A multi-center, adaptive, randomized, platform trial to evaluate the effect of repurposed medicines in outpatients with early coronavirus disease 2019 (COVID-19) and high-risk for complications: the TOGETHER master trial protocol

Background: There remains a need for an effective and affordable outpatient treatment for early COVID-19. Multiple repurposed drugs have shown promise in treating COVID-19. We describe a master protocol that will assess the efficacy of different repurposed drugs as treatments for early COVID-19 among outpatients at a high risk for severe complications. Methods: The TOGETHER Trial is a multi-center platform adaptive randomized, placebo-controlled, clinical trial. Patients are included if they are at least 18 years of age, have a positive antigen test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and have an indication for high risk of disease severity, including co-morbidities, older age, or high body mass index. Eligible patients are randomized with equal chance to an investigational product (IP) or to placebo.The primary endpoint is hospitalization defined as either retention in a COVID-19 emergency setting for greater than 6 hours or transfer to tertiary hospital due to COVID-19. Secondary outcomes include mortality, adverse events, adherence, and viral clearance. Scheduled interim analyses are conducted and reviewed by the Data and Safety Monitoring Committee (DSMC), who make recommendations on continuing or stopping each IP. The platform adaptive design go-no-go decision rules are extended to dynamically incorporate external evidence on COVID-19 interventions from ongoing independent randomized clinical trials. Discussion: Results from this trial will assist in the identification of therapeutics for the treatment of early diagnosed COVID-19. The novel methodological extension of the platform adaptive design to dynamically incorporate external evidence is one of the first of its kind and may provide highly valuable information for all COVID-19 trials going forward. Clinicaltrials.gov registration: NCT04727424 (27/01/2021)

Effect of early treatment with fluvoxamine on risk of emergency care and hospitalisation among patients with COVID-19: the TOGETHER randomised, platform clinical trial

Background

Recent evidence indicates a potential therapeutic role of fluvoxamine for COVID-19. In the TOGETHER trial for acutely symptomatic patients with COVID-19, we aimed to assess the efficacy of fluvoxamine versus placebo in preventing hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to a tertiary hospital due to COVID-19.

Methods

This placebo-controlled, randomised, adaptive platform trial done among high-risk symptomatic Brazilian adults confirmed positive for SARS-CoV-2 included eligible patients from 11 clinical sites in Brazil with a known risk factor for progression to severe disease. Patients were randomly assigned (1:1) to either fluvoxamine (100 mg twice daily for 10 days) or placebo (or other treatment groups not reported here). The trial team, site staff, and patients were masked to treatment allocation. Our primary outcome was a composite endpoint of hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to tertiary hospital due to COVID-19 up to 28 days post-random assignment on the basis of intention to treat. Modified intention to treat explored patients receiving at least 24 h of treatment before a primary outcome event and per-protocol analysis explored patients with a high level adherence (>80%). We used a Bayesian analytic framework to establish the effects along with probability of success of intervention compared with placebo. The trial is registered at ClinicalTrials.gov (NCT04727424) and is ongoing.

Findings

The study team screened 9803 potential participants for this trial. The trial was initiated on June 2, 2020, with the current protocol reporting randomisation to fluvoxamine from Jan 20 to Aug 5, 2021, when the trial arms were stopped for superiority. 741 patients were allocated to fluvoxamine and 756 to placebo. The average age of participants was 50 years (range 18–102 years); 58% were female. The proportion of patients observed in a COVID-19 emergency setting for more than 6 h or transferred to a teritary hospital due to COVID-19 was lower for the fluvoxamine group compared with placebo (79 [11%] of 741 vs 119 [16%] of 756); relative risk [RR] 0·68; 95% Bayesian credible interval [95% BCI]: 0·52–0·88), with a probability of superiority of 99·8% surpassing the prespecified superiority threshold of 97·6% (risk difference 5·0%). Of the composite primary outcome events, 87% were hospitalisations. Findings for the primary outcome were similar for the modified intention-to-treat analysis (RR 0·69, 95% BCI 0·53–0·90) and larger in the per-protocol analysis (RR 0·34, 95% BCI, 0·21–0·54). There were 17 deaths in the fluvoxamine group and 25 deaths in the placebo group in the primary intention-to-treat analysis (odds ratio [OR] 0·68, 95% CI: 0·36–1·27). There was one death in the fluvoxamine group and 12 in the placebo group for the per-protocol population (OR 0·09; 95% CI 0·01–0·47). We found no significant differences in number of treatment emergent adverse events among patients in the fluvoxamine and placebo groups.

Interpretation

Treatment with fluvoxamine (100 mg twice daily for 10 days) among high-risk outpatients with early diagnosed COVID-19 reduced the need for hospitalisation defined as retention in a COVID-19 emergency setting or transfer to a tertiary hospital.

Funding

FastGrants and The Rainwater Charitable Foundation.

Translation

For the Portuguese translation of the abstract see Supplementary Materials section.

A multi-center, adaptive, randomized, platform trial to evaluate the effect of repurposed medicines in outpatients with early coronavirus disease 2019 (COVID-19) and high-risk for complications: the TOGETHER master trial protocol

Background: Although vaccines are currently available for coronavirus disease 2019 (COVID-19), there remains a need for an effective and affordable outpatient treatment for early COVID-19. Multiple repurposed drugs have shown promise in treating COVID-19. We describe a master protocol that will assess the efficacy of different repurposed drugs as treatments for early COVID-19 among outpatients at a high risk for severe complications. Methods: The TOGETHER Trial is an international (currently in Brazil and Africa), multi-center platform adaptive randomized, placebo-controlled, clinical trial. Patients are included if they are at least 18 years of age, have a positive antigen test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and have an indication for high risk of disease severity, including co-morbidities, older age, or high body mass index. Eligible patients are randomized with equal chance to an investigational product (IP) or to placebo. The primary endpoint is hospitalization due to clinical worsening of COVID-19 or emergency room required observation for more than 6 hours up to 28 days after randomization. Key secondary endpoints include viral clearance, clinical improvement, hospitalization for any cause, mortality for any cause, and safety and tolerability of each IP. Scheduled interim analyses are conducted and reviewed by the Data and Safety Monitoring Committee (DSMC), who make recommendations on continuing or stopping each IP. The platform adaptive design go-no-go decision rules are extended to dynamically incorporate external evidence on COVID-19 interventions from ongoing independent randomized clinical trials. Discussion: Results from this trial will assist in the identification of therapeutics for COVID-19 that can easily be scaled in low- and middle-income settings. The novel methodological extension of the platform adaptive design to dynamically incorporate external evidence is one of the first of its kind and may provide highly valuable information for all COVID-19 trials going forward. Clinicaltrials.gov registration: NCT04727424 (27/01/2021)

[A critical incident during marathon competition as a result of metabolic decompensation]

A case of polyorganic insufficiency syndrome associated with coma, convulsive disorder, acute hepato-renal and respiratory dysfunction, hypovolemic shock, and hyperthermal syndrome in a 46 year-old participant ofa marathon competition is reported. The clinical picture was dominated by acute hepatic insufficiency treated with remaxol to activate substrate phosphorylation under effect of exogenous succinate for slowing down the development of energy deficit in mitochondria under condition of oxygen deficit. This case can be regarded as a variant of correction of mitochondrial dysfunction with the use of a mitochondria-targeted medication such as succinate-containing remaxol. This medication reduced AST and ALT activities and utilization of endogenous enzymes for succinate synthesis from alanine and aspartate under hypoxic conditions. Prescription of remaxol as a form of direct substitution therapy was dictated by pathogenetic considerations.

[Correction of endotoxemia in patients with pancreatic necrosis]

AIM

To study the results of deferoxamine (Deferal) administration in intensive therapy program of 63 patients with severe acute pancreatitis to decrease effect of oxidative stress and endotoxemia.

MATERIAL AND METHODS

In deferoxamine group (31 patients) there were decrease of serum iron's level and inhibition of free radical oxidation that led to early relief of endotoxemia, reducing periods of organs' dysfunction. It was not observed in comparison group (32 patients).

RESULTS

Deferoxamine decrease risk of pancreatic necrosis and pancreatogenic sepsis. It allows reducing ICU- and hospital-stay and number of extended surgical procedures.

[Problem of intraoperative hemotransfusion]

MATERIALS AND METHODS

We studied 66 patients (males aged 39.5 +/- 5.3) with hemorrhagic shock II. Gas composition of arterial and venous blood and a detailed analysis of the blood were studied twice (before and after hemotransfusion).

RESULTS

We found that a low-volume (up to 2 doses) transfusion of erythrocyte mass with terms of storage up to 3 days, held after bleeding stop and hypovolemia correction, is the most effective treatment for hemorrhagic shock II.

CONCLUSIONS

Substitution therapy in operating room does not contribute oxygen transfering in tissues and inhibits stimulation of the bone marrow due to hypoxia. Thus the substitution therapy is an aggravating factor when the bleeding stopped, but hypovolemia not eliminated.

Biological characteristics of influenza A(H1N1)pdm09 virus circulating in West Siberia during pandemic and post-pandemic periods

We studied biological characteristics of influenza A(H1N1)pdm09 virus circulating in Siberia during the 2009 pandemic and the post-pandemic period of 2011. BALB/c mice were chosen as the experimental model. Virus titers in the lungs were evaluated on days 1, 3, 6 and blood serum titers on day 15 after infection with different strains. Blood sera of convalescents after influenza of 2010-2011 epidemic season were analyzed. Influenza A(H1N1)pdm09 virus strains isolated during the post-pandemic period of 2011 were characterized by low epidemic activity and virulence in comparison with the strains isolated during 2009 pandemic period, which indicates completion of the pandemic cycle.

[Efficiency of succinic acid infusion solutions in minor surgery]

A group of 66 patients with purulent-septic surgical pathology on the background of type 2 diabetes mellitus (in the compensation phase) and atherosclerosis of vessels in lower extremities (in the decompensation phase) have been studied. The status of all patients has been determined by the syndrome of systemic inflammation reaction (rated 12.4 +/- 2.2 on the APACHE II scale). Group I (n = 30) included 19 men aged 53.7 +/-7.7 and 11 women aged 54.4 +/- 9.1, which were administered reamberin (single daily dose of 500 ml for three days after operation). Group II (n = 36) included 24 men aged 56.1 +/- 9.2 and 12 women aged 51.9 +/- 8.8 with analogous pathology and general status, which received infusion therapy without reamberin. It is established that the administration of reamberin in patients with purulent-septic surgical pathology on the background of type 2 diabetes mellitus and atherosclerosis of vessels in lower extremities is patho-. genetically justified and allows the reperfusion syndrome upon various operations to be prevented and the critical state in post-operation regime to be eliminated.

[Opportunities of correction of rheological properties of blood in intensive therapy in patients with peritonitis and acute bowel obstruction]

An analysis of efficacy of 1.5% reamberin solution usage was made in 80 patients for correction of blood rheological properties disorder in the case of peritonitis and bowel obstruction. It was established, that reamberin, which was administered in the dose of 500 ml after 12 hours of the beginning of intensive care during 48 hours, efficiently corrected the rheological disorders. It was because the erythron and reticulocyte production were activated, the hyposmolarity was removed, the intensity of free radical oxidation and peroxide oxidation of lipids was decreased and the antioxidant status was restored. This facilitated the hydrophily and erythrocyte volume decrease, the haemolysis reduction and qualitative gas exchange at the level of tissues.

[Biological properties of velogenic strains of the Newcastle disease virus isolated in the Northern Caucasian region]

The results of the biological property investigation of two Newcastle virus strains isolated in Northern Caucasian region--NDV/Adigeya/duck/8/2008 and NDV/Adigeya/duck/15/2008--were presented. The phylogenetic analysis revealed that these strains belonged to genotype 7 of clade 2. Using molecular-biological analysis of established nucleotide sequences including proteolytic site of fusion peptide it was demonstrated that the strains were velogenic. This conclusion was proved by testing the pathogenicity on the model of intracerebral infected chickens (ICPI--IntraCerebral Pathogenic Index--was found to be 2). Pathomorphological study of dead chickens made it possible to classify strains as neurotropic with low level of visceral tropism.

[Respiratory support using multi-level lung ventilation in patients in critical state with systemic inflammatory response syndrome]

PURPOSE

To prove the effectiveness of the method and improve lung gas exchange in patients with non-homogenous lung tissue damage with multi-level (3-level, MLV) ventilation.

MATERIALS AND METHODS

Artificial lung ventilation (ALV) with MLV carried out in 13 patients with severe lung tissue damage (polytrauma, pneumonia and ARDS) treated at the unit of resuscitation and intensive care (for septic patients) SCH No 1 of Omsk since May 2011. The initial values of pO2 and oxygenation index were significantly reduced, the fraction of the intrapulmonary shunting - essentially increased. During the first day after the beginning of respiratory support with the use of MLV, was registered pO2, SaO2 and oxygenation index growth, there was a positive x-ray dynamics of improved lung tissue biomechanics. As a result of the ALV with MLV in 11 patients had achieved steady improvements of arterial oxygenation. The use of respiratory support with MLV in patients with severe lung damage leads to a significant improvement of the alveolar ventilation and arterial oxygenation, and to reduce the intrapulmonary shunting level. The use of this type of ventilation system versus traditional methods of respiratory therapy leads to respiratory failure solution, in reduce of duration of ALV terms and stay in the intensive care unit.

[Effective use of third generation fat emulsion in total parenteral nutrition program in patients with severe sepsis]

The aim of the current research was to measure the clinical efficacy of 3rd generation fat emulsion in the program of complete parenteral nutrition of patients with severe sepsis. The work demonstrates the results of treatment of 25 patients with severe sepsis divided into 2 groups depending on the way of parenteral nutrition. In the 1st group (13 patients) the parenteral nutrition was carried out by 20% glucose, 15% solution of crystallic aminoacids and 20% of 2nd generation fat emulsion. In the 2nd group (12 patients) parenteral nutrition was carried out by 20% glucose, 15% solution of crystallic aminoacids and 20% of 3rd generation fat emulsion. The parenteral nutrition of Ist and 2nd group contributed to the correction of hypermetabolism syndrome and stabilization of the nutritive status parameters. It was observed that the parenteral nutrition used in the 2nd group showed statistically higher positive effect on the parameters of systemic inflammation and cellular part of immunity, rather than parenteral nutrition used in the 1st group. It is revealed that, the used methods of complete parenteral nutrition in patients with severe sepsis effectively eliminate the hypermetabolism syndrome. Parenteral nutrition of patients with severe sepsis by 3rd generation fat emulsion has a positive effect of parapeters of systemic inflammation.

Accurate assessment and identification of naturally occurring cellular cobalamins

BACKGROUND

Accurate assessment of cobalamin profiles in human serum, cells, and tissues may have clinical diagnostic value. However, non-alkyl forms of cobalamin undergo beta-axial ligand exchange reactions during extraction, which leads to inaccurate profiles having little or no diagnostic value.

METHODS

Experiments were designed to: 1) assess beta-axial ligand exchange chemistry during the extraction and isolation of cobalamins from cultured bovine aortic endothelial cells, human foreskin fibroblasts, and human hepatoma HepG2 cells, and 2) to establish extraction conditions that would provide a more accurate assessment of endogenous forms containing both exchangeable and non-exchangeable beta-axial ligands.

RESULTS

The cobalamin profile of cells grown in the presence of [ 57Co]-cyanocobalamin as a source of vitamin B12 shows that the following derivatives are present: [ 57Co]-aquacobalamin, [ 57Co]-glutathionylcobalamin, [ 57Co]-sulfitocobalamin, [ 57Co]-cyanocobalamin, [ 57Co]-adenosylcobalamin, [ 57Co]-methylcobalamin, as well as other yet unidentified corrinoids. When the extraction is performed in the presence of excess cold aquacobalaminacting as a scavenger cobalamin (i.e. "cold trapping"), the recovery of both [ 57Co]-glutathionylcobalamin and [ 57Co]-sulfitocobalamin decreases to low but consistent levels. In contrasts, the [ 57Co]-nitrocobalamin observed in the extracts prepared without excess aquacobalamin is undetected in extracts prepared with cold trapping.

CONCLUSION

This demonstrates that beta-ligand exchange occur with non-covalently bound beta-ligands. The exception to this observation is cyanocobalamin with a non-exchangeable CN- group. It is now possible to obtain accurate profiles of cellular cobalamin.

[Evaluation of the efficiency of balanced and unbalanced crystalloid solutions used in the program of infusion therapy in patients with blood loss]

The authors present a comparative assessment of the efficiency of balanced and unbalanced crystalloid solutions used in the program of infusion therapy in patients with blood loss. It was found that infusion therapy with unbalanced crystalloid solution facilitated the appearance of electrolytic changes and decrease of pH of venous blood while infusion therapy with balanced crystalloid solution did not cause negative changes of the water-electrolytic and acid-base balance.

[Clinical significance of the parameters of a systemic inflammatory response, leukocytic intoxication index, and procalcitonin test in the diagnosis of pyodestructive pyelonephritis of pregnant women]

The clinical significance of the parameters of a systemic inflammatory response, leukocytic intoxication index, and procalcitonin test were studied in 63 patients with pyodestructive pyelonephritis of pregnant women. The blood concentration of procalcitonin was measured in 15 patients, by using the semiquantitative analysis. The authors revealed the high sensitivity and specificity of the method and the high prognostic value of positive results and the low frequency of false-positive results for procalcitonin and the leukocytic index of intoxication.

Nanoparticle doped organic-inorganic hybrid photorefractives

The gain characteristics of liquid crystal photorefractive cells doped with ferroelectric nanoparticles has been measured. The liquid crystal two beam coupling gain is found to reverse in sign and increase in magnitude through the addition of ferroelectric BaTiO(3) nanoparticles, yielding gain coefficients up to 1100 cm(-3) in the Bragg regime. We attribute the novel effects of gain reversal and magnitude increase to interactions between the ferroelectric particles' spontaneous polarization and the local liquid crystal flexopolarization.

Molecular targeting of proteins by L-homocysteine: mechanistic implications for vascular disease

Hyperhomocysteinemia is an independent risk factor for cardiovascular disease, complications of pregnancy, cognitive impairment, and osteoporosis. That elevated homocysteine leads to vascular dysfunction may be the linking factor between these apparently unrelated pathologies. Although a growing body of evidence suggests that homocysteine plays a causal role in atherogenesis, specific mechanisms to explain the underlying pathogenesis have remained elusive. This review focuses on chemistry unique to the homocysteine molecule to explain its inherent cytotoxicity. Thus, the high pKa of the sulfhydryl group (pKa, 10.0) of homocysteine underlies its ability to form stable disulfide bonds with protein cysteine residues, and in the process, alters or impairs the function of the protein. Studies in this laboratory have identified albumin, fibronectin, transthyretin, and metallothionein as targets for homocysteinylation. In the case of albumin, the mechanism of targeting has been elucidated. Homocysteinylation of the cysteine residues of fibronectin impairs its ability to bind to fibrin. Homocysteinylation of the cysteine residues of metallothionein disrupts zinc binding by the protein and abrogates inherent superoxide dismutase activity. Thus, S-homocysteinylation of protein cysteine residues may explain mechanistically the cytotoxicity of elevated L-homocysteine.

[Life quality in patients after endoscopic microdiskectomy for intervertebral hernia of the lumbar spine]

A group of 38 patients with hernia of the lumbar intravertebral disks who had undergone endoscopic microdiskectomy by DESTANDO was evaluated for life quality and compared with the control group (the patients had been operated on by the routine procedure and healthy individuals). The incidence of the postdiskectomic syndrome was studied in the compared groups of patients. It was shown that life quality in patients with lumbar pains could be evaluated, by using the general health status questionnaire and the specific lumbar pain questionnaire MiGAN. The life quality during the follow-up was considerably higher than that after endoscopic microdiskectomy, in males in particular. The use of endoscopic microdiskectomy reduced the incidence of the postdiskectomic syndrome by more than twice.

[Diastolic malfunction in sepsis and septic shock]

The onset and development of cardiac insufficiency is associated with diverse pathophysiological mechanisms with attention being focused recently on studying the significance of "proinflammatory" cytokines, primarily, of TNFalpha. Fifty-nines patients (age--18-24, body weight--54-76) with sepsis (19 persons, group 1), severe sepsis (20 persons, group 2) and with septic shock (20 persons, group 3) were examined. The mechanic function of the left cardiac ventricle and hemodynamic parameters were evaluated by a routine scheme in the modes of 1D (M-echo-cardiography) and sector scanning (2D echo-cardiography) at the SIM-5000 device (Italy). The central hemodynamic indices were investigated by integral tetrapolar rheography according to Tishchenko. The results denote a big significance of diastolic malfunction of the left cardiac ventricle or "rigid" myocardium in shaping of myocardial malfunction as observed in sepsis and septic shock.