Cold Plasma Therapy in Chronic Wounds-A Multicenter, Randomized Controlled Clinical Trial (Plasma on Chronic Wounds for Epidermal Regeneration Study): Preliminary Results

Chronic wounds (CWs) pose a significant health challenge in clinical practice. Standard wound therapy (SWT) is currently considered the gold standard. However, recent evidence suggests that cold plasma therapy (CPT) holds promise for improving CWs. In light of this, the POWER study was conducted as a multicenter, randomized clinical trial to investigate the effect of large-area plasma application compared with SWT in patients with chronic, non-healing arterial or venous wounds on the lower leg. To analyze the interim results, we employed a comprehensive range of statistical tests, including both parametric and non-parametric methods, as well as GLS model regression and an ordinal mixed model. Our findings clearly demonstrate that CPT therapy significantly accelerates wound closure compared with SWT. In fact, complete wound closure was exclusively observed in the CPT group during the intervention period. Additionally, the CPT group required significantly less antibiotic therapy (4%) compared with the SWT group (23%). Furthermore, CPT led to a significant reduction in wound pain and improved quality of life compared with SWT. In conclusion, the study highlights that the combination of CPT and SWT surpasses monotherapy with SWT alone.

Clinical features and management of atypical hemolytic uremic syndrome patient with DGKE gene variants: a case report

Background

Atypical hemolytic uremic syndrome (aHUS) with diacylglycerol kinase epsilon (DGKE) gene variant is a rare variant of thrombotic microangiopathy (TMA). The information on the clinical features, management and long-term outcomes of DGKE-aHUS patients have not yet been fully elucidated. The aim of this study was to report a novel variant of the DGKE gene in a Chinese population with aHUS.

Case presentation

The present work reports a 7-month-old boy with aHUS, possibly triggered by gastrointestinal infection, without complement activation, with little response to plasma therapy and nephroprotective measures. The patient died during the 8th week of his hospital stay. The causes of death were intracranial hemorrhage and multiorgan dysfunction. Comprehensive WES of peripheral blood-derived DNA revealed two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4-6.

Conclusions

This case suggest that atypical HUS with DGKE gene variant has a poor prognosis with a high mortality rate, which typically manifests in the first year of life and presents as a systemic disease with early-onset HUS with rapidly worsening renal function and chronic proteinuria. There is no specific treatment for DGKE-aHUS. There have an uncertain benefit of plasma therapy for DGKE-aHUS patients. The literature demonstrated that anti-complement therapy showed benefits for DGKE-aHUS with complement activation and autoantibodies during the overt TMA presentation but did not prevent TMA relapses. Early diagnosis and treatment may prevent complications and improve prognosis.

Adjuvant composite cold atmospheric plasma therapy increases antitumoral effect of doxorubicin hydrochloride

Introduction

Cancer is a global health concern, with a significant impact on mortality rates. Despite advancements in targeted antitumor drugs, the development of new therapies remains challenging due to high costs and tumor resistance. The exploration of novel treatment approaches, such as combined chemotherapy, holds promise for improving the effectiveness of existing antitumor agents. Cold atmospheric plasma has demonstrated antineoplastic effects in preclinical studies, but its potential in combination with specific ions for lymphosarcoma treatment has not been investigated.

Methods

An in vivo study was conducted using a Pliss lymphosarcoma rat model to evaluate the antitumor effects of composite cold plasma and controlled ionic therapy. Groups of rats were exposed to composite cold plasma for 3, 7, and 14 days, while the control group received no treatment. Additionally, a combination of chemotherapy with cold plasma therapy was assessed, with doxorubicin hydrochloride administered at a dosage of 5 mg/kg. PERENIO IONIC SHIELD™ emitted a controlled ionic formula during the treatment period.

Results

The in vivo study demonstrated tumor growth inhibition in groups exposed to composite cold plasma for 3, 7, and 14 days compared to the control group. Furthermore, combining chemotherapy with cold plasma therapy resulted in a threefold reduction in tumor volume. The most significant antitumor effects were observed when doxorubicin hydrochloride at a dosage of 5 mg/kg was combined with 14 days of PERENIO IONIC SHIELD™ ionic therapy.

Discussion

The use of composite cold plasma therapy, in conjunction with a controlled ionic formula emitted by PERENIO IONIC SHIELD™, in the complex treatment of lymphosarcoma in rats showed promising antitumor effects. The combination therapy, particularly when combined with doxorubicin hydrochloride, demonstrated enhanced efficacy. These findings suggest the potential for utilizing cold atmospheric plasma and controlled ions as an adjunctive treatment approach in lymphosarcoma therapy. Further research is warranted to explore the mechanisms underlying these effects and to evaluate the safety and efficacy in human clinical trials.

Delayed Hematological Remission Predicts Poor Renal Outcome in Children with Atypical Hemolytic Uremic Syndrome

Background

Atypical hemolytic uremic syndrome (aHUS) is hemolytic uremic syndrome (HUS) without a coexisting disease or specific infection. Eculizumab is the standard of care for children with aHUS. However, since it is not yet available in India, plasma therapy remains the treatment of choice in these patients. We studied the clinical profile of children with aHUS and the determinants associated with low estimated glomerular filtration rate (eGFR) on follow-up.

Materials and Methods

A retrospective chart review of children (1-18 years) with aHUS managed at a tertiary care center was done. Demographic details, clinical features, and investigations at presentation and on subsequent visits were noted. Details of treatment and duration of hospital stay were recorded.

Results

Of 26 children, boys outnumbered girls (2:1). The mean age at presentation was 80 ± 37.6 months. All children were hypertensive during the early phase of illness. Anti-factor H antibodies were elevated in 84% (22/26). Plasma therapy was initiated for 25 patients, and in 17 children, additionally immunosuppression was given. The median duration to achieve hematological remission was 17 days. As compared to children with normal eGFR, those with CKD stage 2 or more had significant delay in initiation of plasma therapy (4 vs. 14 days) and also took a longer time to achieve hematological remission (15 vs. 28 days). The prevalence of hypertension and proteinuria at the last follow-up was 63% and 27%, respectively.

Conclusion

Delayed initiation of plasma therapy and longer time to achieve hematological remission are associated with lower eGFR on follow-up. Long-term monitoring of hypertension and proteinuria is needed in these children.

Recent developments on Junin virus, a causative agent for Argentine haemorrhagic fever

Junin virus consists of ribonucleic acid as the genome and is responsible for a rapidly changing tendency of the virus. The virus is accountable for ailments in the human body and causes Argentine Haemorrhagic Fever (AHF). The infection is may be transmitted through contact between an infected animal/host and a person, and later between person to person. Prevention of outbreaks of AHF in humans can be a tough practice, as their occurrence is infrequent and unpredictable. In this review, recent information from the past 5 years available on the Junin virus including the risk of its emergence, infectious agents, its pathogenesis in humans, available diagnostic and therapeutic approaches, and disease management has been summarised. Altogether, this article would be highly significant in understanding the mechanistic basis behind virus interaction and other processes during the life cycle. Currently, no specific therapeutic options are available to treat the Junin virus infection. The information covered in this review could be important for finding possible treatment options for Junin virus infections.

Cold Plasma Treatment Promotes Full-thickness Healing of Skin Wounds in Murine Models

Cold plasma can be beneficial for promoting skin wound healing and has a high potential of being effectively used in treating various wounds. Our aim was to verify the effect of cold plasma in accelerating wound healing and investigate its underlying mechanism in vitro and in vivo. For the in vivo experiments, 2 full-thickness dermal wounds were created in each mouse (n = 30). While one wound was exposed to 2 daily plasma treatments for 3 min, the other wound served as a control. The wounds were evaluated by imaging and histological analyses at 4, 7, and 11 days post the wound infliction process. Immunohistochemical studies were also performed at the same time points. In vitro proliferation and scratch assay using HaCaT keratinocytes and fibroblasts were performed. The expression levels of wound healing-related genes were analyzed by real-time polymerase chain reaction and western blot analysis. On day 7, the wound healing rates were 53.94% and 63.58% for the control group and the plasma-treated group, respectively. On day 11, these rates were 76.05% and 93.44% for the control and plasma-treated groups, respectively, and the difference between them was significant (P = .039). Histological analysis demonstrated that plasma treatment promotes the formation of epidermal keratin and granular layers. Immunohistochemical studies also revealed that collagen 1, collagen 3, and alpha-smooth muscle actin appeared more abundantly in the plasma-treated group than in the control group. In vitro, the proliferation of keratinocytes was promoted by plasma exposure. Scratch assay showed that fibroblast exposure to plasma increased their migration. The expression levels of collagen 1, collagen 3, and alpha-smooth muscle actin were elevated upon plasma treatment. In conclusion, cold plasma can accelerate skin wound healing and is well tolerated.

Composition of Platelet-Rich Plasma Prepared From Knee Osteoarthritic Patients: Platelets, Leukocytes, and Subtypes of Leukocyte

INTRODUCTION

Platelet-rich plasma (PRP) has gained increasing popularity in the orthopedic field. There has been still no consensus on PRP preparation technique, thus providing a variety of final PRP products. Different preparation techniques lead to different compositions of PRP, which include platelet concentration, the number of leukocytes, and their subtypes. Here, we studied those compositions of PRP compared to whole blood samples.

METHODS

There were 335 participants who met the inclusion and exclusion criteria. Each participant underwent a blood drawing process to prepare PRP for their knee osteoarthritis treatment. We categorized baseline platelet concentration in whole blood samples into three groups: less than 2 x 10⁵/µL (Group 1), between 2 x 10⁵/µL and 2.99 x 10⁵/µL (Group 2), and greater than 2.99 x 10⁵/µL (Group 3). The primary outcome was reported as the platelet concentration in PRP and the ratio of platelet concentration in PRP compared to baseline whole blood samples. The secondary outcome was reported as the ratios of leukocyte, lymphocyte, and neutrophil in PRP compared to the baseline whole blood samples.

RESULTS

The average platelet concentration in PRP was 1.26 x 10⁶/µL (6.3 times higher compared to baseline whole blood samples). The mean platelet concentration of PRP in Group 1, Group 2, and Group 3 was 1.08 x 10⁶/µL, 1.38 x 10⁶/µL, and 1.71 x 10⁶/µL, respectively (p-value = 0.0001). The platelet concentration ratio of PRP condition to the baseline whole blood was 6.9, 5.8, and 4.2 in Group 1, Group 2, and Group 3, respectively (p-value = 0.0018). The average ratio of leukocytes in PRP to whole blood was 1.5. The average ratio of lymphocytes and neutrophils in PRP to whole blood was 2.0 and 0.5, respectively.  Conclusion: Different baseline platelet concentrations in whole blood samples provided significantly different platelet concentrations in PRP. The baseline platelet concentration in whole blood also provided an inverse relation to the fold change of the platelet concentration in PRP. Subtypes of leukocytes changed from neutrophil-predominated in the baseline whole blood samples to lymphocyte-predominated in PRP.

Danger signals in traumatic hemorrhagic shock and new lines for clinical applications

Hemorrhage is the leading cause of death in severe trauma injuries. When organs or tissues are subjected to prolonged hypoxia, danger signals-known as damage-associated molecular patterns (DAMPs)-are released into the intercellular environment. The endothelium is both the target and a major provider of damage-associated molecular patterns, which are directly involved in immuno-inflammatory dysregulation and the associated tissue suffering. Although damage-associated molecular patterns release begins very early after trauma, this release and its consequences continue beyond the initial treatment. Here we review a few examples of damage-associated molecular patterns to illustrate their pathophysiological roles, with emphasis on emerging therapeutic interventions in the context of severe trauma. Therapeutic intervention administered at precise points during damage-associated molecular patterns release may have beneficial effects by calming the inflammatory storm triggered by traumatic hemorrhagic shock.

Monoclonal Gammopathy of Renal Significance and Thrombotic Microangiopathy: A Case Report

Monoclonal gammopathy of renal significance (MGRS) is a group of pathologies that includes all kidney disorders related to a monoclonal protein in patients without diagnostic criteria for B-cell malignancies. There are multiple MGRS-associated kidney disorders, and more are still being discovered, which makes this diagnosis challenging. The relationship between monoclonal gammopathies and thrombotic microangiopathy (TMA) is of growing interest in literature. This article describes the case of a patient with newly diagnosed MGRS, presenting with rapidly progressing kidney failure and with histologic characteristics of TMA. The patient progressed to end-stage renal disease (ESRD) despite treatment with plasmapheresis and clone-directed therapy, as is currently advised in the literature. Although rare, the association between these two entities should not be unnoticed because of patients' renal and vital prognosis.

Current therapeutic strategies and possible effective drug delivery strategies against COVID-19

COVID-19 pandemic is the biggest global crisis. The frequent mutations in coronavirus to generate new mutants is of major concern. The pathophysiology of SARS-CoV-2 infection has been well studied to find out suitable molecular targets and candidate drugs for effective treatment. FDA-recommended etiotropic therapies are currently followed along with mass vaccination. The drug delivery system and the route of administration have a great role to enhance the efficacy of therapeutic agents and vaccines. Since COVID-19 primarily infects the lungs in the affected individuals, pulmonary administration may be the best possible route for the treatment of COVID-19. Liposomes, solid lipid nanoparticles, polymeric nanoparticles, porous microsphere, dendrimers, and nanoparticles encapsulated microparticles are the most suitable drug delivery systems for targeted drug delivery. The solubility, permeability, chemical stability, and biodegradability of drug molecules are the key factors for the right selection of suitable nanocarriers. The application of nanotechnology has been instrumental in the successful development of mRNA, DNA and subunit vaccines, as well as the delivery of COVID-19 therapeutic agents.

A Multi-Center, Open-Label, Randomized Controlled Trial to Evaluate the Efficacy of Convalescent Plasma Therapy for Coronavirus Disease 2019: A Trial Protocol (COVIPLA-RCT)

Background: Coronavirus disease 2019 is a global public health concern. As of December 2020, the therapeutic agents approved for coronavirus disease 2019 in Japan were limited to two drugs: remdesivir, an antiviral drug, granted a Special Approval for Emergency on 7 May 2020, and dexamethasone, which has an anti-inflammatory effect. The aim of this study is to evaluate the efficacy of convalescent plasma collected from donors who recovered from coronavirus disease 2019. Methods: This is an open-label, randomized controlled trial comprising two groups: a convalescent plasma and a standard-of-care group. Plasma administered to patients with coronavirus disease 2019 randomized in the convalescent plasma group of this trial will be plasma that has been collected and stored in an associated study. Patients with a diagnosis of mild coronavirus disease 2019 will be included in this trial. The efficacy of convalescent plasma transfusion will be evaluated by comparing the convalescent plasma group to the standard-of-care group (without convalescent plasma transfusion) with respect to changes in the viral load and other measures. The primary endpoint will be time-weighted average changes in the SARS-CoV-2 virus load in nasopharyngeal swabs from day 0 to days 3 and 5. It is hypothesized that the intervention should result in a decrease in the viral load in the convalescent plasma group until day 5. This endpoint has been used as a change in viral load has and been used as an index of therapeutic effect in several previous studies. Discussion: The proposed trial has the potential to prevent patients with mild COVID-19 from developing a more severe illness. Several RCTs of convalescent plasma therapy have already been conducted in countries outside of Japan, but no conclusion has been reached with respect to the efficacy of convalescent plasma therapy, which is likely in part because of the heterogeneity of the types of target patients, interventions, and endpoints among trials. Actually, previous clinical trials on plasma therapy have shown inconsistent efficacy and are sometimes ineffective in COVID-19 patients with severe disease, which is due to unmeasured neutralizing antibody titer in the COVID-19 convalescent plasma. To improve this issue, in this study, we measure neutralizing activity of convalescent plasma before administration and provide the plasma with high neutralizing activity to the subjects. It is hoped that this study will further evidence to support the role of convalescent plasma therapy in COVID-19.

Convalescent Plasma Therapy, Therapeutic Formulations of Repurposed Drugs in 20th Century Epidemics against COVID-19: A Systematic Review

Coronavirus 2019 disease (COVID-19) represents one of the largest pandemics the world has faced, and it is producing a global health crisis. To date, the availability of drugs to treat COVID-19 infections remains limited to supportive care although therapeutic options are being explored. Some of them are old strategies for treating infectious diseases. convalescent plasma (CP) therapy has been used successfully in other viral outbreaks in the 20th century. In this study, we systematically evaluated the effect and safety of CP therapy on hospitalized COVID-19 patients. A structured search was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using Medline (PubMed), SciELO, Cochrane Library Plus, Web of Science, and Scopus. The search included articles published up to January 2022 and was restricted to English- and Spanish-language publications. As such, investigators identified six randomized controlled trials that met the search criteria. The results determined that in hospitalized COVID-19 patients the administration of CP therapy with a volume between 200-500 mL and a single transfusion performed in 1-2 h, compared to the control group, decreased viral load, symptomatology, the period of infection, and mortality, without serious adverse effects. CP did influence clinical outcomes and may be a possible treatment option, although further studies will be necessary.

Convalescent plasma therapy in COVID-19 and discharge status: A systematic review

Objective:

Covid19 has emerged as a greatest threat of the decade worldwide. At present there is no certain treatment for treating coronavirus diseases, while some antiviral drugs (Remdesivir , Lopinavir and Ritonavir) are under investigation. Many countries including India have adopted the convalescent plasma therapy in the treatment of moderate to severely ill patients. Despite the treatment being given ,there are no such evidences on the utility and efficacy of convalescent plasma. Hence this study tries to find out the impact on the discharge status from hospital of the patients receiving the very therapy.

Design:

Systematic review and meta analysis.

Setting:

An extensive search was made, following PRISMA guidelines on online databases such as Pubmed, Google scholar and Science direct. Studies those fulfilled the inclusion and exclusion criteria ,were included and reviewed and analyzed for a common outcome(discharge status).

Participants:

A total of 6 eligible studies were analyzed qualitatively and quantitatively which included three case control, two case series and one case report.

Results:

The overall pooled discharge rate from the above studies was 75.7% after the CP therapy. When analyzed for relative risk , it showed CP therapy having a lower risk of staying in hospital (not getting discharged) when compared to Standard therapy ,overall RR (relative risk) being 0.946.

Conclusion:

Our study shows that there is always a higher rate of discharge and low risk of prolonged hospital stay in those patients who receive plasma therapy. CP therapy being a low cost and easy to administer therapy with very less adverse events, requires more focus on further research as it has a potential to become an ideal effective treatment option for COVID-19.

Evaluation of the therapeutic effect of the plasma of recovered COVID-19 patients for treating the patients admitted to the intensive care unit

The novel coronavirus has infected about 141 million people around the world. So far, about 80.4 million people have been discharged, and nearly 3.01 million people have died (an estimated mortality rate of 2.13%). The study aimed to investigate the effect of plasma therapy from recovered COVID-19 patients to treat the patients hospitalized in the intensive care unit (ICU) of the Shahid Mostafa Khomeini Hospital of Ilam in 2020. The present prospective study was conducted in 2019-2020. Overall, 57 cases of plasma therapy were analysed using the Cox proportional hazard regression model in STATA 12 software. The results showed in patients receiving plasma treatment, the hazard ratio was (HR = 0.68, 95% CI, 0.45-1.04), indicating a 32% lower risk of death in the COVID-19 patients who received plasma therapy compared to those who did not. However, this relationship does not reach statistical significance (p = 0.07). Plasma therapy seems to yield some efficacy among patients with severe COVID-19 and those who have no underlying diseases. It is recommended to be used in combination with pharmaceutical interventions, for example, Actemra, to assess its therapeutic efficiency.

Anti-Inflammatory Properties of Plasma from Children with Short Bowel Syndrome

Sepsis, resulting from a dysregulated host immune response to invading pathogens, is the leading cause of mortality in critically ill patients worldwide. Immunomodulatory treatment for sepsis is currently lacking. Children with short bowel syndrome (SBS) may present with less severe symptoms during gram-negative bacteremia. We, therefore, tested the hypothesis that plasma from children with SBS could confer protection against Escherichia coli sepsis. We showed that SBS plasma at 5% and 10% concentrations significantly (p < 0.05) inhibited the production of both TNF-α and IL-6 induced by either E. coli- or LPS-stimulated host cells when compared to plasma from healthy controls. Furthermore, mice treated intravenously with select plasma samples from SBS or healthy subjects had reduced proinflammatory cytokine levels in plasma and a significant survival advantage after E. coli infection. However, SBS plasma was not more protective than the plasma of healthy subjects, suggesting that children with SBS have other immunomodulatory mechanisms, in addition to neutralizing antibodies, to alleviate their symptoms during gram-negative sepsis.

Sustained Responses of Neutralizing Antibodies Against Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in Recovered Patients and Their Therapeutic Applicability

Background

Zoonotic coronaviruses have emerged as a global threat by causing fatal respiratory infections. Given the lack of specific antiviral therapies, application of human convalescent plasma retaining neutralizing activity could be a viable therapeutic option that can bridges this gap.

Methods

We traced antibody responses and memory B cells in peripheral blood collected from 70 recovered Middle East respiratory syndrome coronavirus (MERS-CoV) patients for 3 years after the 2015 outbreak in South Korea. We also used a mouse infection model to examine whether the neutralizing activity of collected sera could provide therapeutic benefit in vivo upon lethal MERS-CoV challenge.

Results

Anti-spike-specific IgG responses, including neutralizing activity and antibody-secreting memory B cells, persisted for up to 3 years, especially in MERS patients who suffered from severe pneumonia. Mean antibody titers gradually decreased annually by less than 2-fold. Levels of antibody responses were significantly correlated with fever duration, viral shedding periods, and maximum viral loads observed during infection periods. In a transgenic mice model challenged with lethal doses of MERS-CoV, a significant reduction in viral loads and enhanced survival was observed when therapeutically treated with human plasma retaining a high neutralizing titer (> 1/5000). However, this failed to reduce pulmonary pathogenesis, as revealed by pathological changes in lungs and initial weight loss.

Conclusions

High titers of neutralizing activity are required for suppressive effect on the viral replication but may not be sufficient to reduce inflammatory lesions upon fatal infection. Therefore, immune sera with high neutralizing activity must be carefully selected for plasma therapy of zoonotic coronavirus infection.

Current Therapies in Clinical Trials of Parkinson's Disease: A 2021 Update

Parkinson's disease (PD) is a progressive neurodegenerative disorder that currently has no cure, but treatments are available to improve PD symptoms and maintain quality of life. In 2020, about 10 million people worldwide were living with PD. In 1970, the United States Food and Drug Administration approved the drug levodopa as a dopamine replacement to manage PD motor symptoms; levodopa-carbidopa combination became commercialized in 1975. After over 50 years of use, levodopa is still the gold standard for PD treatment. Unfortunately, levodopa therapy-induced dyskinesia and OFF symptoms remain unresolved. Therefore, we urgently need to analyze each current clinical trial's status and therapeutic strategy to discover new therapeutic approaches for PD treatment. We surveyed 293 registered clinical trials on ClinicalTrials.gov from 2008 to 16 June 2021. After excluded levodopa/carbidopa derivative add-on therapies, we identified 47 trials as PD treatment drugs or therapies. Among them, 19 trials are in phase I (41%), 25 trials are in phase II (53%), and 3 trials are in phase III (6%). The three phase-III trials use embryonic dopamine cell implant, 5-HT_1A receptor agonist (sarizotan), and adenosine A_2A receptor antagonist (caffeine). The therapeutic strategy of each trial shows 29, 5, 1, 5, 5, and 2 trials use small molecules, monoclonal antibodies, plasma therapy, cell therapy, gene therapy, and herbal extract, respectively. Additionally, we discuss the most potent drug or therapy among these trials. By systematically updating the current trial status and analyzing the therapeutic strategies, we hope this review can provide new ideas and insights for PD therapy development.

A Possible Role of Remdesivir and Plasma Therapy in the Selective Sweep and Emergence of New SARS-CoV-2 Variants

Since summer 2020, SARS-CoV-2 strains at the origin of the COVID-19 pandemic have suddenly been replaced by new SARS-CoV-2 variants, some of which are highly transmissible and spread at a high rate. These variants include the Marseille-4 lineage (Nextclade 20A.EU2) in Europe, the 20I/501Y.V1 variant first detected in the UK, the 20H/501Y.V2 variant first detected in South Africa, and the 20J/501Y.V3 variant first detected in Brazil. These variants are characterized by multiple mutations in the viral spike protein that is targeted by neutralizing antibodies elicited in response to infection or vaccine immunization. The usual coronavirus mutation rate through genetic drift alone cannot account for such rapid changes. Recent reports of the occurrence of such mutations in immunocompromised patients who received remdesivir and/or convalescent plasma or monoclonal antibodies to treat prolonged SARS-CoV-2 infections led us to hypothesize that experimental therapies that fail to cure the patients from COVID-19 could favor the emergence of immune escape SARS-CoV-2 variants. We review here the data that support this hypothesis and urge physicians and clinical trial promoters to systematically monitor viral mutations by whole-genome sequencing for patients who are administered these treatments.

Efficacy and safety of convalescent plasma therapy in SARS-CoV2 patients on hemodialysis

Background

The passive immunization of patients with SARS‐CoV2 with convalescent plasma (CP) is theoretically beneficial in patients with end‐stage renal disease who are immunosuppressed and unable to mount an adequate immune response. Hence, this study was conducted to evaluate the safety and efficacy of CP in patients with chronic kidney disease on hemodialysis with moderate‐to‐severe SARS‐CoV2 infection.

Methods

A prospective observational cohort study was conducted in consecutive 68 moderate‐to‐severe SARS‐CoV2 infected patients who were on maintenance hemodialysis or with acute worsening of chronic kidney disease which required initiation of hemodialysis. Patients who received CP were compared with those who did not. The primary outcome was death during hospitalization. Clinical characteristics, duration of hospitalization and inflammatory parameters were compared between the two groups. A subgroup analysis was done to find whether early initiation of plasma was associated with better outcome.

Results

Sixteen patients (44%) in the plasma group and 14 (45%) patients in the control group died during hospitalization (p = 0.95). The median duration of hospitalization was 9 (6–14) days in the plasma group and 9 (6–16) in the control group (p = 0.60). There was no difference in mortality or duration of hospitalization with respect to early initiation of CP (p = 0.29). Fistula thrombosis occurred in two patients (11.1%) in the plasma group.

Conclusion

Therapy with CP does not appear to confer any clinical benefit in moderate‐to‐severe SARS‐CoV‐2 infected patients with chronic kidney disease on hemodialysis.

Mortality Benefit of Convalescent Plasma in COVID-19: A Systematic Review and Meta-Analysis

Importance/Background: With a scarcity of high-grade evidence for COVID-19 treatment, researchers and health care providers across the world have resorted to classical and historical interventions. Immunotherapy with convalescent plasma (CPT) is one such therapeutic option. Methods: A systematized search was conducted for articles published between December 2019 and 18th January 2021 focusing on convalescent plasma efficacy and safety in COVID-19. The primary outcomes were defined as mortality benefit in patients treated with convalescent plasma compared to standard therapy/placebo. The secondary outcome was pooled mortality rate and the adverse event rate in convalescent plasma-treated patients. Results: A total of 27,706 patients were included in the qualitative analysis, and a total of 3,262 (2,127 in convalescent plasma-treated patients and 1,135 in the non-convalescent plasma/control group) patients died. The quantitative synthesis in 23 studies showed that the odds of mortality in patients who received plasma therapy were significantly lower than those in patients who did not receive plasma therapy [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.53-0.80, p < 0.0001, I 2 = 15%). The mortality benefit remains the same even for 14 trials/prospective studies (OR 0.59, 95% CI 0.43-0.81, p = 0.001, I 2 = 22%) as well as for nine case series/retrospective observational studies (OR 0.78, 95% CI 0.65-0.94, p = 0.01, I 2 = 0%). However, in a subgroup analysis for 10 randomized controlled trials (RCTs), there was no statistically significant reduction in mortality between the CPT group compared to the non-CPT group (OR 0.76, 95% CI 0.53-1.08, p = 0.13, I 2 = 7%). Furthermore, the sensitivity analysis of 10 RCTs, excluding the study with the highest statistical weight, displayed a lower mortality rate compared to that of non-CPT COVID-19 patients (OR 0.64, 95% CI 0.42-0.97, p = 0.04, I 2 = 0%). The observed pooled mortality rate was 12.9% (95% CI 9.7-16.9%), and the pooled adverse event rate was 6.1% (95% CI 3.2-11.6), with significant heterogeneity. Conclusions and Relevance: Our systemic review and meta-analysis suggests that CPT could be an effective therapeutic option with promising evidence on the safety and reduced mortality in concomitant treatment for COVID-19 along with antiviral/antimicrobial drugs, steroids, and other supportive care. Future exploratory studies could benefit from more standardized reporting, especially in terms of the timing of interventions and clinically relevant outcomes, like days until discharge from the hospital and improvement of clinical symptoms.

Therapeutic approaches against coronaviruses acute respiratory syndrome

Coronaviruses represent global health threat. In this century, they have already caused two epidemics and one serious pandemic. Although, at present, there are no approved drugs and therapies for the treatment and prevention of human coronaviruses, several agents, FDA-approved, and preclinical, have shown in vitro and/or in vivo antiviral activity. An in-depth analysis of the current situation leads to the identification of several potential drugs that could have an impact on the fight against coronaviruses infections. In this review, we discuss the virology of human coronaviruses highlighting the main biological targets and summarize the current state-of-the-art of possible therapeutic options to inhibit coronaviruses infections. We mostly focus on FDA-approved and preclinical drugs targeting viral conserved elements.

Drug repurposing: new strategies for addressing COVID-19 outbreak

Introduction: COVID-19 outbreak has infected 34.20 million people with 1019 thousand deaths in more than 125 countries till 30 September 2020. Due to the unavailability of vaccine or targeted novel drug therapy against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), screening of existential medical treatments facilitates identification of promising drugs for the treatment and management of COVID-19.Areas covered: The review article highlights repurposing of antiviral, antimalarial, antineoplastic, antidiabetic, analgesic, and immunomodulatory drugs. Furthermore, clinical trials, in-vitro studies, benefits, adverse effects, toxicities, mechanisms of action, and regulatory status of drugs are covered in this article.Expert opinion: Lack of conclusive results from randomized clinical trials indicates absence of specific drugs for treatment of COVID-19. Unavailability of complete data regarding safety, efficacy, and adverse reactions of drugs restricts the recommendation of clinical advice on dose and duration of the drug therapy. Remdesivir and favipiravir show promising outcomes but more clinical evidence is required for use in large populations. Experimental and repurposed drug therapies targeting spike and envelope proteins, Mpro, 3CL_pro and PL_pro enzymes, and RdRp and TMPRSS2 genes show capability to produce effective anti-SARS-CoV-2 action. Development of vaccine against SARS-CoV-2 will offer long-term solution to terminate spread of this global pandemic.

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.

Convalescent plasma therapy: a promising coronavirus disease 2019 treatment strategy

The world is passing through a very difficult phase due to the coronavirus disease 2019 (COVID-19) pandemic, which has disrupted almost all spheres of life. Globally, according to the latest World Health Organization report (10 August 2020), COVID-19 has affected nearly 20 million lives, causing 728 013 deaths. Due to the lack of specific therapeutic drugs and vaccines, the outbreak of disease has spawned a corpus of contagious infection all over the world, day by day, without control. As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a very rapid infection rate, it is essential to develop a novel ameliorative and curative strategy as quickly as possible. Convalescent plasma (CP) therapy is a type of adaptive immunity that has already been found to be effective in confronting several infectious diseases from the last two decades. For example, CP therapy was used in the treatment of viral-induced diseases like SARS-CoV epidemics, Middle East respiratory syndrome coronavirus (MERS-CoV) pandemics, Ebola epidemics and H1N1 pandemic. In this review, we have mainly focused on the therapeutic role of CP therapy and its neutralizing effect to fight against the COVID-19 outbreak.

Progress in the Research and Development of Anti-COVID-19 Drugs

The outbreaks of COVID-19 due to SARS-CoV-2 has caused serious physical and psychological damage to global human health. COVID-19 spread rapidly around the world in a short time. Confronted with such a highly infectious respiratory disease, the research and development of anti-COVID-19 drugs became an urgent work due to the lack of specific drugs for the treatment of COVID-19. Nevertheless, several existing drugs are available to relieve the clinical symptoms of COVID-19. We reviewed information on selected anti-SARS-CoV-2 candidate therapeutic agents published until June 2, 2020. We also discussed the strategies of the development of anti-COVID-19 drugs in the future. Our review provides a novel insight into the future development of a safer, efficient, and toxic-less anti-COVID-19 drug.

Onychomycosis: Treatment and prevention of recurrence

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.

Successful living-related renal transplantation in a patient with factor H antibody-associated atypical hemolytic uremic syndrome

CFH-Ab-associated aHUS requires different diagnostic and therapeutic approaches and then the genetically defined aHUS forms. The risk of post-transplant recurrence with graft dysfunction in CFH-Ab aHUS is not well documented. It is suggested that recurrence can be expected if a significant CFH-Ab load persists at the time of transplantation. A pretransplant procedure to reduce CFH-Ab titer seems reasonable, but accurate recommendations are lacking. Whether further prophylactic interventions after transplantation are necessary has to be decided on an individual basis. We report the case of a late diagnosed CFH-Ab HUS with initial ESRD and a successful living-related renal transplantation over a post-transplant period of four and a half years on the basis of a prophylactic pretransplant IVIG admission.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Hereditary ADAMTS 13 deficiency presenting as recurrent acute kidney injury

We report here a case of 26-year-old male who presented with history of recurrent acute renal failure associated with microangiopathic hemolytic anemia and thrombocytopenia. ADAMTS 13 deficiency due to mutation in the gene encoding for ADAMTS 13 was identified as the cause. After eight episodes of acute kidney injury (AKI), patient started developing hypertension, proteinuria, and renal insufficiency. Treatment with regular monthly plasma infusions prevented further episodes of AKI and stabilized the renal function. Hypertension and proteinuria are controlled with angiotensin II receptor blockers.

Atypical hemolytic uremic syndrome in children: complement mutations and clinical characteristics

BACKGROUND

Mutations in complement factor H (CFH), factor I (CFI), factor B (CFB), thrombomodulin (THBD), C3 and membrane cofactor protein (MCP), and autoantibodies against factor H (αFH) with or without a homozygous deletion in CFH-related protein 1 and 3 (∆CFHR1/3) predispose development of atypical hemolytic uremic syndrome (aHUS).

METHODS

Different mutations in genes encoding complement proteins in 45 pediatric aHUS patients were retrospectively linked with clinical features, treatment, and outcome.

RESULTS

In 47% of the study participants, potentially pathogenic genetic anomalies were found (5xCFH, 4xMCP, and 4xC3, 3xCFI, 2xCFB, 6xαFH, of which five had ∆CFHR1/3); four patients carried combined genetic defects or a mutation, together with αFH. In the majority (87%), disease onset was preceeded by a triggering event; in 25% of cases diarrhea was the presenting symptom. More than 50% had normal serum C3 levels at presentation. Relapses were seen in half of the patients, and there was renal graft failure in all except one case following transplant.

CONCLUSIONS

Performing adequate DNA analysis is essential for treatment and positive outcome in children with aHUS. The impact of intensive initial therapy and renal replacement therapy, as well as the high risk of recurrence of aHUS in renal transplant, warrants further understanding of the pathogenesis, which will lead to better treatment options.

aHUS caused by complement dysregulation: new therapies on the horizon

Atypical hemolytic uremic syndrome (aHUS) is a heterogeneous disease that is caused by defective complement regulation in over 50% of cases. Mutations have been identified in genes encoding both complement regulators [complement factor H (CFH), complement factor I (CFI), complement factor H-related proteins (CFHR), and membrane cofactor protein (MCP)], as well as complement activators [complement factor B (CFB) and C3]. More recently, mutations have also been identified in thrombomodulin (THBD), an anticoagulant glycoprotein that plays a role in the inactivation of C3a and C5a. Inhibitory autoantibodies to CFH account for an additional 5-10% of cases and can occur in isolation or in association with mutations in CFH, CFI, CFHR 1, 3, 4, and MCP. Plasma therapies are considered the mainstay of therapy in aHUS secondary to defective complement regulation and may be administered as plasma infusions or plasma exchange. However, in certain cases, despite initiation of plasma therapy, renal function continues to deteriorate with progression to end-stage renal disease and renal transplantation. Recently, eculizumab, a humanized monoclonal antibody against C5, has been described as an effective therapeutic strategy in the management of refractory aHUS that has failed to respond to plasma therapy. Clinical trials are now underway to further evaluate the efficacy of eculizumab in the management of both plasma-sensitive and plasma-resistant aHUS.