The efficacy of thymosin alpha-1 therapy in moderate to critical COVID-19 patients: a systematic review, meta-analysis, and meta-regression

BACKGROUND

Effort to search for the optimal COVID-19 treatment has continuously been attempted. Thymosin alpha-1 have immunomodulatory properties which may be beneficial in case of viral infection. This study's goal is to determine whether thymosin alpha-1 is effective in treating people with moderate-to-severe COVID-19.

METHODS

We searched for literature in 4 database: Scopus, Europe PMC, Medline, ClinicalTrials.gov, and Cochrane Library until March 25th, 2023. If those articles have data on the efficacy of thymosin alpha-1 therapy on COVID-19, they would be included. Risk ratio (RR) and Mean Difference (MD) along with their 95% confidence intervals were used to pool the results of dichotomous and continuous variables, respectively.

RESULTS

Pooled data from 8 studies indicated that moderate to critical Covid-19 patients who were receiving thymosin alpha-1 therapy had significantly lower mortality from COVID-19 (RR 0.59; 95% CI 0.37-0.93, p = 0.02, I2 = 84%), but without any difference in the needs for mechanical ventilation (RR 0.83; 95% CI 0.48-1.44, p = 0.51, I2 = 74%) and hospital length of stay (MD 2.32; 95% CI - 0.93, 5.58, p = 0.16, I2 = 94%) compared to placebo. The benefits of thymosin alpha-1 on the mortality rate were significantly affected only by sample size (p = 0.0000) and sex (p = 0.0117).

CONCLUSION

Our study suggests that treatment with thymosin alpha-1 may reduce mortality rate in moderate to critical COVID-19 patients. Randomized clinical trials (RCTs) are still required to verify the findings of our study.

Effectiveness and safety of normoxic allogenic umbilical cord mesenchymal stem cells administered as adjunctive treatment in patients with severe COVID-19

Inflammatory response in COVID-19 contributes greatly to disease severity. Mesenchymal Stem Cells (MSCs) have the potential to alleviate inflammation and reduce mortality and length of stay in COVID-19 patients. We investigated the safety and effectiveness of normoxic-allogenic umbilical cord (NA-UC)-MSCs as an adjunctive treatment in severe COVID-19 patients. A double-blind, multicentric, randomized, placebo-controlled trial involving severe COVID-19 patients was performed from January to June 2021 in three major hospitals across Java, Indonesia. Eligible participants (n = 42) were randomly assigned to two groups (1:1), namely the intervention (n = 21) and control (n = 21) groups. UC-MSCs dose was 1 × 106 /kg body weight on day D0, D3, and D6. The primary outcome was the duration of hospitalization. Meanwhile, the secondary outcomes were radiographical progression (Brixia score), respiratory and oxygenation parameters, and inflammatory markers, in addition to the safety profile of NA-UC-MSCs. NA-UC-MSCs administration did not affect the length of hospital stay of severe COVID-19 patients, nor did it improve the Brixia score or mMRC dyspnoea scale better than placebo. Nevertheless, NA-UC-MSCs led to a better recuperation in oxygenation index (120.80 ± 72.70 baseline vs. 309.63 ± 319.30 D + 22, p = 0.038) and oxygen saturation (97.24 ± 4.10% vs. 96.19 ± 3.75% in placebo, p = 0.028). Additionally, compared to the placebo group, the treatment group had a significantly smaller increase in PCT level at D + 22 (1.43 vs. 12.76, p = 0.011). No adverse effects, including serious ones, were recorded until D + 91. NA-UC-MSCs therapy is a very safe adjunct for COVID-19 patients. It improves the oxygenation profile and carries potential to suppress inflammation.

High Levels of Anti-SARS-CoV-2 Receptor-Binding Domain (RBD) Antibodies One Year Post Booster Vaccinations among Hospital Workers in Indonesia: Was the Second Booster Needed?

In August 2022, Indonesia prioritized healthcare workers to receive the second booster dose. We conducted a sequential serosurvey to understand the dynamics of the antibody titers. The first serosurvey, which was conducted in June 2021, 1-6 months after Sinovac vaccination, showed a median antibody level of 41.4 BAU/mL (interquartile range (IQR): 10-629.4 BAU/mL). The second serosurvey was conducted one month (August 2021) after the first Moderna booster vaccine and showed a median level of 4000 BAU/mL (IQR: 3081-4000 BAU/mL). The last serosurvey was conducted a year (August 2022) after the booster and showed a median level of 4000 BAU/mL (IQR: 4000-4000 BAU/mL). In this last survey, only 39 (11.9%) of healthcare workers had antibody levels below the maximum level of 4000 BAU/mL. Thus, one year after the first booster dose, we did not observe the waning of antibody levels. The average increase was perhaps because of natural infection. Based on these considerations, we believe that a second booster dose was not necessary for this category of subjects at that time. Because vaccine supply is often limited, priority could be given to the general population or other high-risk patient groups with low antibody titers based on serological tests.

The effect of diabetes mellitus on COVID-19 mortality among patients in a tertiary-level hospital in Bandung, Indonesia

Immune system dysregulation in people with diabetes mellitus (DM) increases the risk of acquiring severe infection. We compared the clinical characteristics and laboratory parameters of coronavirus disease 2019 (COVID-19) patients with and without DM and estimated the effect of DM on mortality among COVID-19 patients. A retrospective cohort study collecting patients' demographic, clinical characteristics, laboratory parameters and treatment outcomes from medical records was conducted in a hospital in Bandung City from March to December 2020. Univariable and multivariable logistic regression was performed to determine the association between DM and death. A total of 664 COVID-19 patients with positive real-time reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 were included in this study, of whom 147 were with DM. Half of DM patients presented HbA1c ≥10%. DM patients were more likely to present with comorbidities and severe to critical conditions at admission (P <0.001). Laboratory parameters such as neutrophil-lymphocyte count ratio, C-reactive protein, D-dimer, ferritin, and lactate dehydrogenase were higher in the DM group. In the univariate analysis, variables associated with death were COVID-19 severity at baseline, neurologic disease, DM, age ≥60 years, hypertension, cardiovascular disease, and chronic kidney disease. DM remained associated with death (aOR 1.82; 95% CI 1.13-2.93) after adjustment with sex, age, hypertension, cardiovascular disease, and chronic kidney disease. In conclusion, COVID-19 patients with DM are more likely to present with a very high HbA1c, comorbidities, and severe-critical illness. Chronic inflammation in DM patients may be aggravated by the disruption of immune response caused by COVID-19, leading to worse laboratory results and poor outcomes.

Antibodies against Histoplasma capsulatum and Aspergillus fumigatus among chronic TB patients in Indonesia: a cross-sectional study

Chronic pulmonary fungal infections may occur in patients with previous history of pulmonary tuberculosis (TB), and are often clinically misclassified as TB, especially when bacteriological confirmation for Mycobacterium tuberculosis is absent. In this study, we investigated the prevalence of antibody against Histoplasma capsulatum and Aspergillus fumigatus in patients with confirmed and clinically chronic TB.

Antibodies against H. capsulatum and A. fumigatus were measured from serum samples using enzyme-linked immunosorbent assay (ELISA). The presence M. tuberculosis in sputum was confirmed using smear microscopy, GeneXpert MTB/RIF assay, or culture.

Antibodies against H. capsulatum and A. fumigatus were elevated in 16.9% and 26.9% of bacteriologically confirmed chronic TB patients, and 4% and 18.2% in those without bacteriological confirmation, respectively. Approximately one third of patients who had positive anti-Histoplasma antibody also had elevated levels of antibody against Aspergillus fumigatus (p &lt; 0.001). Our study highlights the importance of chronic pulmonary fungal infection in post-TB patients with recurrent respiratory symptoms.

Efficacy and safety of tixagevimab-cilgavimab as pre-exposure prophylaxis for COVID-19: A systematic review and meta-analysis

Some proportions of populations, such as immunocompromised patients and organ transplant recipients might have inadequate immune responses to the vaccine for coronavirus disease 2019 (COVID-19). For these groups of populations, administering monoclonal antibodies might offer some additional protection. This review sought to analyze the effectiveness and safety of tixagevimab-cilgavimab (Evusheld) as pre-exposure prophylaxis against COVID-19. We used specific keywords to comprehensively search for potential studies on PubMed, Scopus, Europe PMC, and ClinicalTrials.gov sources until 3 September 2022. We collected all published articles that analyzed tixagevimab-cilgavimab on the course of COVID-19. Review Manager 5.4 was utilized for statistical analysis. Six studies were included. Our pooled analysis revealed that tixagevimab-cilgavimab prophylaxis may decrease the rate of SARS-CoV-2 infection (OR: 0.24; 95% CI: 0.15-0.40, p < 0.00001, I²  = 75%), lower COVID-19 hospitalization rate (OR: 0.13; 95% CI: 0.07-0.24, p < 0.00001, I²  = 0%), decrease the severity risk (OR: 0.13; 95% CI: 0.07-0.24, p < 0.00001, I²  = 0%), and lower COVID-19 deaths (OR: 0.17; 95% CI: 0.03-0.99, p = 0.05, I²  = 72%). In the included studies, no major adverse events were reported. This study proposes that tixagevimab-cilgavimab was effective and safe for preventing COVID-19. Tixagevimab-cilgavimab may be offered to those who cannot be vaccinated or have inadequate immune response from the COVID-19 vaccine to give additional protection.

Distribution of Rifampicin-Resistant Tuberculosis Patients based on Presumptive Drug-Resistant Tuberculosis Criteria at Dr. Hasan Sadikin Hospital 2016–2019

Background: Diagnosis of drug-resistant tuberculosis (DR-TB) begins with identifying presumptive DR-TB patients using Xpert MTB/RIF, as a diagnostic test to detect resistance to rifampicin. The study aimed to identify the distribution of rifampicin-resistant tuberculosis (RR-TB) patients based on presumptive DR-TB criteria at Dr. Hasan Sadikin General Hospital Bandung. Moreover, this study also explored the Xpert MTB/RIF Ct values.Methods: This was a descriptive-retrospective study from 570 medical records of DR-TB patients collected at the Multidrug-resistant tuberculosis (MDR-TB) clinic of Dr. Hasan Sadikin General Hospital from 2016 to 2019. The inclusion criteria were suspected patients with the Xpert MTB/RIF Ct values in the very low-low and medium-high categories. Data were analyzed using frequency distribution. Results: The most common presumptive DR-TB criteria among DR-TB patients were relapse cases (52.3%). Presumptive DR-TB criteria, with a high percentage result of medium-high Ct values, were category II treatment failure (80.9%).Conclusion: Relapse case and category II treatment failure are presumptive DR-TB criteria, which need more attention from clinicians.

MDR Pathogens Organisms as Risk Factor of Mortality in Secondary Pulmonary Bacterial Infections Among COVID-19 Patients: Observational Studies in Two Referral Hospitals in West Java, Indonesia

Purpose

The coronavirus disease (COVID-19) outbreak has created a global health crisis. Secondary pulmonary bacterial infection is a COVID-19 complication, increasing morbidity and mortality. This study aimed to determine the pathogens, antibiotic susceptibility patterns, and risk factors for mortality in hospitalized COVID-19 patients.

Patients and Methods

This retrospective study used secondary data from patients’ electronic medical records at Hasan Sadikin General Hospital and Santo Borromeus Hospital between March 2020 and March 2021. Overall, 2230 hospitalized COVID-19 patients were screened, and 182 of them who were hospitalized ≥48 hours with a procalcitonin level of ≥0.25 ng/mL were enrolled. Culture examination was performed on sputum samples to determine pathogen and antibiotic susceptibilities. Univariate and multivariate analyses were used to determine mortality-related risk factors in hospitalized COVID-19 patients.

Results

The prevalence of secondary pulmonary bacterial infections in COVID-19 patients was 8.2%, with 161/182 pathogen growth from sputum samples. Mainly gram-negative bacteria (64.8%) were present, including Acinetobacter baumannii (31.9%), Klebsiella pneumoniae (19.8%), and Pseudomonas aeruginosa (8.8%). High rate of multidrug-resistant (MDR) pathogens was found among isolate (45.9%), ie carbapenem-resistance A.baumannii (CR-Ab) was 84.2%, extended-spectrum β-lactamase (ESBL) among K. pneumoniae was 61.1%. Secondary infection of MDR pathogens was associated with a higher risk of mortality (AOR 5.63, p = 0.001). Other associated factors were age ≥60 years, ventilator use, and female gender.

Conclusion

Gram-negative bacteria are the predominant pathogens causing secondary pulmonary bacterial infection in COVID-19 patients, implying nosocomial infection. High resistance to first-line antimicrobial drugs was observed in Gram-negative bacteria and Gram-positive bacteria. High rate of MDR pathogens was found among isolate and was associated with a significant risk of mortality.

Factors associated with treatment outcome of MDR/RR-TB patients treated with shorter injectable based regimen in West Java Indonesia

Background and aims

Multi drug or rifampicin resistant tuberculosis (MDR/RR-TB) is a major burden to TB prevention and eradication globally. Since 2016, WHO guidelines have included options for treating MDR/RR-TB with a standard regimen of 9 to 11 months duration (the ’shorter regimen’) rather than an individual regimen of at least 20 months. This regimen has been introduced in Indonesia since September 2017. Therefore, we aimed to determine the success rate and factors associated with the treatment outcome of shorter injectable based regimen in West Java province, Indonesia.

Methods

This was a retrospective cohort study of MDR/RR-TB patients aged over 18 years old who received the shorter injectable based regimen between September 2017 and December 2020. We defined successful outcomes as the combined proportion of patients who were cured or had complete treatment. While, unsuccessful outcomes were defined as the combined proportion of patients who died from any causes, failure, and loss to follow-up (LTFU).

Results

A total of 315 patients were included in this study. The success rate was 64.5%. Multivariate analysis showed male gender (aRR = 1.18, 95% CI 1.04 to 1.34) increased the chance of successful outcome, while malnutrition (aRR = 0.78, 95% CI 0.68 to 0.89), history of previous TB treatment (aRR = 0.80%CI 0.68 to 0.94), and time of culture conversion >2 months (aRR = 0.72 (95% CI 0.59 to 0.87) decreased the chance of successful outcome.

Conclusion

History of previous TB treatment, time of culture conversion >2 months, and malnutrition were independent factors that decrease the chance for success rate, while male gender increase the likelihood for success rate of patients treated by the shorter injectable based regimen.

The role of 99mTc-ethambutol scintigraphy to diagnose pulmonary tuberculosis

Tuberculosis is a significant health problem in many parts of the world. According to the Global Tuberculosis Report 2020, 10 million new tuberculosis cases were reported worldwide in 2019, with only 57% of these cases being bacteriologically confirmed. Current tuberculosis diagnostic tests depend on the quality of the sputum, leaving many diagnostic uncertainties. Diagnostic delays result in ongoing transmission and more severe, progressive disease in the affected person. This shows that current diagnostic tests are not sufficient to establish all tuberculosis cases accurately, and there is a need for a new diagnostic technique. 99mTc-ethambutol scintigraphy was recently reported as a new diagnostic test for tuberculosis, with a sensitivity and specificity of 93.9% and 85.7%, respectively. Here, we report a case of the importance of this new technique for diagnosing tuberculosis when the existing bacteriological and molecular tests failed to confirm the diagnosis.

Association Between Vitamin D Levels and FEV1, Number of Exacerbations, and CAT Score in Stable COPD Patients in Indonesia

Purpose

This study aimed to assess the association between vitamin D levels and forced expiratory volume in one second (FEV1), number of exacerbations, and symptoms based on COPD assessment test (CAT) scores in stable COPD patients in Indonesia.

Patients and Methods

An observational cross-sectional study was conducted. Subjects were stable COPD patients who were treated at a pulmonary clinic in a tertiary referral hospital in West Java from March to June 2018.

Results

Thirty subjects were recruited this study with an average age 62±8 years. The mean vitamin D level was 20.17±8.91 ng/mL. Half of the patients had low vitamin D level (<20ng/mL) (50%). The mean FEV1 (%) predicted value was 37.2±14. The median exacerbation per year was 1 (0-5) and symptoms based on CAT score was 14 (3-34). No correlation was found between vitamin D levels and FEV1 (%) predicted value (r=0.126, p=0.253). Vitamin D level was inversely correlated with number of exacerbations (r=-0.639, p<0.001) and CAT (r= -0.802, p<0.001).

Conclusion

Low level of vitamin D was associated with more frequent exacerbation and higher CAT scores but was not associated with FEV1 (%) predicted.

Asthma does not increase COVID-19 mortality and poor outcomes: A systematic review and meta-analysis

BACKGROUND

The Center for Disease Control and Prevention (CDC) has mentioned Coronavirus Disease 2019 (COVID-19) patients with moderate or severe asthma as a high risk group for severe illness. While WHO mentioned only chronic respiratory diseases, not specifically asthma as a risk factor for severe illness. There has been asthma prevalence discrepancy in studies of COVID-19 across the world.

OBJECTIVE

This meta-analysis aims to investigate the association between asthma and composite poor outcome in patients with coronavirus disease (COVID-19).

METHODS

We conducted a systematic literature search from PubMed and Embase database. We included all original research articles with adult COVID-19 patients > 18 years old and had information related to asthma as a risk factor. Studies with outcomes consisting of mortality, severe COVID-19, use of mechanical ventilation, ICU admission, and hospital admission were included in this study. The outcomes of interest were divided into severe COVID-19, mortality and other poor outcomes.

RESULTS

Eleven studies were included in meta-analysis with a total of 6,046 patients. Asthma was not associated with composite poor outcomes with OR = 0.92 (95%CI 0.71-1.19, p = 0.61, and I2 = 8.49%). Furthermore, subgroup analysis showed that asthma was not associated with severe COVID (p = 0.76), mortality (p = 0.45), and other poor outcomes (p = 0.28).

CONCLUSIONS

Our study showed that asthma was not associated with severe COVID-19, mortality, and other poor outcomes in patients with COVID-19.

Current views on the potentials of convalescent plasma therapy (CPT) as Coronavirus disease 2019 (COVID-19) treatment: A systematic review and meta-analysis based on recent studies and previous respiratory pandemics

Convalescent plasma therapy (CPT) has been investigated as a treatment for COVID-19. This review evaluates CPT in COVID-19 and other viral respiratory diseases, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and influenza. PubMed and Google scholar databases were used to collect eligible publications until 8 December 2020. Meta-analysis used Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI) and pooled analysis for individual patient data with inverse variance weighted average. The study is registered at PROSPERO with the number of CRD4200270579. Forty-four studies with 36,716 participants were included in the pooled analysis and 20 studies in the meta-analysis. Meta-analysis showed reduction of mortality (RR 0.57, 95% CI [0.43, 0.76], z = 3.86 [p < 0.001], I²  = 44% [p = 0.03]) and higher number of discharged patients (RR 2.53, 95% CI [1.72, 3.72], z = 4.70 [p < 0.001], I²  = 3% [p = 0.39]) in patients receiving CPT compared to standard care alone. A possible mechanism of action is prompt reduction in viral titre. Serious transfusion-related adverse events were reported to be less than 1% of cases, suggesting the overall safety of CPT; nevertheless, the number of patients participating in the studies was still limited. It is also important to notice that in all the studies, the majority of patients were also given other medications, such as antivirals, antibiotics and corticosteroid; furthermore, randomized controlled studies involving more patients and in combination with other treatment modalities are urgently needed.

Effect of increased BMI and obesity on the outcome of COVID-19 adult patients: A systematic review and meta-analysis

BACKGROUND AND AIMS

Corona virus diseases 2019 (COVID-19) pandemic spread rapidly. Growing evidences that overweight and obesity which extent nearly a third of the world population were associated with severe COVID-19. This study aimed to explore the association and risk of increased BMI and obesity with composite poor outcome in COVID-19 adult patients.

METHODS

We conducted a systematic literature search from PubMed and Embase database. We included all original research articles in COVID-19 adult patients and obesity based on classification of Body Mass Index (BMI) and composite poor outcome which consist of ICU admission, ARDS, severe COVID-19, use of mechanical ventilation, hospital admission, and mortality.

RESULTS

Sixteen studies were included in meta-analysis with 9 studies presented BMI as continuous outcome and 10 studies presented BMI as dichotomous outcome (cut-off ≥30 kg/m²). COVID-19 patients with composite poor outcome had higher BMI with mean difference 1.12 (95% CI, 0.67-1.57, P < 0.001). Meanwhile, obesity was associated with composite poor outcome with odds ratio (OR) = 1.78 (95% CI, 1.25-2.54, P < 0.001) Multivariate meta-regression showed the association between BMI and obesity on composite poor outcome were affected by age, gender, DM type 2, and hypertension.

CONCLUSION

Obesity is a risk factor of composite poor outcome of COVID-19. On the other hand, COVID-19 patients with composite poor outcome have higher BMI. BMI is an important routine procedure that should always be assessed in the management of COVID-19 patients and special attention should be given to patients with obesity.

Effect of chronic obstructive pulmonary disease and smoking on the outcome of COVID-19

OBJECTIVE: To investigate the association between chronic obstructive pulmonary disease (COPD) and smoking with outcome in patients with COVID-19.METHODS: A systematic literature search was performed using PubMed, EuropePMC, SCOPUS and the Cochrane Central Database. A composite of poor outcome, mortality, severe COVID-19, the need for treatment in an intensive care unit (ICU) and disease progression were the outcomes of interest.RESULTS: Data on 4603 patients were pooled from 21 studies. COPD was associated with an increased risk for composite poor outcome (OR 5.01, 95%CI 3.06-8.22; P < 0.001; I² 0%), mortality (OR 4.36, 95%CI 1.45-13.10; P = 0.009; I² 0%), severe COVID-19 (OR 4.62, 95%CI 2.49-8.56; P < 0.001; I² 0%), ICU care (OR 8.33, 95%CI 1.27-54.56; P = 0.03; I² 0%), and disease progression (OR 8.42, 95%CI 1.60-44.27; P = 0.01; I² 0%). Smoking was found to increase the risk of composite poor outcome (OR 1.52, 95%CI 1.16-2.00; P = 0.005; I² 12%), and subgroup analysis showed that smoking was significant for increased risk of severe COVID-19 (OR 1.65, 95%CI 1.17-2.34; P = 0.004; I² 11%). Current smokers were at higher risk of composite poor outcomes (OR 1.58, 95%CI 1.10-2.27; P = 0.01; I² 0%) than former/non-smokers.CONCLUSION: Our systematic review and meta-analysis revealed that COPD and smoking were associated with poor outcomes in patients with COVID-19.

The use of renin angiotensin system inhibitor on mortality in patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

and Aims; To investigate the association between use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB) and outcomes of hypertensive COVID-19 patients, a systematic review and meta-analysis were performed.

METHODS

We systematically searched PubMed, EuropePMC, ProQuest, and Cochrane Central Databases using the terms "(COVID-19 OR SARS-CoV-2) AND (angiotensin converting enzyme OR angiotensin receptor blocker)". The primary and second outcomes were mortality (non-survivor) and severe COVID-19, respectively.

RESULTS

Totally, 7410 patients were included from 15 studies. Pooled analysis showed that the use of ACEI/ARB was not associated with mortality (OR 0.73 [0.38, 1.40], p = 0.34; I²: 81%) and severity (OR 1.03 [0.73, 1.45], p = 0.87; I²: 65%). Pooled adjusted OR showed no risk/benefit associated with ACEI/ARB use in terms of mortality (OR 0.83 [0.54, 1.27], p = 0.38; I²: 0%). Subgroup analysis showed that the use of ARB was associated with reduced mortality (OR 0.51 [0.29, 0.90], p = 0.02; I²: 22%) but not ACEI subgroup (OR 0.68 [0.39, 1.17], p = 0.16; I²: 0%). Meta-regression showed that the association between ACEI/ARB use and mortality in patients with COVID-19 do not varies by gender (p = 0.104). GRADE showed a very low certainty of evidence for effect of ACEI/ARB on mortality and severity. The certainty of evidence was very low for both ACEI and ARB subgroups.

CONCLUSION

Administration of a renin angiotensin system (RAS) inhibitor, was not associated with increased mortality or severity of COVID-19 in patients with hypertension. Specifically, ARB and not ACEI use, was associated with lower mortality.

Multiorgan Failure With Emphasis on Acute Kidney Injury and Severity of COVID-19: Systematic Review and Meta-Analysis

BACKGROUND

Abnormalities in hematologic, biochemical, and immunologic biomarkers have been shown to be associated with severity and mortality in Coronavirus Disease 2019 (COVID-19). Therefore, early evaluation and monitoring of both liver and kidney functions, as well as hematologic parameters, are pivotal to forecast the progression of COVID-19.

OBJECTIVES

In this study, we performed a systematic review and meta-analysis to investigate the association between several complications, including acute kidney injury (AKI), acute liver injury (ALI), and coagulopathy, with poor outcomes in COVID-19.

DESIGN

Systematic review and meta-analysis.

SETTING

Observational studies reporting AKI, ALI, and coagulopathy along with the outcomes of clinically validated death, severe COVID-19, or intensive care unit (ICU) care were included in this study. The exclusion criteria were abstract-only publications, review articles, commentaries, letters, case reports, non-English language articles, and studies that did not report key exposures or outcomes of interest.

PATIENTS

Adult patients diagnosed with COVID-19.

MEASUREMENTS

Data extracted included author, year, study design, age, sex, cardiovascular diseases, hypertension, diabetes mellitus, respiratory comorbidities, chronic kidney disease, mortality, severe COVID-19, and need for ICU care.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, EuropePMC, and the Cochrane Central Database. AKI and ALI follow the definition of the included studies. Coagulopathy refers to the coagulopathy or disseminated intravascular coagulation defined in the included studies. The outcome of interest was a composite of mortality, need for ICU care, and severe COVID-19. We used random-effects models regardless of heterogeneity to calculate risk ratios (RRs) for dichotomous variables. Heterogeneity was assessed using I 2. Random effects meta-regression was conducted for comorbidities and the analysis was performed for one covariate at a time.

RESULTS

There were 3615 patients from 15 studies. The mean Newcastle-Ottawa scale of the included studies was 7.3 ± 1.2. The AKI was associated with an increased the composite outcome (RR: 10.55 [7.68, 14.50], P < .001; I 2: 0%). Subgroup analysis showed that AKI was associated with increased mortality (RR: 13.38 [8.15, 21.95], P < .001; I 2: 24%), severe COVID-19 (RR: 8.12 [4.43, 14.86], P < .001; I 2: 0%), and the need for ICU care (RR: 5.90 [1.32, 26.35], P = .02; I 2: 0%). The ALI was associated with increased mortality (RR: 4.02 [1.51, 10.68], P = .005; I 2: 88%) in COVID-19. Mortality was higher in COVID-19 with coagulopathy (RR: 7.55 [3.24, 17.59], P < .001; I 2: 69%). The AKI was associated with the composite outcome and was not influenced by age (P = .182), sex (P = .104), hypertension (P = .788), cardiovascular diseases (P = .068), diabetes (P = .097), respiratory comorbidity (P = .762), and chronic kidney disease (P = .77).

LIMITATIONS

There are several limitations of this study. Many of these studies did not define the extent of AKI (grade), which may affect the outcome. Acute liver injury and coagulopathy were not defined in most of the studies. The definition of severe COVID-19 differed across studies. Several articles included in the study were published at preprint servers and are not yet peer-reviewed. Most of the studies were from China; thus, some patients might overlap across the reports. Most of the included studies were retrospective in design.

CONCLUSIONS

This meta-analysis showed that the presence of AKI, ALI, and coagulopathy was associated with poor outcomes in patients with COVID-19.

Report of Two COVID-19 ARDS (CARDS) Cases Who Survived without Intubation and Mechanical Ventilation

The most severe clinical feature of COVID-19 is Acute Respiratory Distress Syndrome (ARDS) which requires intubation and mechanical ventilation and it occurs in approximately 2.3% of cases. About 94% of of these cases end in death. This case series report two confirmed COVID-19 patients who had met criteria of intubation and mechanical ventilation, but not performed to them. Both patients experienced clinical improvement and recovery. Probably this is due to differences of COVID-19 ARDS (CARDS) with typical or classic ARDS.  CARDS is divided into two phenotypes of type L (Low Elastance) and type H (High Elastance). These different phenotypic also distinguish subsequent pathophysiology and clinical management. These phenotype can be differentiate by chest CT scan. This case series emphasizes the importance of understanding this phenotype so that clinicians can provide more appropriate treatment management and also availability of CT scans in health facilities that manage COVID -19.

The Phytochemical Screening, Total Phenolic Contents and Antioxidant Activities in Vitro of White Oyster Mushroom (Pleurotus Ostreatus) Preparations

BACKGROUND

The popular commercially cultivated Pleurotus ostreatus mushroom contains very high nutrients and bioactive compounds with high antioxidant activity. The ethanolic extract seems to be the most active in preparation.

AIM

This study has an aim to compare the phytochemical analysis of a fresh, dry and ethanolic extract of Pleurotus ostreatus, to measure the total phenolic content and antioxidant activities in vitro of ethanolic extracts of Pleurotus ostreatus.

METHODS

The fresh plant's materials (FPM), dry plants materials (DPM), ethanolic extracts were macerated with 70% (EE70) and 96% ethanol (EE96) of Pleurotus ostreatus which were used for phytochemical analysis, and EE96 was used for antioxidant activity in vitro. The phytochemical analysis was conducted using the Dragendorf and Meyer, FeCl3 test, Salkowsky method, Lieberman method, amyl alcohol, foam test and the NaOH reagent. The total phenol test was carried out using the Follin-Ciocalteu method. The antioxidant activity was tested using the ABTS and H2O2 essay.

RESULTS

The phytochemical screening showed that the flavonoid, phenolic compounds, tannin, saponin, alkaloids, and steroids were detected in the FPM, DPM, EE70 and also the EE96. The alkaloid, however, was not identified by the Meyer Reagent in the FPM and DPM. The DPM and EE70 seemed to have the highest amount of saponin based on the foam that was formed. Meanwhile, steroids and flavonoids were detected at a higher level in the EE96, based on the strength of visible colour. However, triterpenoid and quinones could not be identified. In the total phenol test, there was an amount of 6.67 μg phenol in a 1 mg extract sample which was equivalent to 1 mg of Gallic Acid. The EE96 has an IC50 of 108.07 μg/mL for ABTS and an IC50 reduction of 229.17 μg/mL. The process of Pleurotus ostreatus drying did not reduce the content of active substances. The polar active substances seem to be more soluble in the EE70 than the EE96.

CONCLUSION

The higher the bioactive substances in the preparation, the more significant the bio-therapeutic effects. Ethanolic extract of Pleurotus ostreatus has a phenol content and a good antioxidant action.

Evaluation of Xpert MTB-RIF guided diagnosis and treatment of rifampicin-resistant tuberculosis in Indonesia: A retrospective cohort study

BACKGROUND

Rifampicin-resistant tuberculosis (RR-TB) is largely underdetected in Indonesia. Xpert MTB/RIF (Xpert) has recently been introduced, prioritizing patients at risk of RR-TB, followed by phenotypic drug-susceptibility (DST) if rifampicin resistance is detected.

OBJECTIVE

This study investigated Xpert-based management of presumptive RR-TB cases under routine practice in West Java, Indonesia.

METHODS

We examined all records of patients tested with Xpert in the referral hospital for West Java in 2015-2016. We measured loss across a limited cascade of care, time to Xpert diagnosis and the commencement of initial second-line treatment, and identified factors associated with diagnostic and treatment delay. Additionally, we analyzed the appropriateness of treatment according to DST results.

RESULTS

Of 3415 patients with presumptive RR-TB, 3215 (94%) were tested by Xpert, of whom 339 (10.5%) were diagnosed as RR-TB. 288 (85%) of 339 RR-TB patients started initial second-line TB treatment, with 48 (14%) patients being lost between diagnosis and pre-treatment assessment. Second-line treatment was commenced at a median of 41 days (IQR 29-70) after RR-TB diagnosis. Delays in both diagnosis and treatment initiation were observed in 104 (52%) of 201 RR-TB patients with identifiable referral date. Rural residence was associated with delay to diagnosis (adjusted OR 2.7; 95%CI 1.5-5.2) and treatment initiation (adjusted OR 2.0; 1.2-3.4). Of 162 patients with available DST result, 107 (66%) had multidrug-resistant tuberculosis (MDR-TB) and 32 (20%) had either pre-extensively drug resistant (pre-XDR) or extensively drug resistant tuberculosis (XDR-TB). We estimated that with the current algorithm 41% of pre-XDR or XDR-TB patients are diagnosed, and 33% of them started on an appropriate treatment regimen.

CONCLUSIONS

Many patients with Xpert-diagnosed RR-TB either do not start MDR-TB treatment or encountered diagnostic and treatment delays under programmatic conditions in Indonesia, and most pre-XDR and XDR-TB cases remain undiagnosed. Further expansion and ongoing quality improvement of RR-TB services are urgently needed.

Association Between Arg753Gln and Arg677Trp Polymorphisms of TLR2 Gene with Active Pulmonary Tuberculosis in an Indonesian Population

BACKGROUND

Toll-like receptor is a pattern recognition receptor (PRR) that recognize pathogen-associated molecular pattern (PAMP) in a microorganism. Macrophages recognize the presence of mycobacteria through Toll-Like Receptor 2 (TLR2) and signaling further lead to the production of cytokines, both proinflammatory TNF-α, IL-1β, IL-6, IL-12, IL-15, IL-18 and IFN-γ, as well as anti-inflammatory IL4, IL-10 and TGF-β. TLR2 gene polymorphism is strongly determined by ethnicity and geography. Therefore it is necessary to uncovered the existence and association between Arg753Gln and Arg677Trp TLR2 gene polymorphism with TB susceptibility and its underlying mechanisms in Indonesian population in Bandung West Java.

METHODS

analytical observational study with cross-sectional design was conducted in Hasan Sadikin General Hospital Bandung from April 2011 to May 2012. Study population consisted of active pulmonary TB patient with positive AFB smear and Latent TB  to ascertain previous MTb exposure. Polymorphism of gen Arg753Gln and Arg677Trp gene was determined with polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methods. Plasma levels of IFN-γ, TNF-α, IL-10 and IL-12 were also compared between active and latent TB group.

RESULTS

heterozygote Arg753Gln TLR2 gene polymorphism was found in 9 of 86 pulmonary TB subjects (10.5%) but none in the latent TB group. The Arg677Trp polymorphism was not found in both groups. The odds ratio for Arg753Gln existence was 28.07 (p=0.022). No differences in the levels of IFN-γ, TNF-α, IL-10 and IL-12 between active pulmonary TB and latent TB subjects with and without Arg753Gln TLR2 gene polymorphism. Conlusion: Arg753Gln polymorphism of TLR2 gene is a risk factor for active pulmonary TB while Arg677Trp polymorphism is not. The Increased risk is not mediated by the difference in IFN-γ, TNF-α, IL-10 and IL-12 serum levels.