Update I. A systematic review on the efficacy and safety of chloroquine/hydroxychloroquine for COVID-19

Toxicologic Pathology Forum: mRNA Vaccine Safety-Separating Fact From Fiction

SARS-CoV-2 spread rapidly across the globe, contributing to the death of millions of individuals from 2019 to 2023, and has continued to be a major cause of morbidity and mortality after the pandemic. At the start of the pandemic, no vaccines or anti-viral treatments were available to reduce the burden of disease associated with this virus, as it was a novel SARS coronavirus. Because of the tremendous need, the development of vaccines to protect against COVID-19 was critically important. The flexibility and ease of manufacture of nucleic acid-based vaccines, specifically mRNA-based products, allowed the accelerated development of COVID-19 vaccines. Although mRNA-based vaccines and therapeutics had been in clinical trials for over a decade, there were no licensed mRNA vaccines on the market at the start of the pandemic. The rapid development of mRNA-based COVID-19 vaccines reduced serious complications and death from the virus but also engendered significant public concerns, which continue now, years after emergency-use authorization and subsequent licensure of these vaccines. This article summarizes and addresses some of the safety concerns that continue to be expressed about these vaccines and their underlying technology.

Drug repurposing for respiratory infections

Respiratory infections such as Coronavirus disease 2019 are a substantial worldwide health challenge, frequently resulting in severe sickness and death, especially in susceptible groups. Conventional drug development for respiratory infections faces obstacles such as extended timescales, substantial expenses, and the rise of resistance to current treatments. Drug repurposing is a potential method that has evolved to quickly find and reuse existing medications for treating respiratory infections. Drug repurposing utilizes medications previously approved for different purposes, providing a cost-effective and time-efficient method to tackle pressing medical needs. This chapter summarizes current progress and obstacles in repurposing medications for respiratory infections, focusing on notable examples of repurposed pharmaceuticals and their probable modes of action. The text also explores the significance of computational approaches, high-throughput screening, and preclinical investigations in identifying potential candidates for repurposing. The text delves into the significance of regulatory factors, clinical trial structure, and actual data in confirming the effectiveness and safety of repurposed medications for respiratory infections. Drug repurposing is a valuable technique for quickly increasing the range of treatments for respiratory infections, leading to better patient outcomes and decreasing the worldwide disease burden.

Adverse drug reactions to chloroquine/hydroxychloroquine in combination with azithromycin in COVID-19 in-patients: data from intensive pharmacovigilance in Morocco, 2020

In Morocco, chloroquine/hydroxychloroquine + azithromycin have been used off-label for COVID-19 treatment. This study aimed to describe the distribution, nature and seriousness of the adverse drug reactions (ADRs) associated with the two drug combinations in COVID-19 in-patients. We conducted a prospective observational study based on intensive pharmacovigilance in national COVID-19 patients' management facilities from April 1 to June 12, 2020. Hospitalized patients treated with chloroquine/hydroxychloroquine + azithromycin and who experienced ADRs during their hospital stay were included in the study. The causality and seriousness of the ADRs were assessed using the World Health Organization-Uppsala Monitoring Centre method and the agreed criteria in the ICH guideline (E2A) respectively. A total of 237 (51.7%) and 221 (48.3%) COVID-19 in-patients treated respectively with chloroquine + azithromycin and hydroxychloroquine + azithromycin experienced 946 ADRs. Serious ADRs occurred in 54 patients (11.8%). Gastrointestinal system was most affected both in patients taking chloroquine + azithromycin (49.8%) or hydroxychloroquine + azithromycin (54.2%), followed by nervous system and psychiatric. Eye disorders were more frequent in patients receiving chloroquine + azithromycin (10.3%) than those receiving hydroxychloroquine + azithromycin (1.2%). Cardiac ADRs accounted for 6.4% and 5.1% respectively. Chloroquine + azithromycin caused more ADRs by patients than hydroxychloroquine + azithromycin (2.6 versus 1.5 ADRs/patient). Causality assessment was possible for 75.7% of the ADRs. Diabetes was identified as a risk factor for serious ADRs (ORa 3.56; IC: 95% 1.5-8.6). The off-label use of the two drug combinations in COVID-19 in-patients according to the national therapeutic protocol seems to be safe and tolerable. ADRs were mainly expected. However, precaution should be taken in using the drugs in diabetic patients to prevent the risk of serious ADRs.

Mitochondria-induced formation of neutrophil extracellular traps is enhanced in the elderly via Toll-like receptor 9

Neutrophil extracellular traps are potent antimicrobial weapons; however, their formation during sterile inflammation is detrimental, and the mechanism of induction is still unclear. Since advanced age is the primary clinical risk factor for poor outcomes in inflammatory diseases, we hypothesized that sterile stimuli, represented by mitochondria, would induce neutrophil extracellular trap formation in an age-dependent manner. Therefore, we analyzed induction of neutrophil extracellular traps in patients grouped according to age or immune status and observed that neutrophils from elderly patients responded to the presence of mitochondria with enhanced neutrophil extracellular trap formation. These neutrophil extracellular traps were also found to be more oxidized and exhibited higher resistance to DNase I degradation. Additionally, a higher concentration of residual neutrophil extracellular traps was detected in the plasma of the elderly. This plasma was capable of priming neutrophils through TLR9-mediated signaling, leading to further neutrophil extracellular trap formation, which was successfully inhibited with chloroquine. Finally, in a mouse model of mitochondria-induced acute lung injury, we observed that neutrophils from aged mice displayed impaired chemotactic activity but exhibited a trend of higher neutrophil extracellular trap formation. Thus, we propose that residual neutrophil extracellular traps circulating in the elderly preactivate neutrophils, making them more prone to enhanced neutrophil extracellular trap formation when exposed to mitochondria during sterile inflammation. Further investigation is needed to determine whether this vicious circle could be a suitable therapeutic target.

Immunomodulatory therapies for COVID-19

Purpose

As COVID-19 disease progresses, the host inflammatory response contributes to hypoxemia and severe and critical illness. In these latter stages of disease, patients may benefit from immunomodulatory therapies to control the aberrant host inflammatory response. In this review, we provide an overview of these therapies and provide summaries of the studies that led to issuance of FDA Emergency Use Authorization or recommendation by the Infectious Diseases Society of America (IDSA).

Materials and methods

We reviewed English-language studies, Emergency Use Authorizations (EUAs), and guidelines from March 2020 to present.

Conclusion and relevance

There are several therapies with proposed benefit in severe and critical COVID-19 disease. Few have been issued FDA EUA or recommendation by the Infectious Diseases Society of America (IDSA). Physicians should be familiar with the evidence supporting use of these therapies and the patient populations most likely to benefit from each.

Hydroxychloroquine Adsorption in Aqueous Medium Using Clinoptilolite Zeolite

The presence of drugs on a large scale in aquatic matrices raises concern and requires the study of efficient technologies to remove these compounds. This study investigated the adsorption capacity of the natural zeolite clinoptilolite (CP) in removing the drug hydroxychloroquine (HCQ). Zeolite was characterized by BET, XRD, FT-IR, SEM, and pH_pzc techniques. The kinetic model that best fits the experimental data was the pseudo-first-order and the SIPS isotherm provided the best fit. The Langmuir isotherm RL separation factor (> 0.01) indicated that the adsorption process was favorable and the Freundlich isotherm (n > 1) suggested that the adsorption mechanism occurred mainly by physisorption, with intraparticle diffusion as the step limiting the process. The process was spontaneous (ΔG°_ads < 0), endothermic (ΔH°_ads > 0), and with increased randomness at the solid-solution interface (ΔS°_ads > 0). The initial pH variation of the effluent was not favorable for the adsorption process and the zeolite was easily regenerated for later use. The ecotoxicological tests with Artemia salina and Lactuca Sativa proved that the final effluent did not show toxicity after the adsorption treatment. Based on the results obtained in this work, clinoptilolite zeolite is a potential adsorbent for reducing HCQ toxicity in aquatic matrices.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11270-022-05787-3.

Study on Hydroxychloroquinine Sulfate Being Given to the Admitted COVID -19 Positive Patients at Institute of JLNMCH, Bhagalpur, Bihar, India

Background

As the global death toll from new coronavirus illness (COVID-19) rises, the scientific community and healthcare systems are under massive pressure to manage the outbreak and develop effective medical remedies. Meanwhile, desperation has pushed practitioners, scientists, and authorities to recommend and attempt medicines with little or no proof. Despite the lack of clear and unequivocal facts supporting its efficacy and safety, hydroxychloroquine-sulfate (HCQS) has recently received substantial public and political interest in treating and prophylaxis new infectious diseases COVID-19.

Aim

To analyze the impact of HCQS in COVID-19-positive patients admitted at tertiary level government-owned Jawaharlal Nehru Medical College and Hospital (JLNMCH, Bhagalpur) Bihar.

Methods

Two hundred two RT-PCR-positive COVID-19 patients were included in this research. The study participants were randomly distributed into the intervention category and control category, each consisting of 101 study subjects. Study participants in the intervention category were administered hydroxychloroquine in 200 mg tablets. The control category was given placebo tablets that looked similar to tablets of hydroxychloroquine and were given in the same pattern. Chest X-ray PA view, 12 lead ECG, baseline hemogram including a concentration of CD4 cells, ratio between the concentration of CD8 cells and CD4 cells and concentration of CD8 cells, the concentration of C-reactive protein, RT PCR test of samples obtained from the oropharyngeal region and nasopharyngeal region nasopharyngeal for verification COVID-19 were done. These measurements were carried out in both the control and intervention categories at baseline and at the moment of obtaining a negative RT-PCR report.

Results

The confirmed cases of COVID-19 was 52.9% in the intervention category and 53.4% in the control category at the end of the administration of drugs. Symptoms related to COVID-19 were observed in 11.6% of subjects in the intervention category and 13.5% in the control category. Other new symptoms were observed in 16.8% of subjects in the intervention category and 14.5% of study subjects in the control category. One death was reported in the control category. Emergency hospitalization was required for one subject in the intervention category, while two subjects in the control category required emergency hospitalization. 12.4 days was the mean duration of recovery in the intervention category, while 13.6 days were the mean duration of recovery in the control category. The recovery duration and COVID-related symptoms were lesser in the intervention category than in the control category; however, the variation between the two categories was statistically non-significant (p˃0.01).

Conclusion

According to this research, no statistically significant difference was noticed in COVID-19 incidence between the control category and intervention category, showing that hydroxychloroquine sulfate cannot be utilized as the main curative agent in the treatment of COVID-19. However, there was a reduction in recovery days and symptoms related to COVID-19 in study subjects administered with HCQS.

Off-Label Use of Hydroxychloroquine in COVID-19: Analysis of Reports of Suspected Adverse Reactions From the Italian National Network of Pharmacovigilance

This study aimed to characterize adverse drug reactions (ADRs) to hydroxychloroquine in the setting of COVID-19, occurring in Italy in the period March to May 2020. The analysis of the combination therapy with azithromycin or/and lopinavir/ritonavir as well as a comparison with ADRs reported throughout 2019 was performed. ADRs collected by the Italian National Network of Pharmacovigilance were analyzed for their incidence, seriousness, outcome, coadministered drugs, and Medical Dictionary for Regulatory Activities classification. A total of 306 reports were gathered for the quarter of 2020: 54% nonserious and 46% serious, and half of the latter required either the hospitalization or its prolongation. However, most of them were either completely recovered (26%) or in the process of recovery (45%), except for 9 fatal cases. Throughout 2019, 38 reports were collected, 53% nonserious and 47% serious, but no deaths had been reported. Diarrhea, prolonged QT interval, and hypertransaminasemia were the most frequently ADRs reported in 2020, significantly higher than 2019 and specific for COVID-19 subjects treated with hydroxychloroquine. The logistic regression analyses demonstrated that the likelihood of serious ADRs, QT prolongation, and diarrhea significantly increased with hydroxychloroquine dosage. Coadministration of lopinavir/ritonavir and hydroxychloroquine showed a positive correlation with diarrhea and hypertransaminasemia and a negative relationship with the ADR seriousness. The combination therapy with azithromycin was another independent predictor of a serious ADR. Off-label use of hydroxychloroquine for COVID-19, alone or in combination regimens, was associated with increased incidence and/or seriousness of specific ADRs in patients with additional risk factors caused by the infection.

Drug Repurposing for COVID-19: A Review and a Novel Strategy to Identify New Targets and Potential Drug Candidates

In December 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19) was first identified in the province of Wuhan, China. Since then, there have been over 400 million confirmed cases and 5.8 million deaths by COVID-19 reported worldwide. The urgent need for therapies against SARS-CoV-2 led researchers to use drug repurposing approaches. This strategy allows the reduction in risks, time, and costs associated with drug development. In many cases, a repurposed drug can enter directly to preclinical testing and clinical trials, thus accelerating the whole drug discovery process. In this work, we will give a general overview of the main developments in COVID-19 treatment, focusing on the contribution of the drug repurposing paradigm to find effective drugs against this disease. Finally, we will present our findings using a new drug repurposing strategy that identified 11 compounds that may be potentially effective against COVID-19. To our knowledge, seven of these drugs have never been tested against SARS-CoV-2 and are potential candidates for in vitro and in vivo studies to evaluate their effectiveness in COVID-19 treatment.

Pharmaceutical compounds used in the COVID-19 pandemic: A review of their presence in water and treatment techniques for their elimination

During the COVID-19 pandemic, high consumption of antivirals, antibiotics, antiparasitics, antiprotozoals, and glucocorticoids used in the treatment of this virus has been reported. Conventional treatment systems fail to efficiently remove these contaminants from water, becoming an emerging concern from the environmental field. Therefore, the objective of the present work is to address the current state of the literature on the presence and removal processes of these drugs from water bodies. It was found that the concentration of most of the drugs used in the treatment of COVID-19 increased during the pandemic in water bodies. Before the pandemic, Azithromycin concentrations in surface waters were reported to be in the order of 4.3 ng L-1, and during the pandemic, they increased up to 935 ng L-1. Laboratory scale studies conclude that adsorption and advanced oxidation processes (AOPs) can be effective in the removal of these drugs. Up to more than 80% removal of Azithromycin, Chloroquine, Ivermectin, and Dexamethasone in aqueous solutions have been reported using these processes. Pilot-scale tests achieved 100% removal of Azithromycin from hospital wastewater by adsorption with powdered activated carbon. At full scale, treatment plants supplemented with ozonation and artificial wetlands removed all Favipiravir and Azithromycin, respectively. It should be noted that hybrid technologies can improve removal rates, process kinetics, and treatment cost. Consequently, the development of new materials that can act synergistically in technically and economically sustainable treatments is required.

Safety Measures and Risk Analysis for Outdoor Recreation Technicians and Practitioners: A Systematic Review

There is no expectation to suppress all accidents in the outdoor recreation sector; nevertheless, it is expected that all possible safety measures are taken in order to minimize the risk of accidents. The objective of this study was to systematize the knowledge regarding recommended and used safety measures and risk assessments for technicians and outdoor recreation practitioners. We conducted a systematic review on PubMed, BVS, SciELO, Science Direct, ABI/INFORM, Spinger, Web of Knowledge, and Esmerald full text databases, up to February 2021. The eligible criteria followed the PICOS strategy; the included risk assessment studies on outdoor recreation (according to its definition) had methodological quality, were indexed, and peer reviewed. Ten studies, from ten countries, fulfilled these specifications, which focused on different approaches. Five studies focused on risk perception, four studies focused on safety practices, injuries, and risk assessment; three studies addressed safe behaviors; two studies addressed equipment- and risk matrix-related themes. We concluded that there was a concern for this topic, and the 28 mentioned measures could provide important information regarding health and prevention. These measures could be used to develop safety strategies and risk reduction, aimed at reducing accidents in outdoor recreation activities. In order to evaluate the pertinence and importance of the mentioned measures, namely risk perception, safe practices, sport injuries, risk analysis, safe behaviors, as well as equipment and risk assessment matrices, further investigation is needed using experimental or observational designs. These strategies and procedures can contribute to enhanced interventions by technicians with higher security and quality, and therefore, improved well-being and satisfaction of practitioners.

Naphthoquine: A Potent Broad-Spectrum Anti-Coronavirus Drug In Vitro

COVID-19 has spread around the world and caused serious public health and social problems. Although several vaccines have been authorized for emergency use, new effective antiviral drugs are still needed. Some repurposed drugs including Chloroquine, Hydroxychloroquine and Remdesivir were immediately used to treat COVID-19 after the pandemic. However, the therapeutic effects of these drugs have not been fully demonstrated in clinical studies. In this paper, we found an antimalarial drug, Naphthoquine, showed good broad-spectrum anti-coronavirus activity. Naphthoquineinhibited HCoV-229E, HCoV-OC43 and SARS-CoV-2 replication in vitro, with IC₅₀ = 2.05 ± 1.44 μM, 5.83 ± 0.74 μM, and 2.01 ± 0.38 µM, respectively. Time-of-addition assay was also performed to explore at which stage Naphthoquine functions during SARS-CoV-2 replication. The results suggested that Naphthoquine may influence virus entry and post-entry replication. Considering the safety of Naphthoquine was even better than that of Chloroquine, we think Naphthoquine has the potential to be used as a broad-spectrum drug for coronavirus infection.

Meta-analysis of health state utility values measured by EuroQol 5-dimensions (EQ5D) questionnaire in Chinese women with breast cancer

BACKGROUND

To synthesise EQ5D health state utility values in Chinese women with breast cancer for parameterising a cost utility model.

METHODS

Eligible studies had to report health state utility values measured by EQ-5D in Chinese women diagnosed with breast cancer. Risk of bias was assessed using the Newcastle Ottawa Scale (NOS). Data from single arm studies was pooled using meta-analysis of single proportions to provide overall point estimates and 95% confidence intervals for fixed and random effects models using the inverse variance and Der Simonian-Laird methods respectively. Heterogeneity was evaluated using the I2 statistic and sensitivity analysis and meta-regression were conducted.

RESULTS

Five papers were included, when all studies were combined (n = 4,100) the mean utility (95% confidence interval) for random effects model was 0.83 (0.78, 0.89); for TNM 0-1 0.85 (0.75, 0.95); for TNM II 0.85 (0.78, 0.93); for TNM III 0.83 (0.77, 0.90) and for TNM IV 0.73 (0.63, 0.82).The utility of patients in State P (first year after primary breast cancer) 0.84 (0.80, 0.88); in State R (first year after recurrence) 0.73 (0.69, 0.76), in State S (second and following years after primary breast cancer or recurrence) 0.88 (0.83, 0.92); and in State M (metastatic disease) 0.78 (0.74, 0.82). Mean utility for duration since diagnosis 13 to 36 months was 0.88 (0.80, 0.96, I2 =95%); for 37 to 60 months 0.89 (0.82, 0.96, I2 =90%); for more than 60 months 0.86 (0.76, 0.96, I2 =90%). Mean utility for chemotherapy was 0.86 (0.79, 0.92, I2 =97%); for radiotherapy 0.83 (0.69, 0.96, I2 =97%); surgery 0.80 (0.69, 0.91, I2 =98%); concurrent chemo-radiation 0.70 (0.60, 0.81, I2 =86%) and endocrine therapy 0.90 (0.83, 0.97, I2 =91%).

CONCLUSION

This study synthesises the evidence for health state utility values for Chinese women with breast cancer which is useful to inform cost utility models.

Effects of chloroquine or hydroxychloroquine treatment on non-SARS-CoV2 viral infections: A systematic review of clinical studies

Chloroquine (CQ) and hydroxychloroquine (HCQ) have been used as antiviral agents for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. We performed a systematic review to examine whether prior clinical studies that compared the effects of CQ and HCQ to a control for the treatment of non-SARS-CoV2 infection supported the use of these agents in the present SARS-CoV2 outbreak. PubMed, EMBASE, Scopus and Web of Science (PROSPERO CRD42020183429) were searched from inception through 2 April 2020 without language restrictions. Of 1766 retrieved reports, 18 studies met our inclusion criteria, including 17 prospective controlled studies and one retrospective study. CQ or HCQ were compared to control for the treatment of infectious mononucleosis (EBV, n = 4), warts (human papillomavirus, n = 2), chronic HIV infection (n = 6), acute chikungunya infection (n = 1), acute dengue virus infection (n = 2), chronic HCV (n = 2), and as preventive measures for influenza infection (n = 1). Survival was not evaluated in any study. For HIV, the virus that was most investigated, while two early studies suggested HCQ reduced viral levels, four subsequent ones did not, and in two of these CQ or HCQ increased viral levels and reduced CD4 counts. Overall, three studies concluded CQ or HCQ were effective; four concluded further research was needed to assess the treatments' effectiveness; and 11 concluded that treatment was ineffective or potentially harmful. Prior controlled clinical trials with CQ and HCQ for non-SARS-CoV2 viral infections do not support these agents' use for the SARS-CoV2 outbreak.

Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Background

There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil.

Methods

This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann–Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19.

Results

From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren’s syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03–2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19–6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31–3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46–0.98).

Conclusion

Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection.

Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR – 9KTWX6).

QT interval and repolarization dispersion changes during the administration of hydroxychloroquine/chloroquine with/without azithromycin in early COVID 19 pandemic: A prospective observational study from two academic hospitals in Indonesia

BACKGROUND

Hydroxychloroquine/chloroquine (HCQ/CQ) treatment for COVID-19 was associated with QT interval prolongation and arrhythmia risks. This study aimed to investigate QTc interval and ventricular repolarization dispersion changes, as markers of arrhythmia risks, after HCQ/CQ administration with/without azithromycin (AZT) during COVID-19 pandemic.

METHODS

A prospective observational study was performed in two academic hospitals in Indonesia. Adult patients who received HCQ/CQ alone and HCQ/CQ + AZT concomitant treatments for COVID-19 infection were enrolled. Baseline and post HCQ/CQ treatment electrocardiograms were obtained. Baseline and post HCQ/CQ treatment QT interval by Bazett (B-QTc) and Fridericia (F-QTc) formulas and ventricular repolarization dispersion indices by Tpeak-Tend (Tp-e) interval and Tpeak-Tend/QT (Tp-e/QT) ratio were calculated and analyzed.

RESULTS

The study enrolled 55 (HCQ/CQ alone) and 77 subjects (HCQ/CQ + AZT concomitant). F-QTc interval significantly lengthened in subjects with HCQ/CQ + AZT (mean difference 11.89 ms [P = .028]). The incidences of severe B-QTc and F-QTc lengthening were 13.1% and 12.3%, B-QTc and F-QTc prolongation were 25.4% and 12.3%, and severe B-QTc and F-QTc prolongation were 6.2% and 3.2%. Tp-e interval lengthened significantly from baseline to posttreatment in HCQ/CQ alone and HCQ/CQ + AZT (mean difference 10.83 ms [P = .006] and 18.73 ms [P < .001], respectively). Tp-e/QT ratio increased significantly from baseline to posttreatment in HCQ/CQ + AZT concomitant (mean difference 0.035 [P < .001]). No fatal arrhytmia occurred.

CONCLUSIONS

During COVID-19 pandemic, HCQ/CQ + AZT concomitant treatment caused significant F-QTc lengthening, significantly increased Tp-e interval and increased Tp-e/QT ratio. HCQ/CQ alone only caused significant increase of Tp-e interval. Incidences of severe QTc lengthening and prolongation were low in both HCQ/CQ alone and HCQ/CQ + AZT concomitant.

System for administering and monitoring hydroxychloroquine prophylaxis for COVID-19 in accordance with a national advisory: preliminary experience of a tertiary care institute in India

BACKGROUND

Hydroxychloroquine (HCQ) was one of the earliest drugs to be recommended for tackling the COVID-19 threat leading to its widespread usage. We provide preliminary findings of the system, established in a tertiary care academic center for the administration of HCQ prophylaxis to healthcare workers (HCW) based on Indian Council of Medical Research (ICMR) advisory.

METHODS

A dedicated clinical pharmacology and internal medicine team screened for contraindications, administered informed consent, maintained compliance and monitored for adverse events.

RESULTS

Among the 194 HCWs screened for ruling out contraindications for prophylaxis, 9 were excluded and 185 were initiated on HCQ. A total of 55 adverse events were seen in 38 (20.5%) HCWs out of which 70.9%, 29.1% were mild and moderate & none were severe. Before the completion of therapy, a total of 23 participants discontinued. Change in QTc interval on day 2 was 5 (IQR: -3.75, 11) ms and the end of week 1 was 15 ms (IQR: 2, 18). Out of the 5 HCW who turned positive for COVID-19, 2 were on HCQ.

CONCLUSION

HCQ prophylaxis was found to be safe and well tolerated in HCW when administered after appropriate screening and with monitoring for adverse events.

Pharmacological management of COVID-19 in type 2 diabetes

Evidence suggests that diabetes is one the most relevant comorbidity in affecting the prognosis of COVID-19. Albeit there are no specific trials nor subgroup analysis showing the effect of COVID-19 therapies in patients with diabetes, selected features of this disease and the side effects associated with certain drugs require a proper knowledge to optimize the pharmacological therapy of patients with diabetes and COVID-19. While chronic anti-hypertensive and glucose-lowering therapies should not be discontinued nor preferred for preventive purposes, the low-grade pro-inflammatory, the thrombosis-prone status of diabetes, the role of acute hyperglycaemia in promoting adverse outcomes in patients admitted to ICU, and the observed increased mortality in patients with poor long-term glycaemic control delineate a delicate balance in case of severe forms of COVID-19. Here, we briefly summarized some of the key pharmacological issues linked to the management of patients with diabetes and COVID-19, in order to provide indications to minimize the deleterious effects of the concomitant presentation of these diseases and to use the existing pharmacological options in an appropriate manner.

Lack of efficacy of hydroxychloroquine and azithromycin in patients hospitalized for COVID-19 pneumonia: A retrospective study

Background

Hydroxychloroquine combined with azithromycin (HCQ/AZI) has initially been used against coronavirus disease-2019 (COVID-19). In this retrospective study, we assessed the clinical effects of HCQ/AZI, with a 28-days follow-up.

Methods

In a registry-study which included patients hospitalized for COVID-19 between March 15 and April 2, 2020, we compared patients who received HCQ/AZI to those who did not, regarding a composite outcome of mortality and mechanical ventilation with a 28-days follow-up. QT was monitored for patients treated with HCQ/AZI. Were excluded patients in intensive care units, palliative care and ventilated within 24 hours of admission. Three analyses were performed to adjust for selection bias: propensity score matching, multivariable survival, and inverse probability score weighting (IPSW) analyses.

Results

Overall, 203 patients were included: 60 patients treated by HCQ/AZI and 143 control patients. During the 28-days follow-up, 32 (16.3%) patients presented the primary outcome and 23 (12.3%) patients died. Propensity-score matching identified 52 unique pairs of patients with similar characteristics. In the matched cohort (n = 104), HCQ/AZI was not associated with the primary composite outcome (log-rank p-value = 0.16). In the overall cohort (n = 203), survival and IPSW analyses also found no benefit from HCQ/AZI. In the HCQ/AZI group, 11 (18.3%) patients prolonged QT interval duration, requiring treatment cessation.

Conclusions

HCQ/AZI combination therapy was not associated with lower in-hospital mortality and mechanical ventilation rate, with a 28-days follow-up. In the HCQ/AZI group, 18.3% of patients presented a prolonged QT interval requiring treatment cessation, however, control group was not monitored for this adverse event, making comparison impossible.

One Year of Coronavirus Disease 2019 (COVID-19) in Brazil: A Political and Social Overview

Background

Coronavirus Disease 2019 (COVID-19) became the deadliest pandemic of the new millennium. One year after it became a pandemic, the current COVID-19 situation in Brazil is an example of how the impacts of a pandemic are beyond health outcomes and how health, social, and political actions are intertwined.

Objectives

We aimed to provide an overview of the first year of the COVID-19 pandemic in Brazil, from a social and political point of view, and to discuss the perspectives from now on.

Methods

This is a narrative review using official, scientific (PubMed, Medline, and SciELO databases) and publicly available data. Press articles were also used that contain important information not found in these databases.

Findings

We address the impacts of COVID-19 in different regions of Brazil, on indigenous populations, health care workers, and how internal social contrasts impacted the pandemics advance across the country. We also discuss key points that culminated in the countrys failed management of the COVID-19 spread, such as poor management of the public health care system, disparities between public and private health care infrastructure, lack of mass testing and viral spread tracking, lack of preparedness and planning to implement strict isolation and social distancing measures, and, most importantly, political instability, a deteriorating Health Ministry and sabotaging attitudes of the countrys president, including anti-scientific actions, underplaying COVID-19 severity, spreading and powering fake news about the pandemic, promoting knowingly inefficient medications for COVID-19 treatment, and interference in collective health policies, including the countrys vaccination plan.

Conclusions

After one year of COVID-19 and a disastrous management of the disease, Brazil has more than 11 million cases, 270,000 deaths, and the highest number of daily deaths due to COVID-19 in the world, most of which could have been avoided and can be credited to negligence of municipal, state, and federal authorities, especially President Jair Messias Bolsonaro. Unfortunately, the country is an example of what not to do in a pandemic setting.

Key Points

One year after COVID-19 was declared a pandemic, Brazil had the second higher number of cases and deaths, and the highest number of daily deaths due to the disease. Lack of massive testing, non-stringent and ineffective collective health policies, poor management of the public health care system, and political instability were the main drivers of the countrys flawed management of the COVID-19 advancement. Anti-science and sabotaging actions by government had a pivotal role in the countrys current situation. Brazil has a large territory and is marked by social contrasts among different regions and states, which showed contrasting data regarding the impact caused by COVID-19. COVID-19 databases and data sharing are important to provide an overview of epidemiological aspects of the disease; however, Brazil lacks standardization in these datasets.

Therapeutic Potential of Exploiting Autophagy Cascade Against Coronavirus Infection

Since its emergence in December 2019 in Wuhan, China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) created a worldwide pandemic of coronavirus disease (COVID-19) with nearly 136 million cases and approximately 3 million deaths. Recent studies indicate that like other coronaviruses, SARS-CoV-2 also hijacks or usurps various host cell machineries including autophagy for its replication and disease pathogenesis. Double membrane vesicles generated during initiation of autophagy cascade act as a scaffold for the assembly of viral replication complexes and facilitate RNA synthesis. The use of autophagy inhibitors - chloroquine and hydroxychloroquine initially appeared to be as a potential treatment strategy of COVID-19 patients but later remained at the center of debate due to high cytotoxic effects. In the absence of a specific drug or vaccine, there is an urgent need for a safe, potent as well as affordable drug to control the disease spread. Given the intricate connection between autophagy machinery and viral pathogenesis, the question arises whether targeting autophagy pathway might show a path to fight against SARS-CoV-2 infection. In this review we will discuss about our current knowledge linking autophagy to coronaviruses and how that is being utilized to repurpose autophagy modulators as potential COVID-19 treatment.

Mefloquine, a Potent Anti-severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV-2) Drug as an Entry Inhibitor in vitro

Coronavirus disease 2019 (COVID-19) has caused serious public health, social, and economic damage worldwide and effective drugs that prevent or cure COVID-19 are urgently needed. Approved drugs including Hydroxychloroquine, Remdesivir or Interferon were reported to inhibit the infection or propagation of severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), however, their clinical efficacies have not yet been well demonstrated. To identify drugs with higher antiviral potency, we screened approved anti-parasitic/anti-protozoal drugs and identified an anti-malarial drug, Mefloquine, which showed the highest anti-SARS-CoV-2 activity among the tested compounds. Mefloquine showed higher anti-SARS-CoV-2 activity than Hydroxychloroquine in VeroE6/TMPRSS2 and Calu-3 cells, with IC₅₀ = 1.28 μM, IC₉₀ = 2.31 μM, and IC₉₉ = 4.39 μM in VeroE6/TMPRSS2 cells. Mefloquine inhibited viral entry after viral attachment to the target cell. Combined treatment with Mefloquine and Nelfinavir, a replication inhibitor, showed synergistic antiviral activity. Our mathematical modeling based on the drug concentration in the lung predicted that Mefloquine administration at a standard treatment dosage could decline viral dynamics in patients, reduce cumulative viral load to 7% and shorten the time until virus elimination by 6.1 days. These data cumulatively underscore Mefloquine as an anti-SARS-CoV-2 entry inhibitor.

Short term survival of critically ill COVID-19 Egyptian patients on assisted ventilation treated by either Dexamethasone or Tocilizumab

Tocilizumab (TCZ) and Dexamethasone are used for the treatment of critically ill COVID-19 patients. We compared the short-term survival of critically ill COVID-19 patients treated with either TCZ or Dexamethasone. 109 critically ill COVID-19 patients randomly assigned to either TCZ therapy (46 patients) or pulse Dexamethasone therapy (63 patients). Age, sex, neutrophil/ lymphocyte ratio, D-dimer, ferritin level, and CT chest pattern were comparable between groups. Kaplan–Meier survival analysis showed better survival in Dexamethasone group compared with TCZ (P = 0.002), patients didn’t need vasopressor at admission (P < 0.0001), patients on non-invasive ventilation compared to patients on mechanical ventilation (P<0.0001 ), and in patients with ground glass pattern in CT chest (P<0.0001 ) compared with those who have consolidation. Cox regression analysis showed that, TCZ therapy (HR = 2.162, 95% CI, 1.144–4.087, P <0.0001) compared with Dexamethasone group, higher neutrophil/Lymphocyte ratio (HR = 2.40, CI, 1.351–4.185, P = 0.003), lower PaO₂/FiO₂, 2 days after treatment, (HR = 1.147, 95% CI, 1.002–1.624, P < 0.0001) independently predicted higher probability of mortality. Dexamethasone showed better survival in severe COVID-19 compared to TCZ. Considering the risk factors mentioned here is crucial when dealing with severe COVID-19 cases.

Clinical trial registration No clinicalTrials.gov: Nal protocol approved by Hospital Authorities, for data collection and for participation in CT04519385 (19/08/2020).

Efficacy and safety of chloroquine and hydroxychloroquine for treatment of COVID-19 patients-a systematic review and meta-analysis of randomized controlled trials

The coronavirus disease 19 (COVID-19) pandemic has caused significant morbidity and mortality worldwide and an effective treatment is needed. Chloroquine (CQ) and hydroxychloroquine (HCQ) have shown in vitro antiviral activity against SARS-CoV-2 which causes the disease, but the evidence from in vivo studies so far has been inconclusive.

OBJECTIVE

To evaluate the efficacy and safety of CQ and HCQ in the treatment of COVID-19.

DATA SOURCES

We systematically searched the PubMed, Embase, MEDLINE, Cochrane CENTRAL, CINAHL, Scopus, Joanna Briggs Institute Database, ClinicalTrials.gov, and Chinese Clinical Trial Registry (ChiCTR) for all articles published between 01 January 2020 to 15 September 2020 on CQ/HCQ and COVID-19 using a predefined search protocol; without any language restrictions. A search of grey literature repositories (New York Academy of Medicine Grey Literature and Open Grey), and pre-publication server deposits (medRxIV and bioRxIV) was also performed.

STUDY SELECTION

Randomized clinical trials (RCT) which compared CQ/HCQ to standard supportive therapy in treating COVID-19 were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from original publications by four independent reviewers. Risk of bias was assessed using the Cochrane Collaboration's assessment tool. Data were meta-analyzed using a random-effect models. Results are reported according to PRISMA guidelines. Main Outcome(s) and Measure(s): The primary prespecified efficacy outcome was all-cause mortality. The primary safety outcome was any adverse effect attributed to use of CQ/HCQ.

RESULTS

Eight RCTs were included and pooled in the mortality meta-analysis (6,592 unique participants; mean age = 59.4 years; 42% women). CQ/HCQ did not show any mortality benefit when compared to standard supportive therapy (Pooled Relative Risk [RR] 1.07; 95% CI = 0.97-1.18; I2 statistic = 0.00%). Sensitivity and sub-group analyses showed similar findings. Any adverse event was significantly higher in patients randomized to CQ/HCQ (RR = 2.51; 95% CI = 1.53-4.12; n = 1,818 patients), but the risk of developing severe adverse event was not statistically significant (RR = 0.99, 95% CI = 0.53-1.86; n = 6,456 patients).

CONCLUSIONS AND RELEVANCE

Evidence from currently published RCTs do not demonstrate any added benefit for the use of CQ or HCQ in the treatment of COVID-19 patients.

High levels of immunosuppression are related to unfavourable outcomes in hospitalised patients with rheumatic diseases and COVID-19: first results of ReumaCoV Brasil registry

OBJECTIVES

To evaluate risk factors associated with unfavourable outcomes: emergency care, hospitalisation, admission to intensive care unit (ICU), mechanical ventilation and death in patients with immune-mediated rheumatic disease (IMRD) and COVID-19.

METHODS

Analysis of the first 8 weeks of observational multicentre prospective cohort study (ReumaCoV Brasil register). Patients with IMRD and COVID-19 according to the Ministry of Health criteria were classified as eligible for the study.

RESULTS

334 participants were enrolled, a majority of them women, with a median age of 45 years; systemic lupus erythematosus (32.9%) was the most frequent IMRD. Emergency care was required in 160 patients, 33.0% were hospitalised, 15.0% were admitted to the ICU and 10.5% underwent mechanical ventilation; 28 patients (8.4%) died. In the multivariate adjustment model for emergency care, diabetes (prevalence ratio, PR 1.38; 95% CI 1.11 to 1.73; p=0.004), kidney disease (PR 1.36; 95% CI 1.05 to 1.77; p=0.020), oral glucocorticoids (GC) (PR 1.49; 95% CI 1.21 to 1.85; p<0.001) and pulse therapy with methylprednisolone (PR 1.38; 95% CI 1.14 to 1.67; p=0.001) remained significant; for hospitalisation, age >50 years (PR 1.89; 95% CI 1.26 to 2.85; p=0.002), no use of tumour necrosis factor inhibitor (TNFi) (PR 2.51;95% CI 1.16 to 5.45; p=0.004) and methylprednisolone pulse therapy (PR 2.50; 95% CI 1.59 to 3.92; p<0.001); for ICU admission, oral GC (PR 2.24; 95% CI 1.36 to 3.71; p<0.001) and pulse therapy with methylprednisolone (PR 1.65; 95% CI 1.00 to 2.68; p<0.043); the two variables associated with death were pulse therapy with methylprednisolone or cyclophosphamide (PR 2.86; 95% CI 1.59 to 5.14; p<0.018).

CONCLUSIONS

Age >50 years and immunosuppression with GC and cyclophosphamide were associated with unfavourable outcomes of COVID-19. Treatment with TNFi may have been protective, perhaps leading to the COVID-19 inflammatory process.

Evolving Treatment Patterns for Hospitalized COVID-19 Patients in the United States in April 2020-July 2020

We sought to examine the trend (April–July) in the treatment patterns among hospitalized COVID-19 patients using the Premier Healthcare Database (PHD). In the analysis, we identified 53,264 patients from 302 hospitalsthat continuously provided inpatient data from April 1, 2020 to July 31, 2020 to the PHD, a nationwide, population-based multihospital research database in the US. We used generalized estimating equations (GEE) models to assess changes in the proportion of therapies used during the study period. After adjusting for patient and provider factors, a decline in hydroxychloroquine and an increase in azithromycin and dexamethasone were observed among COVID-19 patients during the 4-month study period.

Estimation of the uncertainty of values assigned to calibration materials prepared in-house: An example for hydroxychloroquine calibrators in blood-hemolysate-based matrix

Background

Hydroxychloroquine is an antimalarial drug that has been prescribed for the treatment of patients with COVID-19 infection. To assist in clinician decision-making, several clinical laboratories have developed and validated measurement procedures in-house based on HPLC or HPLC-MS/MS to measure the mass concentration of hydroxychloroquine in different biological fluids. In these cases, laboratories produce their calibration materials but rarely estimate the measurement uncertainty of their assigned values. Thus, we aimed to show how this uncertainty can be calculated, using the preparation of hydroxychloroquine calibrators in blood-hemolysate-based matrix as an example.

Methods

A bottom-up approach was used to estimate the uncertainty related to the values assigned to end-user calibration materials prepared in-house. First, a specification of the measurand and a measurement equation were proposed. Then, different sources of uncertainty related to the preparation of hydroxychloroquine calibration materials were identified and quantified. Afterwards, the combined uncertainty was calculated using the law for the propagation of uncertainty resulting in the final expanded uncertainty.

Results

In this study, the most significant source of uncertainty was that associated with the hydroxychloroquine’s reference material mass obtained via balance, while the smallest contribution was from the uncertainty associated with the hydroxychloroquine reference material purity.

Conclusions

A simple procedure to estimate the measurement uncertainty of values assigned to calibration materials is presented here, which would be easy to implement in clinical laboratories. Also, it could be put into practice for other pharmacological quantities measured by in-house HPLC or HPLC-MS/MS procedures commonly used in clinical laboratories.

An updated systematic review and network meta-analysis of 25 randomized trials assessing the efficacy and safety of treatments in COVID-19 disease

To date, there is no definite effective treatment for the COVID- 19 pandemic. We performed an update network meta-analysis to compare and rank COVID-19 treatments according to their efficacy and safety. Literature search was performed from MEDLINE and CENTRAL databases from inception to September 5, 2020. Randomized clinical trials (RCTs) which compared the effect of any pharmacological drugs versus standard care or placebo 28-day after hospitalization in adult patients with COVID-19 disease were included. Risk ratio (RR) and 95% CI were calculated for 28-day all-cause mortality, clinical improvement, any adverse event (AEs), and viral clearance. A total of 25 RCTs, evaluating 17 different treatments, and 11,597 participants were analyzed. Remdesivir for 10- day compared to standard care (RR 0.69, 95% CI [0.48-0.99]), and a low dose compared to a high dose of HCQ (0.38, [0.17-0.89]) were associated with a lower risk of death. A total of 2,766 patients experienced clinical improvement, a 5-day course of remdesivir was associated with a higher frequency of clinical improvement compared to standard care (RR 1.21, 95% CI [1.00-1.47]). Compared to standard care, remdesivir for both 5 and 10 days, lopinavir/ritonavir, and dexamethasone reduced the risk of any severe AEs by 52% (0.48, 0.34-0.67), 24% (0.77, 0.63-0.92), 40% (0.60, 0.37-0.98), and 50% (0.50, 0.25-0.98) respectively. In this study of hospitalized patients with COVID-19, administration of remdesivir for 10-day compared to standard care was associated with lower 28-day all-cause mortality and serious AEs, and higher clinical improvement rate.

Treatment and prognosis of COVID-19: Current scenario and prospects (Review)

SARS-CoV-2 is the seventh member of the family of coronaviruses that can cause infections in humans, termed as COVID-19, which is now a global pandemic. Because it is a novel virus, considerable efforts and extensive studies are needed to fully understand its characteristics. Its symptoms and severity range from mild to critical, depending on several factors, such as host susceptibility to the virus and their immune system, with the most common symptoms being fever, fatigue, sore throat and runny nose. There is no clear treatment available yet, though several options are being explored, with research for vaccines being at the forefront. Traditional Chinese Medicine may also be used as a treatment option. Since this virus is similar to the SARS-CoV and MERS viruses, considerable insight can be gained from previous studies. Although many patients recover completely, there are several factors that lead to poor prognosis. This review summarizes the research carried out so far in terms of treatment options and prognosis factors associated with COVID-19.

Prevention and treatment of COVID-19: Focus on interferons, chloroquine/hydroxychloroquine, azithromycin, and vaccine

The ongoing pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has drawn the attention of researchers and clinicians from several disciplines and sectors who are trying to find durable solutions both at preventive and treatment levels. To date, there is no approved effective treatment or vaccine available to control the coronavirus disease-2019 (COVID-19). The preliminary in vitro studies on viral infection models showed potential antiviral activities of type I and III interferons (IFNs), chloroquine (CQ)/hydroxychloroquine (HCQ), and azithromycin (AZM); however, the clinical studies on COVID-19 patients treated with CQ/HCQ and AZM led to controversies in different regions due to their adverse side effects, as well as their combined treatment could prolong the QT interval. Interestingly, the treatment with type I IFNs showed encouraging results. Moreover, the different preliminary reports of COVID-19 candidate vaccines showcase promising results by inducing the production of a high level of neutralizing antibodies (NAbs) and specific T cell-mediated immune response in almost all participants. The present review aims to summarize and analyze the recent progress evidence concerning the use of IFNs, CQ/HCQ, and AZM for the treatment of COVID-19. The available data on immunization options to prevent the COVID-19 are also analyzed with the aim to present the promising options which could be investigated in future for sustainable control of the pandemic.

Current state of vaccine development and targeted therapies for COVID-19: impact of basic science discoveries

Coronavirus disease-19 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 is closely related to two other coronaviruses that caused disease epidemic breakouts in humans in the last 2 decades, namely, severe acute respiratory distress syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). The similarities have enabled the scientists to apply the basic scientific discoveries garnered from studying the structure and modus operandi of SARS-CoV and MERS-CoV to develop therapies that specifically target SARS-CoV-2 and to develop vaccines to prevent COVID-19. Targeted therapies including the use of antibodies to prevent virus entry, nucleotide analogues to prevent viral replication, and inhibitors of proteases to prevent virion formation, among others, are being tested for their clinical efficacy. Likewise, complete sequencing of the SARS-CoV-2 and identification of its structural and nonstructural proteins have enabled development of RNA-, DNA-, and peptide-based vaccines as well attenuated viral vaccines to instigate the host-immune responses. The clinical impacts of the basic science discoveries are amply evident on the rapid pace of progress in developing specific antiviral therapies and vaccines against SARS-CoV-2. The progress emphasizes the merit of discovering the fundamental scientific elements, regardless of whether or not they have apparent or immediate clinical applications.

COVID-19: Discovery, diagnostics and drug development

Coronavirus disease 2019 (COVID-19) started as an epidemic in Wuhan in 2019, and has since become a pandemic. Groups from China identified and sequenced the virus responsible for COVID-19, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and determined that it was a novel coronavirus sharing high sequence identity with bat- and pangolin-derived SARS-like coronaviruses, suggesting a zoonotic origin. SARS-CoV-2 is a member of the Coronaviridae family of enveloped, positive-sense, single-stranded RNA viruses that infect a broad range of vertebrates. The rapid release of the sequence of the virus has enabled the development of diagnostic tools. Additionally, serological tests can now identify individuals who have been infected. SARS-CoV-2 infection is associated with a fatality rate of around 1-3%, which is commonly linked to the development of acute respiratory distress syndrome (ARDS), likely resulting from uncontrolled immune activation, the so called "cytokine storm". Risk factors for mortality include advanced age, obesity, diabetes, and hypertension. Drug repurposing has been used to rapidly identify potential treatments for COVID-19, which could move quickly to phase III. Better knowledge of the virus and its enzymes will aid the development of more potent and specific direct-acting antivirals. In the long term, a vaccine to prevent infection is crucial; however, even if successful, it might not be available before 2021-22. To date, except for intravenous remdesivir and dexamethasone, which have modest effects in moderate to severe COVID-19, no strong clinical evidence supports the efficacy of any other drugs against SARS-CoV-2. The aim of this review is to provide insights on the discovery of SARS-CoV-2, its virology, diagnostic tools, and the ongoing drug discovery effort.

An Up-to-Date Overview of Therapeutic Agents for the Treatment of COVID-19 Disease

Acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has a great potential to overwhelm the world healthcare systems that may lead to high morbidity and mortality. It also affects world economic development in the future. Currently, no proven effective drugs or vaccines are available for the management of COVID-19 disease. The pace of normal drug development progression is unacceptable in the context of the current pandemic. Therefore, repurposing the existing drugs that were used for the treatment of malaria, Ebola, and influenza helps rapid drug development for COVID-19. Currently, several repurposing candidate drugs are in a clinical trial including, chloroquine monoclonal antibodies, convalescent plasma, interferon, and antiviral therapies. Antiviral drugs like arbidol, remdesiv and favirnavir are the most promising due to the similarities of the viruses regarding viral entry, fusion, uncoating, and replication. This review article provides an overview of the potential therapeutic agent, which displayed better clinical treatment outcomes. Moreover, with further understanding of the SARS-CoV-2 virus, new drugs targeting specific SARS-CoV-2 viral components arise, and investigations on these novels anti-SARSCoV- 2 agents are also reviewed.

Early hydroxychloroquine but not chloroquine use reduces ICU admission in COVID-19 patients

BACKGROUND

The global push for the use of hydroxychloroquine (HCQ) and chloroquine (CQ) against COVID-19 has resulted in an ongoing discussion about the effectivity and toxicity of these drugs. Recent studies report no effect of (H)CQ on 28-day mortality. We investigated the effect of HCQ and CQ in hospitalized patients on the non-ICU COVID-ward.

METHODS

A nationwide, observational cohort study was performed in The Netherlands. Hospitals were given the opportunity to decide independently on the use of three different COVID-19 treatment strategies: HCQ, CQ, or no treatment. We compared the outcomes between these groups. The primary outcomes were 1) death on the COVID-19 ward, and 2) transfer to the intensive care unit (ICU).

RESULTS

The analysis included 1064 patients from 14 hospitals: 566 patients received treatment with either HCQ (n = 189) or CQ (n = 377), and 498 patients received no treatment. In a multivariate propensity-matched weighted competing regression analysis, there was no significant effect of (H)CQ on mortality on the COVID ward. However, HCQ was associated with a significantly decreased risk of transfer to the ICU (hazard ratio (HR) = 0.47, 95% CI = 0.27-0.82, p =  0.008) when compared with controls. This effect was not found in the CQ group (HR = 0.80, 95% CI = 0.55-1.15, p =  0.207), and remained significant after competing risk analysis.

CONCLUSION

The results of this observational study demonstrate a lack of effect of (H)CQ on non-ICU mortality. However, we show that the use of HCQ - but not CQ - is associated with a 53% reduction in risk of transfer of COVID-19 patients from the regular ward to the ICU. Recent prospective studies have reported on 28-day, all-cause mortality only; therefore, additional prospective data on the early effects of HCQ in preventing transfer to the ICU are still needed.

Prone positioning and convalescent plasma therapy in a critically ill pregnant woman with COVID-19

Prone positioning is feasible in pregnancy and may have contributed to the positive outcome in this case. Doctors should not be reluctant to move a patient to a prone position just because they are pregnant.

Efficacy and Safety of Lopinavir/Ritonavir for Treatment of COVID-19: A Systematic Review and Meta-Analysis

(Background) Lopinavir-ritonavir (LPV/RTV) is a human immunodeficiency virus (HIV) antiviral combination that has been considered for the treatment of COVID-19 disease. (Aim) This systematic review aimed to assess the efficacy and safety of LPV/RTV in COVID-19 patients in the published research. (Methods) A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Articles were selected for review from 8 electronic databases. This review evaluated the effects of LPV/RTV alone or in combination with standard care ± interferons/antiviral treatments compared to other therapies, regarding duration of hospital stay, risk of progressing to invasive mechanical, time to virological cure and body temperature normalization, cough relief, radiological progression, mortality and safety. (Results) A consensus was reached to select 32 articles for full-text screening; only 14 articles comprising 9036 patients were included in this study; and eight of these were included for meta-analysis. Most of these studies did not report positive clinical outcomes with LPV/RTV treatment. In terms of virological cure, three studies reported less time in days to achieve a virological cure for LPV/RTV arm relative to no antiviral treatment (-0.81 day; 95% confidence interval (CI), -4.44 to 2.81; p = 0.007, I2 = 80%). However, the overall effect was not significant (p = 0.66). When comparing the LPV/RTV arm to umifenovir arm, a favorable affect was observed for umifenovir arm, but not statically significant (p = 0.09). In terms of time to body normalization and cough relief, no favorable effects of LPV/RTV versus umifenovir were observed. The largest trials (RECOVERY and SOLIDARITY) have shown that LPV/RTV failed to reduce mortality, initiation of invasive mechanical ventilation or hospitalization duration. Adverse events were reported most frequently for LPV/RTV (n = 84) relative to other antivirals and no antiviral treatments. (Conclusions) This review did not reveal any significant advantage in efficacy of LPV/RTV for the treatment of COVID-19 over standard care, no antivirals or other antiviral treatments. This result might not reflect the actual evidence.

Efficacy and safety outcomes of proposed randomized controlled trials investigating hydroxychloroquine and chloroquine during the early stages of the COVID-19 pandemic

Aims

To assess whether randomized clinical trials (RCTs) proposed to evaluate the treatment of patients with COVID‐19 with hydroxychloroquine (HQ) or chloroquine early in the pandemic included plans to measure outcomes that would translate into meaningful efficacy/effectiveness and safety outcomes.

Methods

The World Health Organization International Clinical Trials Registry Platform database was searched for registers of RCTs evaluating HQ or chloroquine, alone or in combination, compared with other treatments for patients diagnosed with COVID‐19. The final search was performed on 8 April 2020.

Results

Among 51 registered RCTs (median sample size 262; interquartile range: 100, 520), 34 (67%) reported a clinical outcome, 12 (24%) a surrogate outcome, and 5 (10%) a combination of clinical and surrogate outcomes as primary endpoints. Six (15%) trials included the World Health Organization scale for clinical improvement as a primary clinical outcome. Clinical improvement and mortality accounted for 45% of the unique domains among 18 clinical outcome domains of efficacy. Twenty‐four (47%) RCTs did not describe plans to assess safety outcomes; when assessed, safety outcomes were determined in generic terms of total, severe or serious adverse events.

Conclusion

The RCTs investigating HQ or chloroquine during the early stages of the COVID‐19 pandemic included heterogeneous and insufficient approaches to measure efficacy/effectiveness and safety relevant to patients and clinical practice. These findings provide insights to inform clinical and regulatory decisions that can be drawn about the efficacy/effectiveness and safety of these agents in patients with COVID‐19. Trialists need to adapt quickly to the research progress on COVID‐19, ensuring that core outcome measures are assessed in ongoing RCTs.

Survey-reported medication changes among older adults during the SARS-CoV-2 (COVID-19) pandemic

Background

Speculation on benefits and harms of prescription, over-the-counter and complementary medications has been widespread during the SARS-CoV-2 (or COVID-19) pandemic. This community-based survey assessed self-reported changes in medications including those stopped, started, or if access had been impacted.

Methods

A survey was collected via Research Electronic Data Capture (REDCap). The survey was advertised in the community through social media, email lists, websites, and post-cards. Survey responses were collected between 5/21/2020 and 6/24/2020. Variables included demographic characteristics such as age, sex, race, marital status, education, employment, income, and community type. Questions related to medication changes included: “Have you started any medication due to COVID-19?”, “Have you stopped any medication due to COVID-19?” and “Have you had issues getting your prescription medications?”. Respondents aged 50 years or older were included.

Results

There were N = 1397 responses of which 1169 were older adults ≥50 years-old. Of these, 1141 responded to the medication changes survey questions and 28 had missing responses and were excluded from the survey sample for this analysis. Among these, 31 (2.7%) reported a medication change included 5 (0.4%) reported stopping a medication, 18 (1.6%) reported starting a medication, and 8 (0.7%) reported trouble obtaining medications. Medications started included mostly vitamins or other supplements including zinc (n = 9), vitamin C (6), and other supplements (3). Among prescription medications, antidepressants and anti-anxiety medications (4) were reported as well as aspirin (1), losartan (1), and low dose naltrexone (1). One respondent reported unidentified homeopathy. There were no significant differences between those with medication changes and those with none.

Conclusions

In this community-based survey sample of over one thousand older adults, only a small percentage (2.7%; n = 31) reported any changes to medications during the pandemic. As essential workers during this crisis, pharmacists have played a critical role in providing medication information and continued access.

Cardiopulmonary resuscitation in prone position: A scoping review

INTRODUCTION

The ongoing pandemic of COVID-19 brought to the fore prone positioning as treatment for patients with acute respiratory failure. With the increasing number of patients in prone position, both spontaneously breathing and mechanically ventilated, cardiac arrest in this position is more likely to occur. This scoping review aimed to summarize the available evidence on cardiopulmonary resuscitation in prone position ('reverse CPR') and knowledge or research gaps to be further evaluated. The protocol of this scoping review was prospectively registered on 10th May 2020 in Open Science Framework (https://osf.io/nfuh9).

METHODS

We searched PubMed, EMBASE, MEDLINE and pre-print repositories (bioRxiv and medRxiv) for simulation, pre-clinical and clinical studies on reverse CPR until 31st May 2020.

RESULTS

We included 1 study on manikins, 31 case reports (29 during surgery requiring prone position) and 2 nonrandomized studies describing reverse CPR. No studies were found regarding reverse CPR in patients with COVID-19.

CONCLUSIONS

Even if the algorithms provided by the guidelines on basic and advanced life support remain valid in cardiac arrest in prone position, differences exist in the methods of performing CPR. There is no clear evidence of superiority in terms of effectiveness of reverse compared to supine CPR in patients with cardiac arrest occurring in prone position. The quality of evidence is low and knowledge gaps (e.g. protocols, training of healthcare personnel, devices for skill acquisition) should be fulfilled by further research. Meanwhile, a case-by-case evaluation of patient and setting characteristics should guide the decision on how to start CPR in such cases.

International Survey to Establish Prioritized Outcomes for Trials in People With Coronavirus Disease 2019

OBJECTIVES

There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials.

DESIGN

In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7-9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes.

CONCLUSIONS

Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.

Emergency Nursing Care of Patients With Novel Coronavirus Disease 2019

Novel coronavirus disease 2019 is the disease caused by the novel coronavirus originally from Wuhan, China. Its pathophysiology is poorly understood, but it is known to be contagious and deadly. Multiple symptoms and complications from the disease have been described, with the most common complaints being respiratory. Nursing care of patients with novel coronavirus disease 2019 is largely supportive, but it should include a strong focus on mitigating the spread of infection to staff, other patients, and the community.

Tocilizumab for treating severe COVID-19 pneumonia refractory to combined hydroxychloroquine, lopinavir plus ritonavir, and favipiravir: A case series

Three patients diagnosed with severe COVID‐19 pneumonia received treatment with hydroxychloroquine combined with lopinavir, ritonavir, and favipiravir. Two patients diagnosed early, received tocilizumab when the pneumonia became severe and survived. The thrid patient was diagnosed late and received tocilizumab when the disease progressed to acute respiratory distress syndrome, and died.

Traditional Herbal Medicine Candidates as Complementary Treatments for COVID-19: A Review of Their Mechanisms, Pros and Cons

Coronavirus disease 2019 (COVID-19) is a new infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that belongs to the coronavirus family. The first case was reported in December 2019, and the disease has become a pandemic. Impaired immune regulation is one of the factors that play a role in its pathogenesis and results in poor outcomes of COVID-19 patients. There have been many studies with drug candidates used as antivirals or immunomodulators. However, the results of these investigations showed that the drug candidates were not significantly effective against the disease. Meanwhile, people believe that consuming herbal immunomodulators can prevent or even cure COVID-19. Unfortunately, specific preclinical and clinical trials to evaluate the effects of herbal immunoregulators have not been conducted. Certain natural compounds might be effective for the treatment of COVID-19 based on general concepts from previous experiments. This review discusses some herbal agents extracted from various plants, including Echinacea, Cinchona, Curcuma longa, and Curcuma xanthorrhiza, which are considered for the treatment of COVID-19. In addition, we discuss the pros and cons of utilising herbal medicine during the COVID-19 pandemic, draw some conclusions, and make recommendations at the end of the session.

Chloroquine and hydroxychloroquine for combating COVID-19: Investigating efficacy and hypothesizing new formulations using Bio/chemoinformatics tools

Chloroquine (CQ) and hydroxychloroquine (HCQ) are undergoing several clinical trials for evaluating their efficacy and safety as antiviral drugs. Yet, there is still a great debate about their efficacy in combating COVID-19. This study aimed to evaluate the feasibility of intranasal and/or pulmonary administration of CQ/HCQ for COVID-19 using Bio/chemoinformatics tools. We, hereby, hypothesize the success of the intranasal and the pulmonary routes through a gelatin matrix to overcome several challenges related to CQ and HCQ pharmacodynamics and pharmacokinetics properties and to increase their local concentrations at the sites of initial viral entry while minimizing the potential side effects. Molecular docking on the gelatin-simulated matrix demonstrated high loading values and a sustained release profile. Moreover, the docking on mucin as well as various receptors including Angiotensin-converting enzyme 2 (ACE-2), heparin sulphate proteoglycan and Phosphatidylinositol binding clathrin assembly protein (PICALM), which are expressed in the lung and intranasal tissues and represent initial sites of attachment of the viral particles to the surface of respiratory cells, has shown good binding of CQ and HCQ to these receptors. The presented data provide an insight into the use of a novel drug formulation that needs to be tested in adequately powered randomized controlled clinical trials; aiming for a sustained prophylaxis effect and/or a treatment strategy against this pandemic viral infection.

Palestinian strategies, guidelines, and challenges in the treatment and management of coronavirus disease-2019 (COVID-19)

BACKGROUND

Coronavirus disease-2019 (COVID-19) outbreak is a global concern and the World Health Organization (WHO) has declared it as a Public Health Emergency of International Concern. The Palestinian Authority (PA) has quickly and effectively responded to the outbreak of COVID-19, using an internationally and nationally coordinated, to contain the spread of the virus within the borders. The PA approaches are containment and suppression, which is designed to protect the citizens from infection while also mitigating the stress on the health care system. The PA immediately declared a State of Emergency when the first cases in Palestine were diagnosed on 5 March 2020 and launched robust national containment measures to encourage the citizens to protect themselves and follow the guidance.

OBJECTIVES

There is currently no vaccine or effective treatment for COVID-19, the treatment is either supportive and/ or the treatment of symptoms. Several strategies in the treatment of the disease were applied including medications. This review aims to summarize the different strategies, guidelines, challenges, and treatments used against COVID-19 worldwide and in Palestine.

MATERIALS AND METHODS

Different literature and guidelines among different databases were searched. Literature reviewing was conducted using the following search engines, Google Scholar, Medline, Pub Med, EMBASE, Web of Science, and Science Direct. Data also obtained from WHO and PA reports, and the published peer-reviewed articles of 2019-nCoV. The review focuses on the strategies, guidelines, therapeutics, challenges, and different approaches used in the treatment and management of the disease in Palestine and globally.

CONCLUSION

The Palestinian Ministry of Health (MoH) strategies to end the COVID-19 pandemic were; slow and stop transmission; provide optimized care for patients; and minimize the impact of the epidemic on health systems, social services, and economic activity. Thus, proper management, right actions, and effective treatment of the disease should be considered to achieve these strategies. The biggest problem for PA to control and stop the outbreak of the disease is the different challenges which include; the Israeli military and economic control, uncontrol the borders, shortage of medical and financial resources, crowded cities and refugee camps, poverty, food insecurity, and the financial crisis. To date, there are no specific vaccines or medicines for COVID-19; and treatments are under investigation through clinical trials. However, an array of drugs approved for other indications, as well as multiple investigational agents, are being studied for the treatment of COVID-19; in several hundred clinical trials around the World. Treatment is essentially supportive and symptomatic.

Can phytotherapy with polyphenols serve as a powerful approach for the prevention and therapy tool of novel coronavirus disease 2019 (COVID-19)?

Much more serious than the previous severe acute respiratory syndrome (SARS) coronavirus (CoV) outbreaks, the novel SARS-CoV-2 infection has spread speedily, affecting 213 countries and causing ∼17,300,000 cases and ∼672,000 (∼+1,500/day) deaths globally (as of July 31, 2020). The potentially fatal coronavirus disease (COVID-19), caused by air droplets and airborne as the main transmission modes, clearly induces a spectrum of respiratory clinical manifestations, but it also affects the immune, gastrointestinal, hematological, nervous, and renal systems. The dramatic scale of disorders and complications arises from the inadequacy of current treatments and absence of a vaccine and specific anti-COVID-19 drugs to suppress viral replication, inflammation, and additional pathogenic conditions. This highlights the importance of understanding the SARS-CoV-2 mechanisms of actions and the urgent need of prospecting for new or alternative treatment options. The main objective of the present review is to discuss the challenging issue relative to the clinical utility of plants-derived polyphenols in fighting viral infections. Not only is the strong capacity of polyphenols highlighted in magnifying health benefits, but the underlying mechanisms are also stressed. Finally, emphasis is placed on the potential ability of polyphenols to combat SARS-CoV-2 infection via the regulation of its molecular targets of human cellular binding and replication, as well as through the resulting host inflammation, oxidative stress, and signaling pathways.