-ended question about COVID-19's impact on substance use, health, and quality of life.

RESULTS

Veterans with AD+AUD experienced significant increases in urge to drink and alcohol consumption compared to veterans with AD only. Greater urge and frequency of drinking were associated with greater negative impacts of COVID-19 on quality of life. There were no differences among groups in global negative impact on quality of life or level of COVID-19 concern. However, respondents described specific COVID-19 worries, with qualitative findings revealing that those with AD+AUD reported a disproportionate psychosocial burden due to the pandemic.

DISCUSSION

Special attention in screening and treatment should be given to those with a dual AD+AUD diagnosis who may be experiencing both an increase in alcohol use and psychosocial burden as stress increases due to the pandemic.

Contributing factors common to COVID‑19 and gastrointestinal cancer

The devastating complications of coronavirus disease 2019 (COVID-19) result from the dysfunctional immune response of an individual following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events, ultimately leading to COVID-19. The authors have previously identified a number of contributing factors (CFs) common to myriad chronic diseases. Based on these observations, it was hypothesized that there may be a significant overlap between CFs associated with COVID-19 and gastrointestinal cancer (GIC). Thus, in the present study, a streamlined dot-product approach was used initially to identify potential CFs that affect COVID-19 and GIC directly (i.e., the simultaneous occurrence of CFs and disease in the same article). The nascent character of the COVID-19 core literature (~1-year-old) did not allow sufficient time for the direct effects of numerous CFs on COVID-19 to emerge from laboratory experiments and epidemiological studies. Therefore, a literature-related discovery approach was used to augment the COVID-19 core literature-based ‘direct impact’ CFs with discovery-based ‘indirect impact’ CFs [CFs were identified in the non-COVID-19 biomedical literature that had the same biomarker impact pattern (e.g., hyperinflammation, hypercoagulation, hypoxia, etc.) as was shown in the COVID-19 literature]. Approximately 2,250 candidate direct impact CFs in common between GIC and COVID-19 were identified, albeit some being variants of the same concept. As commonality proof of concept, 75 potential CFs that appeared promising were selected, and 63 overlapping COVID-19/GIC potential/candidate CFs were validated with biological plausibility. In total, 42 of the 63 were overlapping direct impact COVID-19/GIC CFs, and the remaining 21 were candidate GIC CFs that overlapped with indirect impact COVID-19 CFs. On the whole, the present study demonstrates that COVID-19 and GIC share a number of common risk/CFs, including behaviors and toxic exposures, that impair immune function. A key component of immune system health is the removal of those factors that contribute to immune system dysfunction in the first place. This requires a paradigm shift from traditional Western medicine, which often focuses on treatment, rather than prevention.

Association of Substance Use With Behavioral Adherence to Centers for Disease Control and Prevention Guidelines for COVID-19 Mitigation: Cross-sectional Web-Based Survey

BACKGROUND

Substance use is a risk factor for COVID-19 infection and adverse outcomes. However, reasons for elevated risk for COVID-19 in substance users are not well understood.

OBJECTIVE

The aim of this study was to evaluate whether alcohol or other drug use is associated with adherence to Centers for Disease Control and Prevention (CDC) guidelines for COVID-19 mitigation. Preregistered analyses tested the hypothesis that greater use of alcohol and other drugs would be associated with lower CDC guideline adherence. A secondary objective was to determine whether substance use was associated with the likelihood of COVID-19 testing or outcome.

METHODS

A cross-sectional web-based survey was administered to a convenience sample recruited through Amazon's Mechanical Turk platform from June 18 to July 19, 2020. Individuals aged 18 years or older and residing in Connecticut, Massachusetts, New Jersey, New York, or Rhode Island were eligible to participate. The exposure of interest was past 7-day use of alcohol, cigarettes, electronic cigarettes, cannabis, stimulants, and nonmedical opioids. The primary outcome was CDC guideline adherence measured using a scale developed from behaviors advised to reduce the spread of COVID-19. Secondary outcomes were likelihood of COVID-19 testing and a positive COVID-19 test result. All analyses accounted for the sociodemographic characteristics.

RESULTS

The sample consisted of 1084 individuals (mean age 40.9 [SD 13.4] years): 529 (48.8%) men, 543 (50.1%) women, 12 (1.1%) other gender identity, 742 (68.5%) White individuals, 267 (24.6%) Black individuals, and 276 (25.5%) Hispanic individuals. Daily opioid users reported lower CDC guideline adherence than nondaily users (B=-0.24, 95% CI -0.44 to -0.05) and nonusers (B=-0.57, 95% CI -0.76 to -0.38). Daily alcohol drinkers reported lower adherence than nondaily drinkers (B=-0.16, 95% CI -0.30 to -0.02). Nondaily alcohol drinkers reported higher adherence than nondrinkers (B=0.10, 95% CI 0.02-0.17). Daily opioid use was related to greater odds of COVID-19 testing, and daily stimulant use was related to greater odds of a positive COVID-19 test.

CONCLUSIONS

In a regionally-specific, racially, and ethnically diverse convenience sample, adults who engaged in daily alcohol or opioid use reported lower CDC guideline adherence for COVID-19 mitigation. Any opioid use was associated with greater odds of COVID-19 testing, and daily stimulant use was associated with greater odds of COVID-19 infection. Cigarettes, electronic cigarettes, cannabis, or stimulant use were not statistically associated with CDC guideline adherence, after accounting for sociodemographic covariates and other substance use variables. Findings support further investigation into whether COVID-19 testing and vaccination should be expanded among individuals with substance-related risk factors.

Investigating Unhealthy Alcohol Use As an Independent Risk Factor for Increased COVID-19 Disease Severity: Observational Cross-sectional Study

BACKGROUND

Unhealthy alcohol use (UAU) is known to disrupt pulmonary immune mechanisms and increase the risk of acute respiratory distress syndrome in patients with pneumonia; however, little is known about the effects of UAU on outcomes in patients with COVID-19 pneumonia. To our knowledge, this is the first observational cross-sectional study that aims to understand the effect of UAU on the severity of COVID-19.

OBJECTIVE

We aim to determine if UAU is associated with more severe clinical presentation and worse health outcomes related to COVID-19 and if socioeconomic status, smoking, age, BMI, race/ethnicity, and pattern of alcohol use modify the risk.

METHODS

In this observational cross-sectional study that took place between January 1, 2020, and December 31, 2020, we ran a digital machine learning classifier on the electronic health record of patients who tested positive for SARS-CoV-2 via nasopharyngeal swab or had two COVID-19 International Classification of Disease, 10th Revision (ICD-10) codes to identify patients with UAU. After controlling for age, sex, ethnicity, BMI, smoking status, insurance status, and presence of ICD-10 codes for cancer, cardiovascular disease, and diabetes, we then performed a multivariable regression to examine the relationship between UAU and COVID-19 severity as measured by hospital care level (ie, emergency department admission, emergency department admission with ventilator, or death). We used a predefined cutoff with optimal sensitivity and specificity on the digital classifier to compare disease severity in patients with and without UAU. Models were adjusted for age, sex, race/ethnicity, BMI, smoking status, and insurance status.

RESULTS

Each incremental increase in the predicted probability from the digital alcohol classifier was associated with a greater odds risk for more severe COVID-19 disease (odds ratio 1.15, 95% CI 1.10-1.20). We found that patients in the unhealthy alcohol group had a greater odds risk to develop more severe disease (odds ratio 1.89, 95% CI 1.17-3.06), suggesting that UAU was associated with an 89% increase in the odds of being in a higher severity category.

CONCLUSIONS

In patients infected with SARS-CoV-2, UAU is an independent risk factor associated with greater disease severity and/or death.

Clinical presentation and hospitalisation duration of 201 coronavirus disease 2019 patients in Abuja, Nigeria

BACKGROUND

Knowledge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is unfolding. Insights from patient features in different environments are therefore vital to understanding the disease and improving outcomes.

AIM

This study aimed to describe patient characteristics associated with symptomatic presentation and duration of hospitalisation in coronavirus disease 2019 (COVID-19) patients managed in Abuja.

SETTING

The study was conducted in Abuja, the Federal Capital Territory, Nigeria.

METHODS

This was a retrospective study of 201 COVID-19 patients hospitalised in the Asokoro District Hospital COVID-19 Isolation and Treatment Centre between April 2020 and July 2020. Demographic and clinical data were obtained and outcomes assessed were symptom presentation and duration of hospitalisation.

RESULTS

Patients' median age was 39.3 years (interquartile range [IQR]: 26-52); 65.7% were male and 33.8% were health workers. Up to 49.2% of the patients were overweight or obese, 68.2% had mild COVID-19 at presentation and the most common symptoms were cough (38.3%) and fever (33.8%). Hypertension (22.9%) and diabetes mellitus (7.5%) were the most common comorbidities. The median duration of hospitalisation was 14.4 days (IQR: 9.5-19). Individuals with secondary and tertiary education had higher percentage symptoms presentation (8.5% and 34%, respectively), whilst a history of daily alcohol intake increased the length of hospital stay by 129.0%.

CONCLUSION

Higher educational levels were linked with symptom presentation in COVID-19 patients and that daily alcohol intake was significantly associated with longer hospital stay. These findings highlight the importance of public education on COVID-19 for symptom recognition, early presentation and improved outcomes.

Alcohol Use and the Risk of Communicable Diseases

The body of knowledge on alcohol use and communicable diseases has been growing in recent years. Using a narrative review approach, this paper discusses alcohol's role in the acquisition of and treatment outcomes from four different communicable diseases: these include three conditions included in comparative risk assessments to date-Human Immunodeficiency Virus (HIV)/AIDS, tuberculosis (TB), and lower respiratory infections/pneumonia-as well as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because of its recent and rapid ascension as a global health concern. Alcohol-attributable TB, HIV, and pneumonia combined were responsible for approximately 360,000 deaths and 13 million disability-adjusted life years lost (DALYs) in 2016, with alcohol-attributable TB deaths and DALYs predominating. There is strong evidence that alcohol is associated with increased incidence of and poorer treatment outcomes from HIV, TB, and pneumonia, via both behavioral and biological mechanisms. Preliminary studies suggest that heavy drinkers and those with alcohol use disorders are at increased risk of COVID-19 infection and severe illness. Aside from HIV research, limited research exists that can guide interventions for addressing alcohol-attributable TB and pneumonia or COVID-19. Implementation of effective individual-level interventions and alcohol control policies as a means of reducing the burden of communicable diseases is recommended.

Effects of the COVID-19 pandemic and lockdown on alcohol use disorders and complications

PURPOSE OF REVIEW

To understand the effect of COVID-19 pandemic and lockdown on persons with alcohol use disorders.

RECENT FINDINGS

From a total of 455 titles on COVID-19 and alcohol, 227 abstracts were screened, and 95 articles were reviewed (on November 25th, 2020). The immediate effect was an increase in alcohol related emergencies including alcohol withdrawal, related suicides, and methanol toxicity. Although there are mixed findings with respect to changes in the quantity of drinking, there are reports of binge/heavy drinking during the lockdown as well as relapse postlockdown. Psychological, social, biological, economic and policy-related factors appear to influence the changes in drinking. Although preliminary data suggest no change in alcohol use among persons with comorbid mental illness, findings in this population are presently limited. Among patients with alcohol related liver disease, outcomes appear worse and caution is warranted with the use of medications. Alcohol also appears to increases the risk of COVID-19 infection and complicates its course.Although some nations banned alcohol sales completely during lockdown, others declared it as an essential commodity, resulting in different problems across countries. Alcohol use has added to the burden of the problem particularly among vulnerable groups like the adolescents, elderly, patients with cancer, as well as health professionals. Services for patients with alcohol use disorders have been affected.

SUMMARY

The COVID-19 pandemic has had considerable impact on alcohol use, with an increase in alcohol related emergencies, changes in alcohol use patterns, increased risk of contracting COVID-19, effect on alcohol policies and sales, and an effect on vulnerable groups. It is essential to understand and respond to the current situation, intervene early, and prevent further repercussions of the pandemic.Video abstract link: https://drive.google.com/file/d/1IJWtIs6e554PryKWhdma4VB--mjSZq1C/view?usp=sharing.

Randomized controlled trials for alcohol use disorder during the COVID-19 pandemic

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) altered the logistics of ongoing randomized controlled trials (RCTs). The need to reduce in-person research and clinical activities, however, presented an additional level of complexity in order to continue conducting RCTs that focused on the development of medications for Alcohol Use Disorder (AUD). The visits required a systematic objective evaluation from the physician and mental health professional and clinical staff, as many of the safety and efficacy assessments are self-reported. The following commentary addresses the successes and limitations our RCTs encountered during the coronavirus (COVID-19) pandemic.