|
51
|
Belhassen-García M, Sánchez-Puente A, Dorado-Díaz PI, López-Bernús A, Sampedro-Gómez J, Azibeiro-Melchor R, Marcano-Millán E, Rodríguez-Alonso B, Sánchez-Barrado ME, Hernández-García I, Madruga I, Hernández-Pérez G, Carbonell C, García-Aparicio J, Burgos L, López-Sánchez E, Reina C, Ramón AM, Cestero-Ramírez L, Boumhir F, Encinas-Sánchez D, Sánchez-Ledesma M, Herráez J, Araoz P, Sánchez-Crespo MJ, Rodríguez-Rodríguez S, Rodríguez-Gude AE, Sánchez-Hernández MV, Borrás R, Sagredo-Meneses V, Sánchez PL, Marcos M, Martín-Oterino JÁ. Date of Admission during COVID-19 Pandemic Impacted Patient Outcomes in Addition to the Higher Efficacy of Tocilizumab Plus High-Dose Corticosteroid Therapy Compared to Tocilizumab Alone. J Clin Med 2021; 11:jcm11010198. [PMID: 35011938 PMCID: PMC8746130 DOI: 10.3390/jcm11010198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The evidence for the efficacy of glucocorticoids combined with tocilizumab (TCZ) in COVID-19 comes from observational studies or subgroup analysis. Our aim was to compare outcomes between hospitalized COVID-19 patients who received high-dose corticosteroid pulse therapy and TCZ and those who received TCZ. METHODS A retrospective single-center study was performed on consecutive hospitalized patients with severe COVID-19 between 1 March and 23 April 2020. Patients treated with either TCZ (400-600 mg, one to two doses) and methylprednisolone pulses (MPD-TCZ group) or TCZ alone were analyzed for the occurrence of a combined endpoint of death and need for invasive mechanical ventilation during admission. The independence of both treatment groups was tested using machine learning classifiers, and relevant variables that were potentially different between the groups were measured through a mean decrease accuracy algorithm. RESULTS An earlier date of admission was significantly associated with worse outcomes regardless of treatment type. Twenty patients died (27.0%) in the TCZ group, and 33 (44.6%) died or required intubation (n = 74), whereas in the MPD-TCZ group, 15 (11.0%) patients died and 29 (21.3%) patients reached the combined endpoint (n = 136; p = 0.006 and p < 0.001, respectively). Machine learning methodology using a random forest classifier confirmed significant differences between the treatment groups. CONCLUSIONS MPD and TCZ improved outcomes (death and invasive mechanical ventilation) among hospitalized COVID-19 patients, but confounding variables such as the date of admission during the COVID-19 pandemic should be considered in observational studies.
Collapse
Affiliation(s)
- Moncef Belhassen-García
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37007 Salamanca, Spain; (M.B.-G.); (A.L.-B.); (G.H.-P.); (C.C.)
- Centro de Investigación de Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), University of Salamanca, 37007 Salamanca, Spain
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Antonio Sánchez-Puente
- Department of Cardiology, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (A.S.-P.); (P.-I.D.-D.); (J.S.-G.); (P.-L.S.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28013 Madrid, Spain
| | - Pedro-Ignacio Dorado-Díaz
- Department of Cardiology, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (A.S.-P.); (P.-I.D.-D.); (J.S.-G.); (P.-L.S.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28013 Madrid, Spain
| | - Amparo López-Bernús
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37007 Salamanca, Spain; (M.B.-G.); (A.L.-B.); (G.H.-P.); (C.C.)
- Centro de Investigación de Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), University of Salamanca, 37007 Salamanca, Spain
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Jesús Sampedro-Gómez
- Department of Cardiology, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (A.S.-P.); (P.-I.D.-D.); (J.S.-G.); (P.-L.S.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28013 Madrid, Spain
| | - Raúl Azibeiro-Melchor
- Department of Hematology, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain;
| | - Edgard Marcano-Millán
- Department of Intensive Care Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (E.M.-M.); (L.C.-R.); (V.S.-M.)
| | - Beatriz Rodríguez-Alonso
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - María-Elisa Sánchez-Barrado
- Department of Anesthesiology and Reanimation, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (M.-E.S.-B.); (M.-V.S.-H.)
| | - Ignacio Hernández-García
- Department of Preventive Medicine and Public Health, Lozano Blesa University Clinical Hospital of Zaragoza, 50009 Zaragoza, Spain;
| | - Ignacio Madruga
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Guillermo Hernández-Pérez
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37007 Salamanca, Spain; (M.B.-G.); (A.L.-B.); (G.H.-P.); (C.C.)
- Centro de Investigación de Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), University of Salamanca, 37007 Salamanca, Spain
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Cristina Carbonell
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37007 Salamanca, Spain; (M.B.-G.); (A.L.-B.); (G.H.-P.); (C.C.)
- Centro de Investigación de Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), University of Salamanca, 37007 Salamanca, Spain
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Judit García-Aparicio
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Laura Burgos
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Eugenia López-Sánchez
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Carlos Reina
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Ana-María Ramón
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Laura Cestero-Ramírez
- Department of Intensive Care Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (E.M.-M.); (L.C.-R.); (V.S.-M.)
| | - Fátima Boumhir
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Daniel Encinas-Sánchez
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - María Sánchez-Ledesma
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Jacinto Herráez
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Patricia Araoz
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - María-José Sánchez-Crespo
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Sandra Rodríguez-Rodríguez
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Ana-Elisa Rodríguez-Gude
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| | - Miguel-Vicente Sánchez-Hernández
- Department of Anesthesiology and Reanimation, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (M.-E.S.-B.); (M.-V.S.-H.)
| | - Rafael Borrás
- Department of Emergency Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain;
| | - Víctor Sagredo-Meneses
- Department of Intensive Care Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (E.M.-M.); (L.C.-R.); (V.S.-M.)
| | - Pedro-Luis Sánchez
- Department of Cardiology, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (A.S.-P.); (P.-I.D.-D.); (J.S.-G.); (P.-L.S.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28013 Madrid, Spain
| | - Miguel Marcos
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
- Correspondence: ; Tel.: +34-923-291100 (ext. 55437); Fax: +34-923-294739
| | - José-Ángel Martín-Oterino
- Department of Internal Medicine, University Hospital of Salamanca-IBSAL, University of Salamanca, 37007 Salamanca, Spain; (B.R.-A.); (I.M.); (J.G.-A.); (L.B.); (E.L.-S.); (C.R.); (A.-M.R.); (F.B.); (D.E.-S.); (M.S.-L.); (J.H.); (P.A.); (M.-J.S.-C.); (S.R.-R.); (A.-E.R.-G.); (J.-Á.M.-O.)
| |
Collapse
|
|
52
|
Kluge S, J. Malin J, Fichtner F, J. Müller O, Skoetz N, Karagiannidis C. Clinical Practice Guideline: Recommendations on the In-hospital Treatment of Patients with COVID-19. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:865-871. [PMID: 34789365 PMCID: PMC8948341 DOI: 10.3238/arztebl.m2021.0374] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The mortality of COVID-19 patients who are admitted to a hospital because of the disease remains high. The implementation of evidence-based treatments can improve the quality of care. METHODS The new clinical practice guideline is based on publications retrieved by a systematic search in the Medline databases via PubMed and in the Cochrane COVID-19 trial registry, followed by a structured consensus process leading to the adoption of graded recommendations. RESULTS Therapeutic anticoagulation can be considered in patients who do not require intensive care and have an elevated risk of thromboembolism (for example, those with D-dimer levels ≥ 2 mg/L). For patients in intensive care, therapeutic anticoagulation has no benefit. For patients with hypoxemic respiratory insufficiency, prone positioning and an early therapy attempt with CPAP/noninvasive ventilation (CPAP, continuous positive airway pressure) or high-flow oxygen therapy is recommended. Patients with IgG-seronegativity and, at most, low-flow oxygen should be treated with SARS-CoV-2-specific monoclonal antibodies (at present, casirivimab and imdevimab). Patients needing no more than low-flow oxygen should additionally be treated with janus kinase (JAK) inhibitors. All patients who need oxygen (low-flow, high-flow, noninvasive ventilation/CPAP, invasive ventilation) should be given systemic corticosteroids. Tocilizumab should be given to patients with a high oxygen requirement and progressively severe COVID-19 disease, but not in combination with JAK inhibitors. CONCLUSION Noninvasive ventilation, high-flow oxygen therapy, prone positioning, and invasive ventilation are important elements of the treatment of hypoxemic patients with COVID-19. A reduction of mortality has been demonstrated for the administration of monoclonal antibodies, JAK inhibitors, corticosteroids, tocilizumab, and therapeutic anticoagulation to specific groups of patients.
Collapse
Affiliation(s)
- Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob J. Malin
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Falk Fichtner
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig Medical Center, Leipzig, Germany
| | - Oliver J. Müller
- Department of Internal Medicine III, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Nicole Skoetz
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Cologne, Germany
| | | |
Collapse
|
|
53
|
Paludan-Müller AS, Lundh A, Page MJ, Munkholm K. Protocol: Benefits and harms of remdesivir for COVID-19 in adults: A systematic review with meta-analysis. PLoS One 2021; 16:e0260544. [PMID: 34843589 PMCID: PMC8629254 DOI: 10.1371/journal.pone.0260544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/10/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Effective drug treatments for Covid-19 are needed to decrease morbidity and mortality for the individual and to alleviate pressure on health care systems. Remdesivir showed promising results in early randomised trials but subsequently a large publicly funded trial has shown less favourable results and the evidence is interpreted differently in clinical guidelines. Systematic reviews of remdesivir have been published, but none have systematically searched for unpublished data, including regulatory documents, and assessed the risk of bias due to missing evidence. METHODS We will conduct a systematic review of randomised trials comparing remdesivir to placebo or standard of care in any setting. We will include trials regardless of the severity of disease and we will include trials examining remdesivir for indications other than Covid-19 for harms analyses. We will search websites of regulatory agencies, trial registries, bibliographic databases, preprint servers and contact trial sponsors to obtain all available data, including unpublished clinical data, for all eligible trials. Our primary outcomes will be all-cause mortality and serious adverse events. Our secondary outcomes will be length of hospital stay, time to death, severe disease, and adverse events. We will assess the risk of bias using the Cochranes Risk of Bias 2 tool and the risk of bias due to missing evidence (e.g. publication bias, selective reporting bias) using the ROB-ME tool. Where appropriate we will synthesise study results by conducting random-effects meta-analysis. We will present our findings in a Summary of Findings table and rate the certainty of the evidence using the GRADE approach. DISCUSSION By conducting a comprehensive systematic review including unpublished data (where available), we expect to be able to provide valuable information for patients and clinicians about the benefits and harms of remdesivir for the treatment of Covid-19. This will help to ensure optimal treatment for individual patients and optimal utilisation of health care resources. SYSTEMATIC REVIEW REGISTRATION CRD42021255915.
Collapse
Affiliation(s)
- Asger Sand Paludan-Müller
- Department of Clinical Research, Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, University of Southern Denmark, Odense, Denmark
- Open Patient Data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- * E-mail:
| | - Andreas Lundh
- Department of Clinical Research, Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, University of Southern Denmark, Odense, Denmark
- Open Patient Data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Infectious Diseases, Hvidovre University Hospital, Hvidovre, Denmark
| | - Matthew J. Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Klaus Munkholm
- Department of Clinical Research, Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, University of Southern Denmark, Odense, Denmark
- Open Patient Data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| |
Collapse
|
|
54
|
Hashimoto T, Murayama A, Mamada H, Saito H, Tanimoto T, Ozaki A. Evaluation of Financial Conflicts of Interest and Drug Statements in the Coronavirus Disease 2019 Clinical Practice Guideline in Japan. Clin Microbiol Infect 2021; 28:460-462. [PMID: 34826620 PMCID: PMC8610564 DOI: 10.1016/j.cmi.2021.11.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Takanao Hashimoto
- Medical Governance Research Institute, Minato City, Tokyo, Japan; Department of Pharmacy, Sendai City Medical Center, Sendai City, Miyagi, Japan
| | - Anju Murayama
- Medical Governance Research Institute, Minato City, Tokyo, Japan; Tohoku University School of Medicine, Sendai City, Miyagi, Japan.
| | - Hanano Mamada
- Medical Governance Research Institute, Minato City, Tokyo, Japan
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kosei Hospital, Sendai City, Miyagi, Japan
| | - Tetsuya Tanimoto
- Department of Internal Medicine, Navitas Clinic, Tachikawa City, Tokyo, Japan
| | - Akihiko Ozaki
- Medical Governance Research Institute, Minato City, Tokyo, Japan; Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki City, Fukushima, Japan
| |
Collapse
|
|
55
|
Onorato L, Pisaturo M, Camaioni C, Grimaldi P, Codella AV, Calò F, Coppola N. Risk and Prevention of Hepatitis B Virus Reactivation during Immunosuppression for Non-Oncological Diseases. J Clin Med 2021; 10:5201. [PMID: 34768721 PMCID: PMC8584565 DOI: 10.3390/jcm10215201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/30/2021] [Accepted: 11/03/2021] [Indexed: 12/31/2022] Open
Abstract
Reactivation of overt or occult HBV infection (HBVr) is a well-known, potentially life-threatening event which can occur during the course of immunosuppressive treatments. Although it has been described mainly in subjects receiving therapy for oncological or hematological diseases, the increasing use of immunosuppressant agents in non-oncological patients observed in recent years has raised concerns about the risk of reactivation in several other settings. However, few data can be found in the literature on the occurrence of HBVr in these populations, and few clear recommendations on its management have been defined. The present paper was written to provide an overview of the risk of HBV reactivation in non-neoplastic patients treated with immunosuppressive drugs, particularly for rheumatological, gastrointestinal, dermatological and neurological diseases, and for COVID-19 patients receiving immunomodulating agents; and to discuss the potential strategies for prevention and treatment of HBVr in these settings.
Collapse
Affiliation(s)
- Lorenzo Onorato
- Department of Mental Health and Public Medicine, Faculty of Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80138 Naples, Italy; (L.O.); (M.P.); (C.C.); (P.G.)
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Via Pansini 5, 80138 Naples, Italy; (A.V.C.); (F.C.)
| | - Mariantonietta Pisaturo
- Department of Mental Health and Public Medicine, Faculty of Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80138 Naples, Italy; (L.O.); (M.P.); (C.C.); (P.G.)
| | - Clarissa Camaioni
- Department of Mental Health and Public Medicine, Faculty of Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80138 Naples, Italy; (L.O.); (M.P.); (C.C.); (P.G.)
| | - Pierantonio Grimaldi
- Department of Mental Health and Public Medicine, Faculty of Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80138 Naples, Italy; (L.O.); (M.P.); (C.C.); (P.G.)
| | - Alessio Vinicio Codella
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Via Pansini 5, 80138 Naples, Italy; (A.V.C.); (F.C.)
| | - Federica Calò
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Via Pansini 5, 80138 Naples, Italy; (A.V.C.); (F.C.)
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Faculty of Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80138 Naples, Italy; (L.O.); (M.P.); (C.C.); (P.G.)
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Via Pansini 5, 80138 Naples, Italy; (A.V.C.); (F.C.)
| |
Collapse
|
|
56
|
Maraolo AE, Crispo A, Piezzo M, Di Gennaro P, Vitale MG, Mallardo D, Ametrano L, Celentano E, Cuomo A, Ascierto PA, Cascella M. The Use of Tocilizumab in Patients with COVID-19: A Systematic Review, Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Studies. J Clin Med 2021; 10:4935. [PMID: 34768455 PMCID: PMC8584705 DOI: 10.3390/jcm10214935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Among the several therapeutic options assessed for the treatment of coronavirus disease 2019 (COVID-19), tocilizumab (TCZ), an antagonist of the interleukine-6 receptor, has emerged as a promising therapeutic choice, especially for the severe form of the disease. Proper synthesis of the available randomized clinical trials (RCTs) is needed to inform clinical practice. METHODS A systematic review with a meta-analysis of RCTs investigating the efficacy of TCZ in COVID-19 patients was conducted. PubMed, EMBASE, and the Cochrane COVID-19 Study Register were searched up until 30 April 2021. RESULTS The database search yielded 2885 records; 11 studies were considered eligible for full-text review, and nine met the inclusion criteria. Overall, 3358 patients composed the TCZ arm, and 3131 the comparator group. The main outcome was all-cause mortality at 28-30 days. Subgroup analyses according to trials' and patients' features were performed. A trial sequential analysis (TSA) was also carried out to minimize type I and type II errors. According to the fixed-effect model approach, TCZ was associated with a better survival odds ratio (OR) (0.84; 95% confidence interval (CI): 0.75-0.94; I2: 24% (low heterogeneity)). The result was consistent in the subgroup of severe disease (OR: 0.83; 95% CI: 0.74-0.93; I2: 53% (moderate heterogeneity)). However, the TSA illustrated that the required information size was not met unless the study that was the major source of heterogeneity was omitted. CONCLUSIONS TCZ may represent an important weapon against severe COVID-19. Further studies are needed to consolidate this finding.
Collapse
Affiliation(s)
- Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, AORN dei Colli, 80131 Naples, Italy;
| | - Anna Crispo
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (P.D.G.); (E.C.)
| | - Michela Piezzo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy;
| | - Piergiacomo Di Gennaro
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (P.D.G.); (E.C.)
| | - Maria Grazia Vitale
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto NazionaleTumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (M.G.V.); (D.M.); (P.A.A.)
| | - Domenico Mallardo
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto NazionaleTumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (M.G.V.); (D.M.); (P.A.A.)
| | - Luigi Ametrano
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131 Naples, Italy;
| | - Egidio Celentano
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (P.D.G.); (E.C.)
| | - Arturo Cuomo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (A.C.); (M.C.)
| | - Paolo A. Ascierto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto NazionaleTumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (M.G.V.); (D.M.); (P.A.A.)
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131 Naples, Italy; (A.C.); (M.C.)
| |
Collapse
|
|
57
|
Kimber C, Valk SJ, Chai KL, Piechotta V, Iannizzi C, Monsef I, Wood EM, Lamikanra AA, Roberts DJ, McQuilten Z, So-Osman C, Estcourt LJ, Skoetz N. Hyperimmune immunoglobulin for people with COVID-19. Hippokratia 2021. [DOI: 10.1002/14651858.cd015167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Sarah J Valk
- Center for Clinical Transfusion Research/Clinical Epidemiology; Sanquin/Leiden University Medical Center; Leiden Netherlands
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Vanessa Piechotta
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematology; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | | | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne; Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematology; Cologne Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | | | - David J Roberts
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Cynthia So-Osman
- Sanquin Blood Bank; Erasmus Medical Center; Amsterdam Netherlands
| | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, Department of Internal Medicine; Center for Integrated Oncology, University of Cologne; Cologne Germany
| |
Collapse
|
|
58
|
Dęborska-Materkowska D, Kamińska D. The Immunology of SARS-CoV-2 Infection and Vaccines in Solid Organ Transplant Recipients. Viruses 2021; 13:1879. [PMID: 34578460 PMCID: PMC8473113 DOI: 10.3390/v13091879] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022] Open
Abstract
Since its outbreak in December 2019, the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), led to an enormous rise in scientific response with an excess of COVID-19-related studies on the pathogenesis and potential therapeutic approaches. Solid organ transplant (SOT) recipients are a heterogeneous population with long-lasting immunosuppression as a joining element. Immunocompromised patients are a vulnerable population with a high risk of severe infections and an increased infection-related mortality rate. It was postulated that the hyperinflammatory state due to cytokine release syndrome during severe COVID-19 could be alleviated by immunosuppressive therapy in SOT patients. On the other hand, it was previously established that T cell-mediated immunity, which is significantly weakened in SOT recipients, is the main component of antiviral immune responses. In this paper, we present the current state of science on COVID-19 immunology in relation to solid organ transplantation with prospective therapeutic and vaccination strategies in this population.
Collapse
Affiliation(s)
- Dominika Dęborska-Materkowska
- Department of Transplantation Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland;
| | - Dorota Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| |
Collapse
|
|
59
|
Kirkham AM, Monaghan M, Bailey AJM, Shorr R, Lalu MM, Fergusson DA, Allan DS. Mesenchymal stromal cells as a therapeutic intervention for COVID-19: a living systematic review and meta-analysis protocol. Syst Rev 2021; 10:249. [PMID: 34526123 PMCID: PMC8441251 DOI: 10.1186/s13643-021-01803-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mesenchymal stromal cells (MSCs) have significant immunomodulatory and tissue repair capabilities, mediated partly by conditioned media or through secreted extracellular vesicles (MSC-EVs). Infection with SARS-CoV-2 can cause mild to life-threatening illness due to activated immune responses that may be dampened by MSCs or their secretome. Many clinical studies of MSCs have been launched since the beginning of the global pandemic, however, few have been completed and most lack power to assess efficacy. Repeated systematic searches and meta-analyses are needed to understand, in real time, the extent of potential benefit in different patient populations as the evidence emerges. METHODS This living systematic review will be maintained to provide up-to-date information as the pandemic evolves. A systematic literature search of Embase, MEDLINE, and Cochrane Central Register of Controlled Trials databases will be performed. All clinical studies (e.g., randomized, pseudorandomized and non-randomized controlled trials, uncontrolled trials, and case series) employing MSCs or their secretome as a therapeutic intervention for COVID-19 will be included. Patients must have confirmed SARS-CoV-2 infection. Study screening and data extraction will be performed in duplicate. Information concerning interventions, patient populations, methods of MSC isolation and characterization, primary and secondary clinical and/or laboratory outcomes, and adverse events will be extracted. Key clinical outcomes will be pooled through random-effects meta-analysis to determine the efficacy of MSCs and their secreted products for COVID-19. DISCUSSION Our systematic review and subsequent updates will inform the scientific, medical, and health policy communities as the pandemic evolves to guide decisions on the appropriate use of MSC-related products to treat COVID-19. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD 42021225431.
Collapse
Affiliation(s)
- Aidan M Kirkham
- Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada
| | - Madeline Monaghan
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada
| | - Adrian J M Bailey
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada.,School of Medicine, University of Ottawa, Ottawa, Canada
| | - Risa Shorr
- Medical Information and Learning Services, The Ottawa Hospital, Ottawa, Canada
| | - Manoj M Lalu
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Canada.,Regenerative Medicine, Ottawa Hospital Research Institute, 501 Smyth Rdx, Box 704, Ottawa, ON, K1H 8L6, Canada.,Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada.,School of Public Health and Epidemiology, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - David S Allan
- Department of Biochemistry, Microbiology & Immunology, University of Ottawa, Ottawa, Canada. .,Clinical Epidemiology, Ottawa Hospital Research Institute, 501 Smyth Rd, Box 704, Ottawa, ON, K1H 8L6, Canada. .,Regenerative Medicine, Ottawa Hospital Research Institute, 501 Smyth Rdx, Box 704, Ottawa, ON, K1H 8L6, Canada. .,Department of Medicine, The Ottawa Hospital, Ottawa, Canada.
| |
Collapse
|
|
60
|
Kelly MM, Wilkinson JD, Rastegar M, Lewis MS, Betancourt J. Two Patients With Severe COVID Pneumonia Treated With the Seraph-100 Microbind Affinity Blood Filter. J Intensive Care Med 2021; 36:1228-1232. [PMID: 34516306 DOI: 10.1177/08850666211039744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We present 2 patients with rapidly escalating oxygen requirements from severe acute respiratory syndrome coronavirus 2 infection (COVID-19) treated with the Seraph100 Microbind Affinity Blood Filter under Emergency Use Authorization from the US Federal Drug Administration. The Seraph100 is an extracorporeal hemoperfusion filter previously demonstrated to remove viral particles and pro-inflammatory cytokines from the blood. Treatment with the Seraph100 filter was associated with a rapid improvement in oxygenation and both patients were discharged from the hospital without supplemental oxygen.
Collapse
Affiliation(s)
- Mark M Kelly
- 8783UCLA, Los Angeles, CA, USA.,19975VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jared D Wilkinson
- 8783UCLA, Los Angeles, CA, USA.,19975VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mandana Rastegar
- 8783UCLA, Los Angeles, CA, USA.,19975VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michael S Lewis
- 8783UCLA, Los Angeles, CA, USA.,19975VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jaime Betancourt
- 8783UCLA, Los Angeles, CA, USA.,19975VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
|
61
|
Tocilizumab treatment in severe COVID-19: a multicenter retrospective study with matched controls. Rheumatol Int 2021; 42:457-467. [PMID: 34515808 PMCID: PMC8436189 DOI: 10.1007/s00296-021-04965-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/03/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease-2019 (COVID-19) associated pneumonia may progress into acute respiratory distress syndrome (ARDS). Some patients develop features of macrophage activation syndrome (MAS). Elevated levels of IL-6 were reported to be associated with severe disease, and anti-IL-6R tocilizumab has been shown to be effective in some patients. This retrospective multicenter case–control study aimed to evaluate the efficacy of tocilizumab in hospitalized COVID-19 patients, who received standard of care with or without tocilizumab. Primary outcome was the progression to intubation or death. PSMATCH (SAS) procedure was used to achieve exact propensity score (PS) matching.
Data from 1289 patients were collected, and study population was reduced to 1073 based on inclusion–exclusion criteria. The composite outcome was observed more frequently in tocilizumab-users, but there was a significant imbalance between arms in all critical parameters. Primary analyses were carried out in 348 patients (174 in each arm) after exact PS matching according to gender, ferritin, and procalcitonin. Logistic regression models revealed that tocilizumab significantly reduced the intubation or death (OR 0.40, p = 0.0017). When intubation is considered alone, tocilizumab-users had > 60% reduction in odds of intubation. Multiple imputation approach, which increased the size of the matched patients up to 506, provided no significant difference between arms despite a similar trend for intubation alone group. Analysis of this retrospective cohort showed more frequent intubation or death in tocilizumab-users, but PS-matched analyses revealed significant results for supporting tocilizumab use overall in a subset of patients matched according to gender, ferritin and procalcitonin levels.
Collapse
|
|
62
|
Kreuzberger N, Hirsch C, Chai KL, Tomlinson E, Khosravi Z, Popp M, Neidhardt M, Piechotta V, Salomon S, Valk SJ, Monsef I, Schmaderer C, Wood EM, So-Osman C, Roberts DJ, McQuilten Z, Estcourt LJ, Skoetz N. SARS-CoV-2-neutralising monoclonal antibodies for treatment of COVID-19. Cochrane Database Syst Rev 2021; 9:CD013825. [PMID: 34473343 PMCID: PMC8411904 DOI: 10.1002/14651858.cd013825.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Monoclonal antibodies (mAbs) are laboratory-produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID-19). OBJECTIVES To assess the effectiveness and safety of SARS-CoV-2-neutralising mAbs for treating patients with COVID-19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS-CoV-2-targeting mAbs from first tests in humans onwards. SEARCH METHODS: We searched MEDLINE, Embase, the Cochrane COVID-19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)-only search on 30 July 2021. SELECTION CRITERIA We included studies that evaluated SARS-CoV-2-neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID-19. We excluded studies on prophylactic use of SARS-CoV-2-neutralising mAbs. DATA COLLECTION AND ANALYSIS Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all-cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. MAIN RESULTS We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non-hospitalised participants, and 61 years in two studies of hospitalised participants. Non-hospitalised individuals with COVID-19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3-4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3-4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3-4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID-19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3-4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. AUTHORS' CONCLUSIONS: The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non-hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS-CoV-2-neutralising mAbs. Further studies and long-term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS-CoV-2 variants may impact the effectiveness of SARS-CoV-2-neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS-CoV-2-neutralising mAbs for the treatment of COVID-19 and possible subgroup differences.
Collapse
Affiliation(s)
- Nina Kreuzberger
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Caroline Hirsch
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Zahra Khosravi
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Miriam Neidhardt
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Susanne Salomon
- Laboratory of Experimental Immunology, Institute of Virology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sarah J Valk
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, Netherlands
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - David J Roberts
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
|
63
|
Saravolatz LD. Early Use of Remdesivir: A Good Start. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021; 29:e265-e266. [PMID: 34539160 PMCID: PMC8436809 DOI: 10.1097/ipc.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
|
64
|
Nezametdinova VZ, Yunes RA, Dukhinova MS, Alekseeva MG, Danilenko VN. The Role of the PFNA Operon of Bifidobacteria in the Recognition of Host's Immune Signals: Prospects for the Use of the FN3 Protein in the Treatment of COVID-19. Int J Mol Sci 2021; 22:ijms22179219. [PMID: 34502130 PMCID: PMC8430577 DOI: 10.3390/ijms22179219] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/11/2022] Open
Abstract
Bifidobacteria are some of the major agents that shaped the immune system of many members of the animal kingdom during their evolution. Over recent years, the question of concrete mechanisms underlying the immunomodulatory properties of bifidobacteria has been addressed in both animal and human studies. A possible candidate for this role has been discovered recently. The PFNA cluster, consisting of five core genes, pkb2, fn3, aaa-atp, duf58, tgm, has been found in all gut-dwelling autochthonous bifidobacterial species of humans. The sensory region of the species-specific serine-threonine protein kinase (PKB2), the transmembrane region of the microbial transglutaminase (TGM), and the type-III fibronectin domain-containing protein (FN3) encoded by the I gene imply that the PFNA cluster might be implicated in the interaction between bacteria and the host immune system. Moreover, the FN3 protein encoded by one of the genes making up the PFNA cluster, contains domains and motifs of cytokine receptors capable of selectively binding TNF-α. The PFNA cluster could play an important role for sensing signals of the immune system. Among the practical implications of this finding is the creation of anti-inflammatory drugs aimed at alleviating cytokine storms, one of the dire consequences resulting from SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Venera Z. Nezametdinova
- Laboratory of Bacterial Genetics, The Vavilov Institute of General Genetics, 117971 Moscow, Russia; (V.Z.N.); (R.A.Y.); (M.G.A.)
| | - Roman A. Yunes
- Laboratory of Bacterial Genetics, The Vavilov Institute of General Genetics, 117971 Moscow, Russia; (V.Z.N.); (R.A.Y.); (M.G.A.)
| | - Marina S. Dukhinova
- International Institute ‘Solution Chemistry of Advanced Materials and Technologies’, ITMO University, 197101 Saint-Petersburg, Russia;
| | - Maria G. Alekseeva
- Laboratory of Bacterial Genetics, The Vavilov Institute of General Genetics, 117971 Moscow, Russia; (V.Z.N.); (R.A.Y.); (M.G.A.)
| | - Valery N. Danilenko
- Laboratory of Bacterial Genetics, The Vavilov Institute of General Genetics, 117971 Moscow, Russia; (V.Z.N.); (R.A.Y.); (M.G.A.)
- Correspondence:
| |
Collapse
|
|
65
|
Chu CF, Sabath F, Fibi-Smetana S, Sun S, Öllinger R, Noeßner E, Chao YY, Rinke L, Winheim E, Rad R, Krug AB, Taher L, Zielinski CE. Convalescent COVID-19 Patients Without Comorbidities Display Similar Immunophenotypes Over Time Despite Divergent Disease Severities. Front Immunol 2021; 12:601080. [PMID: 34867933 PMCID: PMC8634761 DOI: 10.3389/fimmu.2021.601080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 07/23/2021] [Indexed: 01/12/2023] Open
Abstract
COVID-19, the disease caused by SARS-CoV-2 infection, can assume a highly variable disease course, ranging from asymptomatic infection, which constitutes the majority of cases, to severe respiratory failure. This implies a diverse host immune response to SARS-CoV-2. However, the immunological underpinnings underlying these divergent disease courses remain elusive. We therefore set out to longitudinally characterize immune signatures of convalescent COVID-19 patients stratified according to their disease severity. Our unique convalescent COVID-19 cohort consists of 74 patients not confounded by comorbidities. This is the first study of which we are aware that excludes immune abrogations associated with non-SARS-CoV-2 related risk factors of disease severity. Patients were followed up and analyzed longitudinally (2, 4 and 6 weeks after infection) by high-dimensional flow cytometric profiling of peripheral blood mononuclear cells (PBMCs), in-depth serum analytics, and transcriptomics. Immune phenotypes were correlated to disease severity. Convalescence was overall associated with uniform immune signatures, but distinct immune signatures for mildly versus severely affected patients were detectable within a 2-week time window after infection.
Collapse
Affiliation(s)
- Chang-Feng Chu
- Institute of Virology, Technical University of Munich, Munich, Germany
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Infection Immunology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Friedrich Schiller University, Jena, Germany
| | - Florian Sabath
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
| | - Silvia Fibi-Smetana
- Institute of Biomedical Informatics, Graz University of Technology, Graz, Austria
| | - Shan Sun
- Institute of Virology, Technical University of Munich, Munich, Germany
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
| | - Rupert Öllinger
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
| | - Elfriede Noeßner
- Immunoanalytics-Tissue Control of Immunocytes, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich, Germany
| | - Ying-Yin Chao
- Institute of Virology, Technical University of Munich, Munich, Germany
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
| | - Linus Rinke
- Institute for Immunology, Biomedical Center, Faculty of Medicine, Ludwig-Maximilians-University Munich, Planegg-Martinsried, Germany
| | - Elena Winheim
- Institute for Immunology, Biomedical Center, Faculty of Medicine, Ludwig-Maximilians-University Munich, Planegg-Martinsried, Germany
| | - Roland Rad
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
| | - Anne B. Krug
- Institute for Immunology, Biomedical Center, Faculty of Medicine, Ludwig-Maximilians-University Munich, Planegg-Martinsried, Germany
| | - Leila Taher
- Institute of Biomedical Informatics, Graz University of Technology, Graz, Austria
| | - Christina E. Zielinski
- Institute of Virology, Technical University of Munich, Munich, Germany
- Central Institute for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany
- Infection Immunology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Friedrich Schiller University, Jena, Germany
| |
Collapse
|
|
66
|
Neubauer A, Johow J, Mack E, Burchert A, Meyn D, Kadlubiec A, Torje I, Wulf H, Vogelmeier CF, Hoyer J, Skevaki C, Muellenbach RM, Keller C, Schade-Brittinger C, Rolfes C, Wiesmann T. The janus-kinase inhibitor ruxolitinib in SARS-CoV-2 induced acute respiratory distress syndrome (ARDS). Leukemia 2021; 35:2917-2923. [PMID: 34385593 PMCID: PMC8358255 DOI: 10.1038/s41375-021-01374-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 01/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 (coronavirus disease 2019), which is associated with high morbidity and mortality, especially in elder patients. Acute respiratory distress syndrome (ARDS) is a life-threatening complication of COVID-19 and has been linked with severe hyperinflammation. Dexamethasone has emerged as standard of care for COVID-19 associated respiratory failure. In a non-randomized prospective phase II multi-center study, we asked whether targeted inhibition of Janus kinase-mediated cytokine signaling using ruxolitinib is feasible and efficacious in SARS-CoV-2- induced ARDS with hyperinflammation. Sixteen SARS-CoV-2 infected patients requiring invasive mechanical ventilation for ARDS were treated with ruxolitinib in addition to standard treatment. Ruxolitinib treatment was well tolerated and 13 patients survived at least the first 28 days on treatment, which was the primary endpoint of the trial. Immediate start of ruxolitinib after deterioration was associated with improved outcome, as was a lymphocyte-to-neutrophils ratio above 0.07. Together, treatment with the janus-kinase inhibitor ruxolitinib is feasible and might be efficacious in COVID-19 induced ARDS patients requiring invasive mechanical ventilation. The trial has been registered under EudraCT-No.: 2020-001732-10 and NCT04359290.
Collapse
Affiliation(s)
- Andreas Neubauer
- Klinik für Innere Medizin, Hämatologie, Onkologie, Immunologie, Philipps Universität and UKGM, Marburg, Germany.
| | - Johannes Johow
- Coordinating Center for Clinical Trials, Philipps Universität, Marburg, Germany
| | - Elisabeth Mack
- Klinik für Innere Medizin, Hämatologie, Onkologie, Immunologie, Philipps Universität and UKGM, Marburg, Germany
| | - Andreas Burchert
- Klinik für Innere Medizin, Hämatologie, Onkologie, Immunologie, Philipps Universität and UKGM, Marburg, Germany
| | | | - Andrea Kadlubiec
- Klinik für Innere Medizin, Hämatologie, Onkologie, Immunologie, Philipps Universität and UKGM, Marburg, Germany.,Coordinating Center for Clinical Trials, Philipps Universität, Marburg, Germany
| | - Iuliu Torje
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Kassel, Kassel, Germany
| | - Hinnerk Wulf
- Klinik für Anästhesiologie und Intensivmedizin, Philipps Universität and UKGM, Marburg, Germany
| | - Claus F Vogelmeier
- Klinik für Innere Medizin, Schwerpunkt Pneumologie, Intensiv- und Schlafmedizin, Philipps Universität and UKGM, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Joachim Hoyer
- Klinik für Innere Medizin, Nephrologie, Philipps Universität and UKGM, Marburg, Germany
| | - Chrysanthi Skevaki
- Institut für Labormedizin, Universities of Giessen and Marburg Lung Center (UGMLC), Philipps Universität Marburg, German Center for Lung Research (DZL), Marburg, Germany
| | | | - Christian Keller
- Institut für Virologie, Philipps Universität and UKGM, Marburg, Germany
| | | | - Caroline Rolfes
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Kassel, Kassel, Germany.,Klinik für Anästhesiologie und Intensivmedizin, Philipps Universität and UKGM, Marburg, Germany
| | - Thomas Wiesmann
- Klinik für Anästhesiologie und Intensivmedizin, Philipps Universität and UKGM, Marburg, Germany
| |
Collapse
|
|
67
|
Chen PK, Lan JL, Huang PH, Hsu JL, Chang CK, Tien N, Lin HJ, Chen DY. Interleukin-18 Is a Potential Biomarker to Discriminate Active Adult-Onset Still's Disease From COVID-19. Front Immunol 2021; 12:719544. [PMID: 34367188 PMCID: PMC8343229 DOI: 10.3389/fimmu.2021.719544] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background Hyperinflammation with dysregulated production of galectins and cytokines may develop in COVID-19 or adult-onset Still's disease (AOSD). Given the similar clinical features in both diseases, it is necessary to identify biomarkers that can differentiate COVID-19 from AOSD. However, the related data remain scarce currently. Methods In this cross-sectional study, plasma levels of galectin-3, galectin-9, and soluble TIM-3 (sTIM-3) were determined by ELISA in 55 COVID-19 patients (31 non-severe and 24 severe), 23 active AOSD patients, and 31 healthy controls (HC). The seropositivity for SARS-CoV-2 was examined using an immunochromatographic assay, and cytokine profiles were determined with the MULTIPLEX platform. Results Significantly higher levels of galectin-3, galectin-9, IL-1β, IL-1Ra, IL-10, IFN-α2, IL-6, IL-18, and TNF-α were observed in severe COVID-19 and active AOSD patients compared with HC (all p<0.001). AOSD, but not COVID-19, showed significantly higher IFN-γ and IL-17A compared with HC (both p<0.01). Moreover, active AOSD patients had 68-fold higher IL-18 levels and 5-fold higher ferritin levels than severe COVID-19 patients (both p<0.001). IL-18 levels at the cut-off value 190.5pg/mL had the highest discriminative power for active AOSD and severe COVID-19, with AUC 0.948, sensitivity 91.3%, specificity 95.8%, and accuracy of 91.5% (p<0.005). Multivariate regression analysis revealed IL-18 as a significant predictor of active AOSD (p<0.05). Conclusion Active AOSD patients share features of hyperinflammation and cytokine storm with severe COVID-19 patients but possess a distinct cytokine profile, including elevated IL-18, IL-6, IFN-γ, and IL-17A. IL-18 is a potential discriminator between AOSD and COVID-19 and may significantly predict active AOSD.
Collapse
Affiliation(s)
- Po-Ku Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- Translational Medicine Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Joung-Liang Lan
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- Rheumatic Diseases Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Po-Hao Huang
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Jye-Lin Hsu
- College of Medicine, China Medical University, Taichung, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Ching-Kun Chang
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Ni Tien
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hui-Ju Lin
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Der-Yuan Chen
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- Translational Medicine Laboratory, China Medical University Hospital, Taichung, Taiwan
- Ph.D. Program in Translational Medicine and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| |
Collapse
|
|
68
|
Parums DV. Editorial: Tocilizumab, a Humanized Therapeutic IL-6 Receptor (IL-6R) Monoclonal Antibody, and Future Combination Therapies for Severe COVID-19. Med Sci Monit 2021; 27:e933973. [PMID: 34276042 PMCID: PMC8299871 DOI: 10.12659/msm.933973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
Vaccinated, non-vaccinated, and immunosuppressed individuals will continue to be infected with SARS-CoV-2. Therefore, there is a priority to develop treatments that reduce the severity of COVID-19 in patients who require hospital admission. Interleukin-6 (IL-6) is a proinflammatory cytokine. In 2011, a humanized monoclonal antibody to the IL-6 receptor (IL-6R), tocilizumab, was approved by the US Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, and Castleman's disease. In 2017, tocilizumab was approved to treat chimeric antigen receptor (CAR) T-cell therapy-induced cytokine release syndrome (CRS). In 2021, the results of the REMAP-CAP clinical trial (NCT02735707) and the COVID-19 Therapy (RECOVERY) clinical trial (NCT04381936) supported FDA Emergency Use Authorization (EUA) for tocilizumab to treat hospitalized patients with moderate and severe COVID-19. Monoclonal antibodies are currently in clinical development or undergoing clinical trials to treat COVID-19. Further clinical trials will provide safety and efficacy data on targeting IL-6 and IL-6R and provide rationales for more personalized combination treatments to control the systemic effects of SARS-CoV-2 infection in hospitalized patients with moderate and severe COVID-19. This Editorial aims to present the background to the recent authorization of tocilizumab, a humanized therapeutic monoclonal antibody to the IL-6 receptor (IL-6R), for hospitalized patients with moderate and severe COVID-19 and future combination therapies.
Collapse
Affiliation(s)
- Dinah V Parums
- Science Editor, Medical Science Monitor, International Scientific Information, Inc., Mellville, NY, USA
| |
Collapse
|
|
69
|
Campi I, Gennari L, Merlotti D, Mingiano C, Frosali A, Giovanelli L, Torlasco C, Pengo MF, Heilbron F, Soranna D, Zambon A, Di Stefano M, Aresta C, Bonomi M, Cangiano B, Favero V, Fatti L, Perego GB, Chiodini I, Parati G, Persani L. Vitamin D and COVID-19 severity and related mortality: a prospective study in Italy. BMC Infect Dis 2021; 21:566. [PMID: 34126960 PMCID: PMC8200788 DOI: 10.1186/s12879-021-06281-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 06/03/2021] [Indexed: 12/17/2022] Open
Abstract
Background Vitamin D deficiency has been suggested to favor a poorer outcome of Coronavirus disease-19 (COVID-19). We aimed to assess if 25-hydroxyvitamin-D (25OHD) levels are associated with interleukin 6 (IL-6) levels and with disease severity and mortality in COVID-19. Methods We prospectively studied 103 in-patients admitted to a Northern-Italian hospital (age 66.1 ± 14.1 years, 70 males) for severely-symptomatic COVID-19. Fifty-two subjects with SARS-CoV-2 infection but mild COVID-19 symptoms (mildly-symptomatic COVID-19 patients) and 206 subjects without SARS-CoV-2 infection were controls. We measured 25OHD and IL-6 levels at admission and focused on respiratory outcome during hospitalization. Results Severely-symptomatic COVID-19 patients had lower 25OHD levels (18.2 ± 11.4 ng/mL) than mildly-symptomatic COVID-19 patients and non-SARS-CoV-2-infected controls (30.3 ± 8.5 ng/mL and 25.4 ± 9.4 ng/mL, respectively, p < 0.0001 for both comparisons). 25OHD and IL-6 levels were respectively lower and higher in severely-symptomatic COVID-19 patients admitted to intensive care Unit [(ICU), 14.4 ± 8.6 ng/mL and 43.0 (19.0–56.0) pg/mL, respectively], than in those not requiring ICU admission [22.4 ± 1.4 ng/mL, p = 0.0001 and 16.0 (8.0–32.0) pg/mL, p = 0.0002, respectively]. Similar differences were found when comparing COVID-19 patients who died in hospital [13.2 ± 6.4 ng/mL and 45.0 (28.0–99.0) pg/mL] with survivors [19.3 ± 12.0 ng/mL, p = 0.035 and 21.0 (10.5–45.9) pg/mL, p = 0.018, respectively). 25OHD levels inversely correlated with: i) IL-6 levels (ρ − 0.284, p = 0.004); ii) the subsequent need of the ICU admission [relative risk, RR 0.99, 95% confidence interval (95%CI) 0.98–1.00, p = 0.011] regardless of age, gender, presence of at least 1 comorbidity among obesity, diabetes, arterial hypertension, creatinine, IL-6 and lactate dehydrogenase levels, neutrophil cells, lymphocytes and platelets count; iii) mortality (RR 0.97, 95%CI, 0.95–0.99, p = 0.011) regardless of age, gender, presence of diabetes, IL-6 and C-reactive protein and lactate dehydrogenase levels, neutrophil cells, lymphocytes and platelets count. Conclusion In our COVID-19 patients, low 25OHD levels were inversely correlated with high IL-6 levels and were independent predictors of COVID-19 severity and mortality.
Collapse
Affiliation(s)
- Irene Campi
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Christian Mingiano
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alessandro Frosali
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Camilla Torlasco
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, 20100, Milan, Italy
| | - Martino F Pengo
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, 20100, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, 20100, Milan, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Marta Di Stefano
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Carmen Aresta
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Bonomi
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Biagio Cangiano
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Letizia Fatti
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanni Battista Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy. .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS, Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, 20100, Milan, Italy
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases & Lab of Endocrine and Metabolic Research, IRCCS, Istituto Auxologico Italiano, Via Magnasco 2, 20149, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| |
Collapse
|
|
70
|
Hirsch C, Valk SJ, Piechotta V, Chai KL, Estcourt LJ, Monsef I, Salomon S, Tomlinson E, Popp M, Wood EM, So-Osman C, Roberts DJ, McQuilten Z, Skoetz N, Kreuzberger N. SARS-CoV-2-neutralising monoclonal antibodies to prevent COVID-19. Hippokratia 2021. [DOI: 10.1002/14651858.cd014945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Caroline Hirsch
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | - Sarah J Valk
- Jon J van Rood Center for Clinical Transfusion Research; Sanquin/Leiden University Medical Center; Leiden Netherlands
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | - Susanne Salomon
- Laboratory of Experimental Immunology, Institute of Virology; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers; 1st Floor Education Centre, Royal United Hospital; Bath UK
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine; University Hospital Wuerzburg; Wuerzburg Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | | | - David J Roberts
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | - Nina Kreuzberger
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| |
Collapse
|
|
71
|
Verma AA, Pai M, Saha S, Bean S, Fralick M, Gibson JL, Greenberg RA, Kwan JL, Lapointe-Shaw L, Tang T, Morris AM, Razak F. Managing drug shortages during a pandemic: tocilizumab and COVID-19. CMAJ 2021; 193:E771-E776. [PMID: 33952621 PMCID: PMC8177913 DOI: 10.1503/cmaj.210531] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Amol A Verma
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont.
| | - Menaka Pai
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Sally Bean
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Michael Fralick
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Jennifer L Gibson
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Rebecca A Greenberg
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Janice L Kwan
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Terence Tang
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Andrew M Morris
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| | - Fahad Razak
- Li Ka Shing Knowledge Institute (Verma, Saha, Razak), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Verma, Fralick, Kwan, Lapointe-Shaw, Tang, Morris, Razak); Institute of Health Policy, Management and Evaluation (Verma, Gibson, Razak); Dalla Lana School of Public Health (Bean, Gibson); Joint Centre for Bioethics (Bean, Gibson); and Department of Paediatrics (Greenberg), University of Toronto; Sunnybrook Health Sciences Centre (Bean); Sinai Health System (Fralick, Greenberg, Kwan, Morris); Department of Medicine (Lapointe-Shaw), and Toronto General Hospital Research Institute (Lapointe-Shaw), University Health Network; Women's Institute for Health System Solutions and Virtual Care (Lapointe-Shaw), Women's College Hospital; ICES Central (Lapointe-Shaw); Institute for Better Health (Tang), Trillium Health Partners; Division of Infectious Diseases (Morris), Sinai Health System and University Health Network, Toronto, Ont.; Department of Medicine (Pai), McMaster University; Hamilton Regional Laboratory Medicine Program (Pai); Hamilton Health Sciences (Pai), Hamilton, Ont
| |
Collapse
|