Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19

Targeting USP22 to promote K63-linked ubiquitination and degradation of SARS-CoV-2 nucleocapsid protein

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) generally hijacks the cellular machinery of host cells for survival. However, how SARS-CoV-2 employs the host's deubiquitinase to facilitate virus replication remains largely unknown. In this study, we identified the host deubiquitinase USP22 as a crucial regulator of the expression of SARS-CoV-2 nucleocapsid protein (SARS-CoV-2 NP), which is essential for SARS-CoV-2 replication. We demonstrated that SARS-CoV-2 NP proteins undergo ubiquitination-dependent degradation in host cells, while USP22 interacts with SARS-CoV-2 NP and downregulates K63-linked polyubiquitination of SARS-CoV-2 NP, thereby protecting SARS-CoV-2 NP from degradation. Importantly, we further revealed that sulbactam, an antibiotic, can reduce USP22 protein levels, eventually promoting the degradation of SARS-CoV-2 NP in vitro and in vivo. This study reveals the mechanism by which SARS-CoV-2-encoded NP protein employs host deubiquitinase for virus survival and provides a potential strategy to fight against SARS-CoV-2 infection.IMPORTANCESevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein (SARS-CoV-2 NP) plays a pivotal role in viral infection by binding to viral RNA, stabilizing the viral genome, and promoting replication. However, the interactions between SARS-CoV-2 NP and host intracellular proteins had not been elucidated. In this study, we provide evidence that SARS-CoV-2 NP interacts with the deubiquitinase USP22 in host cells, which downregulates SARS-CoV-2 NP ubiquitination. This reduction in ubiquitination effectively prevents intracellular degradation of SARS-CoV-2 NP, thereby enhancing its stability, marking USP22 as a potential target for antiviral strategies. Additionally, our findings indicate that sulbactam significantly decreases the protein levels of USP22, thereby reducing SARS-CoV-2 NP levels. This discovery suggests a novel therapeutic pathway in which sulbactam could be repurposed as an antiviral agent, demonstrating how certain antibiotics might contribute to antiviral treatment. This work thus opens avenues for drug repurposing and highlights the therapeutic potential of targeting host pathways to inhibit viral replication.

Cyclosporine may reduce the risk of symptomatic COVID-19 in patients with systemic lupus erythematosus: a retrospective cohort study

This study aimed to explore the effect of cyclosporine (CsA) on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in systemic lupus erythematosus (SLE) patients to provide a valuable reference for clinical treatment strategies in the context of the long-term risk of SARS-CoV-2 infection. SLE patients who visited the Rheumatology Outpatient Department of Fujian Medical University Union Hospital between 1 May and 31 October 2022 were included. Data on SARS-CoV-2 infection in patients between 1 November 2022 and 31 July 2023 were obtained by telephone follow-up. Patients were divided into two groups according to whether CsA was used during the observation period: the glucocorticoid or hydroxychloroquine group and the CsA group. To assess the robustness of the results, Data sets 1 and 2 were established to be analyzed independently. Multivariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for symptomatic coronavirus disease (COVID-19). A total of 184 patients were included, among whom 129 were definite symptomatic COVID-19 patients; 29 were presumptive symptomatic COVID-19 patients; and 4 had signs and symptoms of COVID-19, but tested negative for SARS-CoV-2 in a virological test. According to the multivariable-adjusted models, CsA was associated with lower odds of symptomatic COVID-19 (P = 0.042, OR = 0.316, 95% CI: 0.104-0.959 in Data set 1 and P = 0.021, OR = 0.257, 95% CI: 0.081-0.812 in Data set 2). CsA is associated with lower odds of contracting symptomatic COVID-19. The use of CsA may be considered an appropriate therapeutic option for disease management in patients with rheumatic diseases who have severe disease activity and persistent SARS-CoV-2 infection.

IMPORTANCE

Our study indicated that cyclosporine may reduce the risk of symptomatic COVID-19 in systemic lupus erythematosus patients in spite of its immunosuppressive effects. This study provides a reference for clinical treatment strategies for AIIRD patients in the context of the long-term risk of SARS-CoV-2 infection.

Bioinformatics and systems biology analysis revealed PMID26394986-Compound-10 as potential repurposable drug against covid-19

The global health pandemic known as COVID-19, which stems from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a significant concern worldwide. Several treatment methods exist for COVID-19; however, there is an urgent demand for previously established drugs and vaccines to effectively combat the disease. Since, discovering new drugs poses a significant challenge, making the repurposing of existing drugs can potentially reduce time and costs compared to developing entirely new drugs from scratch. The objective of this study is to identify hub genes and associated repurposed drugs targeting them. We analyzed differentially expressed genes (DEGs) by analyzing RNA-seq transcriptomic datasets and integrated with genes associated with COVID-19 present in different databases. We detected 173 Covid-19 associated genes for the construction of a protein-protein interaction (PPI) network which resulted in the identification of the top 10 hub genes/proteins (STAT1, IRF7, MX1, IRF9, ISG15, OAS3, OAS2, OAS1, IRF3, and IRF1). Hub genes were subjected to GO functional and KEGG pathway enrichment analyses, which indicated some key roles and signaling pathways that were strongly related to SARS-CoV-2 infections. We conducted drug repurposing analysis using CMap, TTD, and DrugBank databases with these 10 hub genes, leading to the identification of Piceatannol, CKD-712, and PMID26394986-Compound-10 as top-ranked candidate drugs. Finally, drug-gene interactions analysis through molecular docking and validated via molecular dynamic simulation for 80 ns suggests PMID26394986-Compound-10 as the only potential drug. Our research demonstrates how in silico analysis might produce repurposing candidates to help respond faster to new disease outbreaks.Communicated by Ramaswamy H. Sarma.

A review on hazards and treatment methods of released antibiotics in hospitals wastewater during the COVID-19 pandemic

Drugs and related goods are widely used in order to promote public health and the quality of life. One of the most serious environmental challenges affecting public health is the ongoing presence of antibiotics in the effluents generated by pharmaceutical industries and hospitals. Antibiotics cannot be entirely removed from wastewater using the traditional wastewater treatment methods. Unmetabolized antibiotics generated by humans can be found in urban and livestock effluent. The antibiotic present in effluent contributes to issues with resistance to antibiotics and the creation of superbugs. Over the recent 2 years, the coronavirus disease 2019 pandemic has substantially boosted hospital waste volume. In this situation, a detailed literature review was conducted to highlight the harmful effects of untreated hospital waste and outline the best approaches to manage it. Approximately 50 to 70% of the emerging contaminants prevalent in the hospital wastewater can be removed using traditional treatment strategies. This paper emphasizes the numerous treatment approaches for effectively eliminating emerging contaminants and antibiotics from hospital wastewater and provides an overview of global hospital wastewater legislation and guidelines on hospital wastewater administration. Around 90% of ECs might be eliminated by biological or physical treatment techniques when used in conjunction with modern oxidation techniques. According to this research, hybrid methods are the best approach for removing antibiotics and ECs from hospital wastewater. The document outlines the many features of effective hospital waste management and might be helpful during and after the coronavirus disease 2019 outbreak, when waste creation on all hospitals throughout the globe has considerably increased.

Applying EBM epistemology and the GRADE system to address practitioners' disagreements in medical malpractice allegations during COVID-19 pandemic

RATIONALE

The GRADE system of clinical recommendations has deontic implications and can discriminate between mandatory, prohibited, and merely permitted medical decisions.

AIMS AND OBJECTIVES

The recommendation categories of the GRADE framework map onto deontological imperatives that can lead to a better understanding and management of allegations of imprudence and appropriateness of treatments. Allegations made during the worst phase of COVID-19 pandemic are used as a case study for exploring the deontic implications of GRADE.

METHOD

Conceptual theoretical analysis, case study analysis, and argumentation in defence of hypotheses.

RESULTS

Strong GRADE recommendations for or against treatment are justified by high-quality evidence and can be construed as ethical obligations and prohibitions. In contrast, when evidence for benefit or harm is of lower quality, GRADE yields weak, discretionary recommendations. In such grey area cases, the absence of a duty to prescribe or refuse to prescribe a requested treatment is compatible with the privilege of considering unproven but possibly beneficial options in a private setting. This privilege, however, does not extend to healthcare policymakers, who have a duty to promote actions that serve the public and whose recommendations should not be guided by personal or idiosyncratic preferences or values.

CONCLUSION

If there is no prima facie evidence that a proposed treatment is harmful, doctors are not negligent in considering it in shared doctor-patient decision-making. But these clinical decisions under uncertainty do not transfer obligations to health authorities, who are not part of the decision-making process in clinical settings. The clinical decision-making process concerns particulars and is guided by contextual and specific reasons that do not fall within the scope of a general policy. Thus, in the context of a serious epidemic in which patients need and demand treatments, if the body of evidence is still changing and fragile, an attitude of tolerance and connivance may ensure a smoother transition to a more stable phase of progress, both in scientific and clinical medicine.

Antimalarial Drugs at the Intersection of SARS-CoV-2 and Rheumatic Diseases: What Are the Potential Opportunities?

Background and Objectives: The coronavirus disease of 2019 (COVID-19) pandemic has posed a serious threat to humanity and is considered a global health emergency. Antimalarial drugs (ADs) have been used in the treatment of immuno-inflammatory arthritis (IIA) and coronavirus infection (COVID-19). The aim of this review is to analyze the current knowledge about the immunomodulatory and antiviral mechanisms of action, characteristics of use, and side effects of antimalarial drugs. Material and Methods: A literature search was carried out using PubMed, MEDLINE, SCOPUS, and Google Scholar databases. The inclusion criteria were the results of randomized and cohort studies, meta-analyses, systematic reviews, and original full-text manuscripts in the English language containing statistically confirmed conclusions. The exclusion criteria were summary reports, newspaper articles, and personal messages. Qualitative methods were used for theoretical knowledge on antimalarial drug usage in AIRDs and SARS-CoV-2 such as a summarization of the literature and a comparison of the treatment methods. Results: The ADs were considered a "candidate" for the therapy of a new coronavirus infection due to mechanisms of antiviral activity, such as interactions with endocytic pathways, the prevention of glycosylation of the ACE2 receptors, blocking sialic acid receptors, and reducing the manifestations of cytokine storms. The majority of clinical trials suggest no role of antimalarial drugs in COVID-19 treatment or prevention. These circumstances do not allow for their use in the treatment and prevention of COVID-19. Conclusions: The mechanisms of hydroxychloroquine are related to potential cardiotoxic manifestations and demonstrate potential adverse effects when used for COVID-19. Furthermore, the need for high doses in the treatment of viral infections increases the likelihood of gastrointestinal side effects, the prolongation of QT, and retinopathy. Large randomized clinical trials (RCTs) have refuted the fact that there is a positive effect on the course and results of COVID-19.

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022)

There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.

A real-world pharmacovigilance study of polatuzumab vedotin based on the FDA adverse event reporting system (FAERS)

Background

Polatuzumab vedotin, the first FDA-approved antibody-drug conjugate (ADC) targeting CD79b, is utilized in the treatment of previously untreated diffuse large B-cell lymphoma (DLBCL) or high-grade B-cell lymphoma (HGBL), as well as relapsed or refractory (R/R) DLBCL. Despite its approval, concerns persist regarding the long-term safety profile of polatuzumab vedotin. This study aims to evaluate the adverse events (AEs) associated with polatuzumab vedotin since its approval in 2019, utilizing data mining strategies applied to the FDA Adverse Event Reporting System (FAERS).

Methods

Signal detection employed four methodologies, including reporting odds ratio (ROR), proportional reporting ratio (PRR), bayesian confidence propagation neural network (BCPNN), and multi-item gamma poisson shrinker (MGPS), to evaluate and quantify the signals of polatuzumab vedotin-associated AEs. Additionally, subgroup analyses based on patients age, gender, and fatal cases were conducted to investigate AEs occurrences in specific subpopulations.

Results

A total of 1,521 reports listing polatuzumab vedotin as a "principal suspect (PS)" drug were collected from the FAERS database. Through concurrent compliance with four algorithms, 19 significant Standardized MedDRA Query (SMQ) AEs and 92 significant Preferred Term (PT) AEs were detected. Subgroup analyses revealed a higher incidence of PTs in male patients compared to female patients, increased likelihood of polatuzumab vedotin-associated AEs in elder patients (>65 years), and AEs with a high risk of fatal cases include: blood lactate dehydrogenase increased, cytopenia, and hydronephrosis. The median time to AEs occurrence following polatuzumab vedotin initiation was 18.5 (5∼57.75) days, with 95% of AEs occurred within 162 days.

Conclusion

This study identified various AEs associated with polatuzumab vedotin, offering critical insights for clinical monitoring and risk identification in patients receiving polatuzumab vedotin therapy.

Zinc complexes of chloroquine and hydroxychloroquine versus the mixtures of their components: Structures, solution equilibria/speciation and cellular zinc uptake

The zinc complexes of chloroquine (CQ; [Zn(CQH+)Cl3]) and hydroxychloroquine (HO-CQ; [Zn(HO-CQH+)Cl3]) were synthesized and characterized by X-Ray structure analysis, FT-IR, NMR, UV-Vis spectroscopy, and cryo-spray mass spectrometry in solid state as well as in aqueous and organic solvent solutions, respectively. In acetonitrile, up to two Zn2+ ions bind to CQ and HO-CQ through the tertiary amine and aromatic nitrogen atoms (KN-aminCQ = (3.8 ± 0.5) x 104 M-1 and KN-aromCQ = (9.0 ± 0.7) x 103 M-1 for CQ, and KN-aminHO-CQ = (3.3 ± 0.4) x 104 M-1 and KN-aromHO-CQ = (1.6 ± 0.2) x 103 M-1 for HO-CQ). In MOPS buffer (pH 7.4) the coordination proceeds through the partially deprotonated aromatic nitrogen, with the corresponding equilibrium constants of KN-arom(aq)CQ = (3.9 ± 1.9) x 103 M-1and KN-arom(aq)HO-CQ = (0.7 + 0.4) x 103 M-1 for CQ and HO-CQ, respectively. An apparent partition coefficient of 0.22 was found for [Zn(CQH+)Cl3]. Mouse embryonic fibroblast (MEF) cells were treated with pre-synthesized [Zn((HO-)CQH+)Cl3] complexes and corresponding ZnCl2/(HO-)CQ mixtures and zinc uptake was determined by application of the fluorescence probe and ICP-OES measurements. Administration of pre-synthesized complexes led to higher total zinc levels than those obtained upon administration of the related zinc/(hydroxy)chloroquine mixtures. The differences in the zinc uptake between these two types of formulations were discussed in terms of different speciation and character of the complexes. The obtained results suggest that intact zinc complexes may exhibit biological effects distinct from that of the related zinc/ligand mixtures.

Assessing medication use patterns by clinical outcomes severity among inpatients with COVID-19: A retrospective drug utilization study

PURPOSE

This study assessed medication patterns for inpatients at a central hospital in Portugal and explored their relationships with clinical outcomes in COVID-19 cases.

METHODS

A retrospective study analyzed inpatient medication data, coded using the Anatomical Therapeutic Chemical classification system, from electronic patient records. It investigated the association between medications and clinical severity outcomes such as ICU admissions, respiratory/circulatory support needs, and hospital discharge status, including mortality (identified by ICD-10-CM/PCS codes). Multivariate analyses incorporating demographic data and comorbidities were used to adjust for potential confounders and understand the impact of medication patterns on disease progression and outcomes.

RESULTS

The analysis of 2688 hospitalized COVID-19 patients (55.3% male, average age 62.8 years) revealed a significant correlation between medication types and intensity and disease severity. Cases requiring ICU admission or ECMO support often involved blood and blood-forming organ drugs. Increased use of nervous system and genitourinary hormones was observed in nonsurvivors. Corticosteroids, like dexamethasone, were common in critically ill patients, while tocilizumab was used in ECMO cases. Medications for the alimentary tract, metabolism, and cardiovascular system, although widely prescribed, were linked to more severe cases. Invasive mechanical ventilation correlated with higher usage of systemic anti-infectives and musculoskeletal medications. Trends in co-prescribing blood-forming drugs with those for acid-related disorders, analgesics, and antibacterials were associated with intensive interventions and worse outcomes.

CONCLUSIONS

The study highlights complex medication regimens in managing severe COVID-19, underscoring specific drug patterns associated with critical health outcomes. Further research is needed to explore these patterns.

COVID-19 in patients with Down syndrome: A systematic review

INTRODUCTION

Down syndrome (DS) is associated with multiple comorbid conditions and chronic immune dysfunction. Persons with DS who contract COVID-19 are at high risk for complications and have a poor prognosis. We aimed to study the clinical symptoms, laboratory and biochemical profiles, radiologic findings, treatment, and outcomes of patients with DS and COVID-19.

METHOD

We systematically searched PubMed, MEDLINE, Web of Science, Scopus, and the Cochrane Library using the keywords COVID-19 or coronavirus or SARS-CoV-2 and DS or trisomy 21. Seventeen articles were identified: eight case reports and nine case series published from December 2019 through March 2022, with a total of 55 cases.

RESULTS

Patients averaged 24.8 years (26 days to 60 years); 29 of the patients were male. The most common symptoms were fever, dyspnea, and cough. Gastrointestinal and upper respiratory tract symptoms were commonly reported for pediatric patients. The most common comorbidities present in patients with DS were obesity (49.0%), hypothyroidism (21.6%) and obstructive sleep apnea (15.6%). The patients were hospitalized for a mean of 14.8 days. When the patients were compared with the general COVID-19 population, the mean number of hospitalized days was higher. Most patients had leukopenia, lymphopenia, and elevated inflammatory markers (d-dimer and C-reactive protein). Bilateral infiltrations and bilateral ground-glass opacifications were frequently seen in chest radiographs and chest computed tomographic imaging. Most of the patients were treated with methylprednisolone, macrolides, and hydroxychloroquine. Of the 55 patients, 22 died. The mean age of the patients who died was 42.8 years. Mortality rate was higher in individuals with DS over 40 years of age.

CONCLUSION

More studies are needed to better understand COVID-19 infections among persons with DS. In addition, the study was limited by a lack of statistical analyses and a specific comparison group.

Hydroxychloroquine and COVID-19 story: is the low-dose treatment the missing link? A comprehensive review and meta-analysis

Hydroxychloroquine (HCQ) has been repurposed and used for the treatment of COVID-19 patients; however, its efficacy remains controversial, maybe partly due to the dosage, ranging from 200 to 800 mg/day, reported in different studies. Indeed, HCQ low dose (≤ 2.4 g/5 days) showed a lower risk of side effects compared to high doses. In this study, we performed a systematic review and meta-analysis to investigate the effect of low-dose HCQ used alone on three outcomes including in-hospital mortality, the need for mechanical ventilation, and ICU admission in COVID-19 patients. A systematic review of English literature was conducted from January 2020 to April 2022, in PubMed, Cochrane Library, and Google Scholar. Studies reporting a dosage of 400 mg twice the first day, followed by 200 mg twice for four days were included. Pooled odds ratios and 95% confidence intervals were calculated using random-effects models. Eleven studies (12,503 patients) were retained in the quantitative analysis, four observational cohort studies, and seven RCTs. When pooling both observational and RCTs, low-dose HCQ was associated with decreased mortality (OR = 0.73, 95% CI: [0.55-0.97], I2 = 58%), but not with mechanical ventilation need (OR = 1.03, 95% CI: [0.56-1.89], I2 = 67%) and ICU admission rate (OR = 0.70, 95% CI: [0.42-1.17], I2 = 47%). However, no effect was observed when pooling only RCTs. Despite RCTs limitations, treatment with low-dose HCQ was not associated with improvement in mortality, mechanical ventilation need and ICU admission rate in COVID-19 patients.

Deaths induced by compassionate use of hydroxychloroquine during the first COVID-19 wave: an estimate

BACKGROUND

During the first wave of COVID-19, hydroxychloroquine (HCQ) was used off-label despite the absence of evidence documenting its clinical benefits. Since then, a meta-analysis of randomised trials showed that HCQ use was associated with an 11% increase in the mortality rate. We aimed to estimate the number of HCQ-related deaths worldwide.

METHODS AND FINDINGS

We estimated the worldwide in-hospital mortality attributable to HCQ use by combining the mortality rate, HCQ exposure, number of hospitalised patients, and the increased relative risk of death with HCQ. The mortality rate in hospitalised patients for each country was calculated using pooled prevalence estimated by a meta-analysis of published cohorts. The HCQ exposure was estimated using median and extreme estimates from the same systematic review. The number of hospitalised patients during the first wave was extracted from dedicated databases. The systematic review included 44 cohort studies (Belgium: k = 1, France: k = 2, Italy: k = 12, Spain: k = 6, Turkey: k = 3, USA: k = 20). HCQ prescription rates varied greatly from one country to another (range 16-84%). Overall, using median estimates of HCQ use in each country, we estimated that 16,990 HCQ-related in-hospital deaths (range 6267-19256) occurred in the countries with available data. The median number of HCQ-related deaths in Belgium, Turkey, France, Italy, Spain, and the USA was 240 (range not estimable), 95 (range 92-128), 199 (range not estimable), 1822 (range 1170-2063), 1895 (range 1475-2094) and 12739 (3244- 15570), respectively.

CONCLUSIONS

Although our estimates are limited by their imprecision, these findings illustrate the hazard of drug repurposing with low-level evidence.

Proposal for priority emerging pollutants in the Nakdong river, Korea: Application of EU watch list mechanisms

The Nakdong River, the longest in Korea, has received numerous pollutants from heavily industrialized and densely populated areas while being used as a drinking water source. A number of research have reported occurrences of emerging pollutants (EPs) in the river. The results requested efficient monitoring and systematic management strategies such as EU watch list under Water Framework Directive. The aim of this study is to propose a watch list through preliminary monitoring of the river and risk-based prioritization approach. As candidates for monitoring target, 632 substances were selected based on literature and database searches. Among them, 175 substances were subjected to target screening method whereas 457 were evaluated via suspect screening. A risk-based prioritization was applied to substances quantified through target screening based on concentrations, and a scoring-based prioritization was applied to substances tentatively identified through suspect screening. Sampling campaigns (n = 12) were conducted from October 2020 to September 2021, at 8 sampling sites along the river. As a result, 130 target substances were quantified above the LOQ. Among the 21 substances whose priority score was assigned through risk-based prioritization, telmisartan and iprobenfos were identified with very high environmental risk while candesartan, TBEP, imidacloprid, azithromycin and clotrimazole were classified with high or intermediate risk. As result of the scoring system for 39 tentatively identified substances, 6 substances (benzophenone, caprolactam, metolachlor oxanilic acid, heptaethylene glycol, octaethylene glycol and pentaethylene glycol), which were then confirmed with reference standards, showed a potential environmental risk. Those substances prioritized through target and suspect screening followed by scoring systems can be a subset for the watch list and potential targets for nationwide water quality monitoring program in the future.

Preclinical and Clinical Investigations of Potential Drugs and Vaccines for COVID-19 Therapy: A Comprehensive Review With Recent Update

The COVID-19 pandemic-led worldwide healthcare crisis necessitates prompt societal, ecological, and medical efforts to stop or reduce the rising number of fatalities. Numerous mRNA based vaccines and vaccines for viral vectors have been licensed for use in emergencies which showed 90% to 95% efficacy in preventing SARS-CoV-2 infection. However, safety issues, vaccine reluctance, and skepticism remain major concerns for making mass vaccination a successful approach to treat COVID-19. Hence, alternative therapeutics is needed for eradicating the global burden of COVID-19 from developed and low-resource countries. Repurposing current medications and drug candidates could be a more viable option for treating SARS-CoV-2 as these therapies have previously passed a number of significant checkpoints for drug development and patient care. Besides vaccines, this review focused on the potential usage of alternative therapeutic agents including antiviral, antiparasitic, and antibacterial drugs, protease inhibitors, neuraminidase inhibitors, and monoclonal antibodies that are currently undergoing preclinical and clinical investigations to assess their effectiveness and safety in the treatment of COVID-19. Among the repurposed drugs, remdesivir is considered as the most promising agent, while favipiravir, molnupiravir, paxlovid, and lopinavir/ritonavir exhibited improved therapeutic effects in terms of elimination of viruses. However, the outcomes of treatment with oseltamivir, umifenovir, disulfiram, teicoplanin, and ivermectin were not significant. It is noteworthy that combining multiple drugs as therapy showcases impressive effectiveness in managing individuals with COVID-19. Tocilizumab is presently employed for the treatment of patients who exhibit COVID-19-related pneumonia. Numerous antiviral drugs such as galidesivir, griffithsin, and thapsigargin are under clinical trials which could be promising for treating COVID-19 individuals with severe symptoms. Supportive treatment for patients of COVID-19 may involve the use of corticosteroids, convalescent plasma, stem cells, pooled antibodies, vitamins, and natural substances. This study provides an updated progress in SARS-CoV-2 medications and a crucial guide for inventing novel interventions against COVID-19.

Small molecules in the race of COVID-19 drug development

COVID-19, caused by SARS-CoV-2, is spreading worldwide, regardless of different continents, increasing the death toll to almost five million, with more than 300 million reported cases. Researchers have been fighting the greatest threats to human civilization. This report provides a glimpse of ongoing small-molecule research on COVID-19 drugs to save millions of lives, which may provide researchers with a better understanding of rigorously investigated therapeutic agents. This report emphasizes the chemical structures and mechanisms of activity along with drug target information for several small molecules, including marketable drugs and agents under investigation.

Poor regulation, desperation, and misinformation, a countrywide analysis of self-medication and prescription patterns in Ecuador during the COVID-19 pandemic

BACKGROUND

The rapid spread of the SARS-CoV-2 virus during the early phase of the pandemic led to an unprecedented global health crisis. Various factors have influenced self-medication practices among the general population and unsubstantiated prescribing practices among healthcare professionals.

OBJECTIVE

This study aimed to describe trends in the purchase and sale of medicines during the COVID-19 pandemic period (2020-2022) in Ecuador, by comparing them with pre-pandemic periods.

METHODS

In this study, a cross-sectional design was employed to conduct a comprehensive analysis of 28 pharmacological groups, categorized according to the Anatomical Therapeutic Chemical Classification (ATC). Utilizing an integrated drug consumption database, the study examined physician prescribing data, medicine usage, and spending levels in Ecuador during the COVID-19 pandemic. The analysis involved computing absolute differences in monthly resolution, calculating excessive expenditure in comparison to previous yearly averages, and using Defined Daily Dose (DDD) methodology for internationally comparable results. Furthermore, a correlation analysis was performed to investigate potential associations between prescribed and consumed medicines and the number of new cases and deaths.

RESULTS

In Ecuador, the average yearly expenditure among these groups prior to the pandemic (2017-2019) amounted to $150,646,206 USD, whereas during 2020 and 2021, the same groups represented a total expenditure of $228,327,210, reflecting a significant increase. The excess expenditure during this period reached 51.4%, equivalent to $77,681,004 USD. Notably, 13% of this expenditure consisted of Over the Counter (OTC) Medicines. The study also identified a remarkable surge in sales of ivermectin, which increased by 2,057%, and hydroxychloroquine, which increased by 171%, as measured by DDD.

CONCLUSIONS

This study highlights the substantial consumption of medicines by the population in Ecuador during the pandemic. It is concerning that many medications were sold without proven therapeutic indications, indicating that misinformation and desperation may have led to improper prescribing by physicians and patients resorting to ineffective drugs. Moreover, since the sale of these therapeutic drugs requires a prescription, poor regulation, and a lack of control within pharmacies likely contributed to such practices.

Wastewater surveillance of pharmaceuticals during the COVID-19 pandemic in Mexico City and the Mezquital Valley: A comprehensive environmental risk assessment

This study tracked five pharmaceutically active compounds (PhACs) in Mexico City's sewage, namely, famotidine, indomethacin, dexamethasone, azithromycin, and ivermectin, which were used to treat COVID-19. The monitoring campaign was carried out over 30 months (May 2020 to November 2022), covering the five COVID-19 waves in Mexico. In the Central Emitter, the main sewage outflow, famotidine displayed levels of 132.57 ± 28.16 ng L-1 (range from < LOQ to 189.1 ng L-1), followed by indomethacin (average 672.46 ± 116.4 ng L-1, range from 516.7 to 945.2 ng L-1), dexamethasone (average 610.4 ± 225.7 ng L-1, range from 233.4 to 1044.5 ng L-1), azithromycin (average 4436.2 ± 903.6 ng L-1, range from 2873.7 to 5819.6 ng L-1), and ivermectin (average 3413.3 ± 1244.6 ng L-1, range from 1219.8 to 4622.4 ng L-1). The concentrations of dexamethasone, azithromycin and ivermectin were higher in sewage from a temporary COVID-19 care unit, by a factor of 3.48, 3.52 and 2.55, respectively, compared with those found in municipal wastewater. In the effluent of the Atotonilco Wastewater Treatment Plant (AWWTP), which treats near 60 % of the Mexico City's sewage, famotidine was absent, while concentrations of indomethacin, dexamethasone, azithromycin and ivermectin were 78.2 %, 76.7 %, 74.4 %, and 88.1 % lower than those in the influent, respectively. The occurrence of PhACs in treated and untreated wastewater resulted in medium to high environmental risk since Mexico City's wastewater is reused for irrigation in the Mezquital Valley. There, PhACs were found in irrigation canals at lower levels than those observed in Mexico City throughout the monitoring. On the other hand, famotidine, indomethacin, and dexamethasone were not found in surface water resulting from the infiltration of wastewater through soil in Mezquital Valley, while azithromycin and ivermectin sporadically appeared in surface water samples collected through 2021. Using an optimized risk assessment based on a semi-probabilistic approach, the PhACs were prioritized as ivermectin > azithromycin > dexamethasone > famotidine > indomethacin.

Fabrication of an Azithromycin Sensor

Azithromycin (AZY) is a well-known top-prioritized antibiotic and is used by humans in strong concentrations. However, the side effects of the AZY antibiotic may cause some serious and significant damage to humans and the environment. Thus, there is a need to develop effective and sensitive sensors to monitor accurate concentrations of AZY. In the last decade, electrochemistry-based sensors have received enormous attention from the scientific community because of their high sensitivity, selectivity, cost-effectiveness, fast response, rapid detection response, simple fabrication, and working principle. It is important to mention that electrochemical sensors rely on the properties of electrode modifiers. Hence, the selection of electrode materials is of great significance when designing and developing efficient and robust electrochemical sensors. In this study, we fabricated an AZY sensor by utilizing a molybdenum disulfide/titanium aluminum carbide (MoS2@Ti3AlC2) composite as the electrode material. The MoS2@Ti3AlC2 composite was synthesized via a simple sonication process. The synthesized MoS2@Ti3AlC2 composite was characterized using a powder X-ray diffraction (XRD) method to examine the phase purity and formation of the MoS2@Ti3AlC2 composite. Scanning electron microscopy (SEM) was used to study the surface morphological features of the prepared MoS2@Ti3AlC2 composite, whereas energy dispersive X-ray spectroscopy (EDAX) was adopted to determine the elemental composition of the prepared MoS2@Ti3AlC2 composite. The glassy carbon (GC) electrode was modified with the prepared MoS2@Ti3AlC2 composite and applied as the AZY sensor. The sensing performance of the MoS2@Ti3AlC2 composite-modified GC electrode was studied using linear sweep voltammetry. The sensor demonstrated excellent performance when determining AZY and showed a good detection limit of 0.009 µM with a sensitivity of 6.77 µA/µM.cm2.

Prevalence of overweight and obesity and their effect on COVID-19 severity and hospitalization among younger than 50 years versus older than 50 years population: A systematic review and meta-analysis

Cohort studies have shown that both overweight and obesity have their impact by increasing hospitalization with COVID-19. We conducted a systematic literature search in PubMed, Google Scholar, and MedRxiv databases following the PRISMA guidelines. Statistical analyses were performed using STATA software version 16 MP (Stata Corp, College Station, TX, USA) and Med Calc software version 22.009(Med Calc software Ltd, Ostend, Belgium). The primary outcome was to measure the prevalence of overweight and obesity and their impact on the risk of hospitalization among COVID-19 patients under and above 50 years of age. In total, 184 studies involving 2,365,377 patients were included. The prevalence of overweight was highest among those younger than 50 years of age over those older than 50 years of age, (26.33% vs. 30.46%), but there was no difference in obesity (36.30% vs. 36.02%). Overall, the pooled prevalence of overweight and obesity among hospitalized COVID-19 patients was 31.0% and 36.26%, respectively. Compared with normal weight, the odds of hospitalization with overweight (odds ratio [OR] 2.186, 95% confidence interval [CI] [1.19, 3.99], p < 0.01) and obesity (OR 3.069, 95% CI [1.67, 5.61], p < 0.001) in those younger than 50 years and obesity (OR 3.977, 95% CI [2.75, 5.73], p < 0.001) in the older than 50 years age group were significantly high. The increased prevalence of overweight and obesity among the under 50 years age group and obesity among the older than 50 years age group significantly increased the rate of COVID-19 infections, severity and hospitalization.

Efficacy and safety of in-hospital treatment of Covid-19 infection with low-dose hydroxychloroquine and azithromycin in hospitalized patients: A retrospective controlled cohort study

Objectives

In this study we evaluate the efficacy and safety of a treatment protocol with standard dose of hydroxychloroquine plus azithromycin in patients hospitalized with COVID-19 infection.

Methods

We conducted a retrospective analysis to compare the 28-day mortality rate in 352 patients treated with hydroxychloroquine with or without azithromycin (HCQ-group) in our hospital with a contemporary control group of 3533 patients receiving standard of care from the Belgian Collaborative Group on COVID-19 Hospital Surveillance.

Results

All patients who received at least one dose of treatment were included in the analysis. A statistically significant reduction in crude mortality rate at 28 days was observed in the HCQ-group compared to standard of care (16.8% vs 25.9%,p ​= ​0.001).Patients in the treatment group were on average younger (69,7 vs73,1 years, p ​= ​0,0002), were less likely to smoke or to have malignancy and more likely to be male. Patients in the treatment group were more likely to be obese, immunocompromised or to have arterial hypertension, liver disease and lung disease.After adjustment for these variables the OR for mortality was 0.635 (95%CI 0.464-0.875). Patients who did not receive HCQ had a 57% higher risk of mortality. A survival benefit in the treatment group was consistent across all age groups. 13 patients discontinued treatment due to side effects (4 with QTc-prolongation>60msec (1.1%) and 9 because of gastro-intestinal symptoms (2.55%)). No episodes of ventricular arrhythmia or torsade de pointes were recorded during treatment.

Conclusion

Treatment of COVID-19 using a combination of hydroxychloroquine plus azithromycin was safe and was associated with a statistically significant mortality benefit in the treatment of COVID-19 infection in hospitalized patients. Our findings do not support the current negative recommendations regarding this treatment.

The role of SARS-COV-2 infection in promoting abnormal immune response and sepsis: A comparison between SARS-COV-2-related sepsis and sepsis from other causes

BACKGROUND

COVID-19 caused by SARS-CoV-2 virus is characterized by respiratory compromise and immune system involvement, even leading to serious disorders, such as cytokine storm.

METHODS

We then conducted a literature review on the topic of sepsis and covid-19, and in parallel conducted an experimental study on the histological finding of patients who died from SARS-Covid 19 infection and a control group.

RESULTS

Sepsis associated with covid-19 infection has some similarities and differences from that from other causes.

CONCLUSION

In this paper the complex interplay between the 2 disorders was discussed, focusing on the similarities and on the effect that one could have on the other. A preliminary experimental section that demonstrates the multisystemic involvement in subjects who die from SARS-CoV-2 is also proposed.

Bias in observational studies on the effectiveness of in hospital use of hydroxychloroquine in COVID-19

PURPOSE

During the first waves of the coronavirus pandemic, evidence on potential effective treatments was urgently needed. Results from observational studies on the effectiveness of hydroxychloroquine (HCQ) were conflicting, potentially due to biases. We aimed to assess the quality of observational studies on HCQ and its relation to effect sizes.

METHODS

PubMed was searched on 15 March 2021 for observational studies on the effectiveness of in-hospital use of HCQ in COVID-19 patients, published between 01/01/2020 and 01/03/2021 on. Study quality was assessed using the ROBINS-I tool. Association between study quality and study characteristics (journal ranking, publication date, and time between submission and publication) and differences between effects sizes found in observational studies compared to those found in RCTs, were assessed using Spearman's correlation.

RESULTS

Eighteen of the 33 (55%) included observational studies were scored as critical risk of bias, eleven (33%) as serious risk and only four (12%) as moderate risk of bias. Biases were most often scored as critical in the domains related to selection of participants (n = 13, 39%) and bias due to confounding (n = 8, 24%). There were no significant associations found between the study quality and the characteristics nor between the study quality and the effect estimates.

DISCUSSION

Overall, the quality of observational HCQ studies was heterogeneous. Synthesis of evidence of effectiveness of HCQ in COVID-19 should focus on RCTs and carefully consider the added value and quality of observational evidence.

Epidemiological, clinical, therapeutic features and predictors of death among COVID-19 patients hospitalized in Parakou: a cross-sectional study in Northern Benin

BACKGROUND

COVID-19 is an emerging contagious infection with polymorphic clinical manifestations. The purpose of this study was to describe the epidemiological, clinical, therapeutic features and identify the predictors of mortality among COVID-19 hospitalized cases in Parakou.

METHODS

This was a cross-sectional, descriptive and analytic study. Systematic recruitment was used to include all patients hospitalized with COVID-19 from May 8, 2020, to December 31, 2021, whose medical records were available and usable. The variables studied were clinical and paraclinical signs, diagnostic and therapeutic means, evolution under treatment and prognostic factors. This study was approved by the Local Ethical Committee. The data were analyzed using Stata/MP 14.1 software.

RESULTS

A total of 198 cases of COVID-19 were identified, 117 of whom were men. The mean age was 51.53 ± 19.51 years. The presenting signs were fever 146 (74.11%), cough 157 (79.70%) and dyspnea 118 (53.90%). It was severe COVID-19 in 108 cases (54.55%). Therapeutically, 95 patients (47.98%) had received the combination of Lopinavir/ritonavir and Ribavirin and 95 others (47.98%) received chloroquine. Recovery was noted in 151 (76.26%) patients. Mortality rate was 18.18%. Predictors of death were high blood pressure, presence of signs of severity, high-concentration mask ventilation used, and elevated transaminases.

CONCLUSION

COVID-19 was a reality in Parakou, with a significant number of severe cases requiring hospitalization. Several factors are associated with the prognosis of the disease.

Molecular interaction of lysozyme with therapeutic drug azithromycin: Effect of sodium dodecyl sulfate on binding profile

This paper describes an inclusive biophysical study elucidating the interaction of therapeutic drug azithromycin (Azith) with hen egg white lysozyme (HEWL). Spectroscopic and computational tools have been employed to study the interaction of Azith with HEWL at pH 7.4. The fluorescence quenching constant values (Ksv) exhibited a decrease with the increase in temperature which revealed the occurrence of static quenching mechanism between Azith and HEWL. The thermodynamic data demonstrated that hydrophobic interactions were predominantly involved in the Azith-HEWL interaction. The negative value of standard Gibbs free energy (ΔG°) stated that the Azith-HEWL complex formed via spontaneous molecular interactions. The effect of sodium dodecyl sulfate (SDS) surfactant monomers on the binding propensity of Azith with HEWL was insignificant at lower concentrations however the binding significantly decreased at increased concentrations of the former. Far-UV CD data revealed alteration in the secondary structure of HEWL in the presence of Azith and the overall HEWL conformation changed. Molecular docking results revealed that the binding of Azith with HEWL takes place through hydrophobic interactions and hydrogen bonds.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Evaluation of patients treated by telemedicine in the beginning of the COVID-19 pandemic in São Paulo, Brazil: A non-randomized clinical trial preliminary study

We performed a pilot open-label, non-randomized controlled clinical trial in a clinic in São Paulo, Brazil in the beginning of the COVID-19 pandemic. "This medical pilot project was carried out during the pandemic of a new and unknown agent. It was necessary to find a new and safe therapeutic approach for pathogens with high potential for severity and contamination. The repositioning of safe and accessible pre-existing and approved medications and the telemedicine approach improved treated covid patients' symptoms and reduced the risk of disease transmission. The emergency application of a new medical technology was the major limitation of the study. This innovative care model is a low-cost safe strategy, and we understand that applicability can be expanded to other regions in emergency situations." The 187 patients of the study (mean age of 37.6 ± 15,6 years) were divided into four groups: (1) asymptomatic, (2) mild symptoms, (3) moderate symptoms and (4) severe symptoms and were followed up for five days. A drug intervention was performed in group 3 and the patients of Group 4 were oriented to seek hospital care. Of all the patients, 23.0% were asymptomatic, 29.4% reported mild symptoms, 43.9% moderate symptoms and 3.7% severe symptoms. Three patients were hospitalized and discharged after recovery. Our results indicate that the use of telemedicine with diagnosis and drug treatment is a safe and effective strategy to reduce overload of health services and the exposure of healthcare providers and the population. The patients that initiated the treatment in the early stages of the disease presented satisfactory clinical response, reducing the need of face-to-face consultations and hospitalizations. The patients who followed the protocol treatment for COVID-19 with hydroxychloroquine and azithromycin for five days presented statistically significant improvement of clinical symptoms when compared to moderate patients who opted for not following the protocol (p < 0.05) and to all no treatment patients (p < 0.001).

New insights from nanotechnology in SARS-CoV-2 detection, treatment strategy, and prevention

The recent outbreak of SARS-CoV-2 resulted into the deadly COVID-19 pandemic, which has made a profound impact on mankind and the world health care system. SARS-CoV-2 is mainly transmitted within the population via symptomatic carriers, enters the host cell via ACE2 and TMPSSR2 receptors and damages the organs. The standard diagnostic tests and treatment methods implemented lack required efficiency to beat SARS-CoV-2 in the race of its spreading. The most prominently used diagnostic test,reverse transcription-polymerase chain reaction (a nucleic acid-based method), has limitations including a prolonged time taken to reveal results, limited sensitivity, a high rate of false negative results, and lacking specificity due to a homology with other viruses. Furthermore, as part of the treatment, antiviral drugs such as remdesivir, favipiravir, lopinavir/ritonavir, chloroquine, daclatasvir, atazanavir, and many more have been tested clinically to check their potency for the treatment of SARS-CoV-2 but none of these antiviral drugs are the definitive cure or suitable prophylaxis. Thus, it is always required to combat SARS-CoV-2 spread and infection for a better and precise prognosis. This review answers the above mentioned challenges by employing nanomedicine for the development of improved detection, treatment, and prevention strategies for SARS-CoV-2. In this review, nanotechnology-based detection methods such as colorimetric assays, photothermal biosensors, molecularly imprinted nanoparticles sensors, electrochemical nanoimmunosensors, aptamer-based biosensors have been discussed. Furthermore, nanotechnology-based treatment strategies involving polymeric nanoparticles, metallic nanoparticles, lipid nanoparticles, and nanocarrier-based antiviral siRNA delivery have been depicted. Moreover, SARS-CoV-2 prevention strategies, which include the nanotechnology for upgrading personal protective equipment, facemasks, ocular protection gears, and nanopolymer-based disinfectants, have been also reviewed. This review will provide a one-site informative platform for researchers to explore the crucial role of nanomedicine in managing the COVID-19 curse more effectively.

Comorbidities in the COVID-19 Pandemic: Scopus-Based Bibliometric Analysis

BACKGROUND

Comorbidities attract enormous attention amid the coronavirus disease 2019 (COVID-19) pandemic. Mapping knowledge based on these clinical conditions is increasingly important since the pandemic is still raging and primarily affecting subjects with chronic diseases and comorbidities. Clinical presentation and complications of COVID-19 are still hot topics which are explored in numerous evidence-based publications. The aim of this study was to analyze Scopus-indexed COVID-19 papers covering comorbidities.

METHODS

Searches through the Scopus database were performed on September 19, 2022 using the following keywords: "Diabetes mellitus" OR "Cardiovascular Diseases" OR "Rheumatic Diseases" OR "Obesity" OR "Malignancies" AND "COVID-19." All retrieved articles were analyzed using the following categories: document type, authorship, keywords, journal, citation score, country of origin, and language. Using the software tool VOSviewer version 1.6.18, we visualized the network of authors and keywords co-occurrence of the most prevalent comorbidities reported in connection with COVID-19.

RESULTS

Reports on COVID-19 and diabetes mellitus (DM) were most frequently published (n = 12,282). The US was the most productive country (n = 3,005) in the field of COVID-19 and comorbidities. There were 1,314 documents on COVID-19 and rheumatic diseases which is the least number in comparison with other comorbidities (COVID-19 and DM: 12,282, COVID-19 and cardiovascular disease: 9,911, COVID-19 and obesity: 7,070, and COVID-19 and malignancies: 1,758).

CONCLUSION

This mapping of COVID-19-related documents in connection with comorbidities may prioritize future research directions.

Treating diabetes with combination of phosphodiesterase 5 inhibitors and hydroxychloroquine-a possible prevention strategy for COVID-19?

Type 2 diabetes (T2D) is one of the major risk factors for developing cardiovascular disease and the resultant devastating morbidity and mortality. The key features of T2D are hyperglycemia, hyperlipidemia, insulin resistance, and impaired insulin secretion. Patients with diabetes and myocardial infarction have worse prognosis than those without T2D. Moreover, obesity and T2D are recognized risk factors in developing severe form of COVID-19 with higher mortality rate. The current lines of drug therapy are insufficient to control T2D and its serious cardiovascular complications. Phosphodiesterase 5 (PDE5) is a cGMP specific enzyme, which is the target of erectile dysfunction drugs including sildenafil, vardenafil, and tadalafil. Cardioprotective effects of PDE5 inhibitors against ischemia/reperfusion (I/R) injury were reported in normal and diabetic animals. Hydroxychloroquine (HCQ) is a widely used antimalarial and anti-inflammatory drug and its hyperglycemia-controlling effect in diabetic patients is also under investigation. This review provides our perspective of a potential use of combination therapy of PDE5 inhibitor with HCQ to reduce cardiovascular risk factors and myocardial I/R injury in T2D. We previously observed that diabetic mice treated with tadalafil and HCQ had significantly reduced fasting blood glucose and lipid levels, increased plasma insulin and insulin-like growth factor-1 levels, and improved insulin sensitivity, along with smaller myocardial infarct size following I/R. The combination treatment activated Akt/mTOR cellular survival pathway, which was likely responsible for the salutary effects. Therefore, pretreatment with PDE5 inhibitor and HCQ may be a potentially useful therapy not only for controlling T2D but also reducing the rate and severity of COVID-19 infection in the vulnerable population of diabetics.

Lessons Learnt from COVID-19: Computational Strategies for Facing Present and Future Pandemics

Since its outbreak in December 2019, the COVID-19 pandemic has caused the death of more than 6.5 million people around the world. The high transmissibility of its causative agent, the SARS-CoV-2 virus, coupled with its potentially lethal outcome, provoked a profound global economic and social crisis. The urgency of finding suitable pharmacological tools to tame the pandemic shed light on the ever-increasing importance of computer simulations in rationalizing and speeding up the design of new drugs, further stressing the need for developing quick and reliable methods to identify novel active molecules and characterize their mechanism of action. In the present work, we aim at providing the reader with a general overview of the COVID-19 pandemic, discussing the hallmarks in its management, from the initial attempts at drug repurposing to the commercialization of Paxlovid, the first orally available COVID-19 drug. Furthermore, we analyze and discuss the role of computer-aided drug discovery (CADD) techniques, especially those that fall in the structure-based drug design (SBDD) category, in facing present and future pandemics, by showcasing several successful examples of drug discovery campaigns where commonly used methods such as docking and molecular dynamics have been employed in the rational design of effective therapeutic entities against COVID-19.

The dangers of non-randomized, observational studies: experience from the COVID-19 epidemic

In regulatory evaluations, high-quality randomized controlled trials (RCTs) are considered the gold standard for assessing the efficacy of medical interventions. However, during the COVID-19 pandemic, the urgent need for treatment options led to regulatory approvals being made based on evidence from non-randomized, observational studies. In this study we contrast results from observational studies and RCTs of six drugs to treat COVID-19 infection. Across a range of studies evaluating hydroxychloroquine, remdesivir, ivermectin, aspirin, molnupiravir and tenofovir for COVID-19, there was statistically significant evidence of benefit from non-randomized observational studies, which was then not seen in RCTs. We propose that all observational studies need to be labelled as 'non-randomized' in the title. This should indicate that they are not as reliable for evaluating the efficacy of a drug and should not be used independently for regulatory approval decisions.

Effectiveness of different treatment regimens on patients with COVID-19, hospitalized in Sanandaj hospitals: a retrospective cohort study

OBJECTIVES

Different drugs have different effects on the prognosis of patients with COVID-19. This study aimed to evaluate the effect of different drug regimens on patients with COVID-19, hospitalized in Sanandaj city.

METHODS

In this retrospective cohort study, 660 patients with COVID-19, hospitalized in the Tohid, Kowsar and Besat hospitals located Sanandaj (Kurdistan Province, Iran) were studied from February 2020 to February 2021 with clinical symptoms and positive test results.

RESULTS

The results of multivariate regression analysis showed the days of hospitalization for patients who had received the drug regimen 2 (Interferons (ReciGen/Ziphron) or Interferon Vectra (lopinavir/ritonavir)) was 1.92 times higher than those who had received the drug regimen 1 (hydroxychloroquine group or a combination of chloroquine and azithromycin) while a significant association was observed (OR = 1.92, 95% CI: 1.16-3.16, P = 0.011). Also, the hospitalization in ICU was longer in patients treated by the drug regimen 2 (Interferons (ReciGen/Ziphron) or Interferon Vectra (lopinavir/ritonavir)) (OR = 4.63, 95% CI: 1.80-11.82, P = 0.001), however, drug regimens did not show a significant effect on mortality and use of ventilator in patients (P > 0.05).

CONCLUSION

The study results showed the drug regimens 2 and 5 increased the days of hospitalization and hospitalization in ICU, respectively, while the other drug regimens had no significant effect on mortality and use a ventilator in the studied patients and none of the drug regimens had an effect on reducing mortality compared to other ones.

Safety, Tolerability, and Pharmacokinetics of Nebulized Hydroxychloroquine: A Pilot Study in Healthy Volunteers

Background: Early in the coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) drew substantial attention as a potential COVID-19 treatment based on its antiviral and immunomodulatory effects in vitro. However, HCQ showed a lack of efficacy in vivo, and different groups of researchers attributed this failure to the insufficient drug concentration in the lung following oral administration (HCQ is only available in the market in the tablet form). Delivering HCQ by inhalation represents a more efficient route of administration to increase HCQ exposure in the lungs while minimizing systemic toxicity. In this pilot study, the safety, tolerability, and pharmacokinetics of HCQ nebulizer solution were evaluated in healthy volunteers. Methods: Twelve healthy participants were included in this study and were administered 2 mL of HCQ01 solution (equivalent to 25 mg of HCQ sulfate) through Aerogen^® Solo, a vibrating mesh nebulizer. Local tolerability and systemic safety were assessed by forced expiratory volume in the first and second electrocardiograms, clinical laboratory results (e.g., hematology, biochemistry, and urinalysis), vital signs, and physical examinations. Thirteen blood samples were collected to determine HCQ01 systemic exposure before and until 6 hours after inhalation. Results: The inhalation of HCQ01 was well tolerated in all participants. The mean value of C_max for the 12 participants was 9.66 ng/mL. T_max occurred at around 4.8 minutes after inhalation and rapidly decreased thereafter. The reported systemic exposure was very low with a mean value of 5.28 (0.6-15.6) ng·h/mL. Conclusion: The low systemic concentrations of HCQ01 of 9.66 ng/mL reported by our study compared with 1 μg/mL previously predicted after 200 mg BID oral administration, and the safety and tolerability of HCQ01 administered as a single dose through nebulization, support the assessment of its efficacy, safety, and tolerability in further studies for the treatment of COVID-19.

Correlation between Medications Used during COVID Infection and Post-conditions after the Acute Phase of Infection: A Cross-sectional Study

Background:

During the COVID-19 pandemic, off-label medication prescribing and utilizing herbal products and multiple vitamins in the treatment, prevention, and symptom management of COVID-19 was an urgently needed practice to halt the SARS-CoV-2 infection crisis and progression.

Objectives:

This study aimed to determine the correlation between medications used during the pandemic and SARS-CoV-2 infection post-recovery symptoms.

Methods:

A cross-sectional questionnaire-based study was conducted on recovered COVID-19 patients. There were 20 multiple-choice questions, including patient demographics, treatment, and post-recovery symptoms. Chi-square and Fisher’s exact tests were used to investigate significant relationships. In addition, Binary logistic regression was performed to determine confounders. Data were analyzed using SPSS version 22.

Results:

Medications and supplements varied in their therapeutic effects on SARS-CoV-2 post-recovery symptoms. Patients who took vitamin D and calcium experienced increased symptom frequency, and patients taking ACE inhibitors experienced more headaches and coughs. Furthermore, patients receiving azithromycin were asymptomatic after recovery. Patients who took H2 antagonists reported persistent headaches and muscle pain.

Conclusion:

Patients infected with SARS-CoV-2 have responded differently to medications, multivitamins, and herbal supplements. Patients reported resolution of some symptoms and persistence of others post-recovery. Therefore, expert opinion should be considered in COVID-19 management until randomized controlled trials answer many questions and determine medications' safety and efficacy in prevention, treatment strategies, and symptoms of SARS-CoV-2 infection post-recovery.

Synthesis, Characterization, DFT Mechanistic Study, Antimicrobial Activity, Molecular Modeling, and ADMET Properties of Novel Pyrazole-isoxazoline Hybrids

A series of new heterocycle hybrids incorporating pyrazole and isoxazoline rings was successfully synthesized, characterized, and evaluated for their antimicrobial responses. The synthesized compounds were obtained utilizing N-alkylation and 1,3-dipolar cycloaddition reactions, as well as their structures were established through spectroscopic methods and confirmed by mass spectrometry. To get more light on the regioselective synthesis of new hybrid compounds, mechanistic studies were performed using DFT calculations with B3LYP/6-31G(d,p) basis set. Additionally, the results of the preliminary screening indicate that some of the examined hybrids showed potent antimicrobial activity, compared to standard drugs. The results confirm that the antimicrobial activity is strongly dependent on the nature of the substituents linked pyrazole and isoxazoline rings. Furthermore, molecular docking studies were conducted to highlight the interaction modes between the investigated hybrid compounds and the Escherichia coli and Candida albicans receptors. Notably, the results demonstrate that the investigated compounds have strong protein binding affinities. The stability of the formed complexes by the binding between the hybrid compound 6c, and the target proteins was also confirmed using a 100 ns molecular dynamics simulation. Finally, the prediction of ADMET properties suggests that almost all hybrid compounds possess good pharmacokinetic profiles and no signs of observed toxicity, except for compounds 6e, 6f, and 6g.

Antibiotics Use in COVID-19 Patients: A Systematic Literature Review

The issue of bacterial infections in COVID-19 patients has received increasing attention among scientists. Antibiotics were widely prescribed during the early phase of the pandemic. We performed a literature review to assess the reasons, evidence and practices on the use of antibiotics in COVID-19 in- and outpatients. Published articles providing data on antibiotics use in COVID-19 patients were identified through computerized literature searches on the MEDLINE and SCOPUS databases. Searching the MEDLINE database, the following search terms were adopted: ((antibiotic) AND (COVID-19)). Searching the SCOPUS database, the following search terms were used: ((antibiotic treatment) AND (COVID-19)). The risk of bias in the included studies was not assessed. Both quantitative and qualitative information were summarized by means of textual descriptions. Five-hundred-ninety-three studies were identified, published from January 2020 to 30 October 2022. Thirty-six studies were included in this systematic review. Of the 36 included studies, 32 studies were on the use of antibiotics in COVID-19 inpatients and 4 on antibiotic use in COVID-19 outpatients. Apart from the studies identified and included in the review, the main recommendations on antibiotic treatment from 5 guidelines for the clinical management of COVID-19 were also summarized in a separate paragraph. Antibiotics should not be prescribed during COVID-19 unless there is a strong clinical suspicion of bacterial coinfection or superinfection.

Biologic Functions of Hydroxychloroquine in Disease: From COVID-19 to Cancer

Chloroquine (CQ) and Hydroxychloroquine (HCQ), initially utilized in the treatment of malaria, have now developed a long list of applications. Despite their clinical relevance, their mechanisms of action are not clearly defined. Major pathways by which these agents are proposed to function include alkalinization of lysosomes and endosomes, downregulation of C-X-C chemokine receptor type 4 (CXCR4) expression, high-mobility group box 1 protein (HMGB1) inhibition, alteration of intracellular calcium, and prevention of thrombus formation. However, there is conflicting data present in the literature. This is likely the result of the complex overlapping pathways between these mechanisms of action that have not previously been highlighted. In fact, prior research has focused on very specific portions of particular pathways without describing these in the context of the extensive CQ/HCQ literature. This review summarizes the detailed data regarding CQ/HCQ's mechanisms of action while also providing insight into the overarching themes. Furthermore, this review provides clinical context to the application of these diverse drugs including their role in malaria, autoimmune disorders, cardiovascular disease, thrombus formation, malignancies, and viral infections.

Occurrence and distribution of azithromycin in wastewater treatment plants, seawater, and sediments of the northern part of the Persian Gulf around Bushehr port: A comparison with Pre-COVID 19 pandemic

One of the environmental effects of COVID 19 is the contamination of ecosystems with antibiotics due to their high consumption to treat this disease. Many years ago, the distribution of antibiotics including azithromycin (Azi) in wastewater treatment plants in Bushehr city, seawater, and sediment of the Persian Gulf has been investigated. As Azi has been prescribed to COVID 19 patients, contamination of the environment with this drug can also be assumed. Thus, we decided to examine this hypothesis by repeating our previous study during COVID 19 period. We collected wastewater samples from influent, effluent, and different units of three wastewater treatment plants (WWTPs) including one municipal WWTP (Plant A) and two hospital-WWTPs (Plant B and C). Seawater and adjusted sediments were gathered from 8 stations located in the Persian Gulf in two seasons to evaluate the special and temporal variation. The results showed a huge growth of Azi pollution in all studied matrixes. The mean Azi values in the influent of Plant A, B, and C were 145 ng/L, 110 ng/L, and 896 ng/L, which represented an 9, 6, and 48-time increase compared with those obtained in 2017 (before COVID 19). The Azi removal efficiency had a different behavior compared to before COVID 19. The mean concentration of Azi in seawater and sediment samples was 9 ng/L and 6 ng/g, which was 3 and 4-fold higher than the previous study. Opposed to our former study, the Azi amount in the aqueous phase was less subjected to temporal seasonal variations. Our observations indicated the wide distribution of Azi in the environment and a future threat of intense growth of antibiotic resistance in ecosystems.

Azithromycin use and outcomes in patients with COVID-19: an observational real-world study

OBJECTIVES

Previous studies ruled out the benefits of azithromycin for treatment of patients with COVID-19 who are hospitalized. However, the effects of azithromycin for treatment of patients with positive SARS-CoV-2 test results in the community remains a matter of debate. This study aimed to assess whether azithromycin, when used in subjects with positive test results for SARS-CoV-2, is associated with a reduced risk of hospitalization, in-hospital COVID-19 outcomes, and death.

METHODS

Two study cohorts were selected. Cohort A included subjects with positive test results for SARS-CoV-2 between February 20, 2020 and December 10, 2020; cohort B included subjects infected with SARS-CoV-2 and hospitalized between February 20, 2020 and December 31, 2020. We compared the risk of hospitalization, intensive care unit access, need for mechanical ventilation, and death in azithromycin users versus nonusers. A clustered Fine-Gray analysis was employed to assess the risk of hospitalization; logistic and Cox regressions were performed to assess the risk of intensive care unit access, mechanical ventilation, and death.

RESULTS

In cohort A, among 4861 azithromycin users and 4861 propensity-matched nonusers, azithromycin use was associated with higher risk of hospitalization (hazard ratio [HR] 1.59, 95% confidence interval [CI] 1.45-1.75) compared with nonuse. In cohort B, among 997 subjects selected in both groups, azithromycin use was not significantly associated with intensive care unit access (odds ratio [OR] 1.22, 95% CI 0.93-1.56), mechanical ventilation (OR 1.30, 95% CI 0.99-1.70), 14-day mortality (HR0.88, 95% CI 0.74-1.05), or 30-day mortality (HR 0.89, 95% CI 0.77-1.03).

CONCLUSION

Our findings confirm the lack of benefits of azithromycin treatment among community patients infected with SARS-CoV-2, raising concern on potential risks associated with its inappropriate use.

Factors Associated with Self-Medication during the COVID-19 Pandemic: A Cross-Sectional Study in Pakistan

Self-medication (SM) is characterized by the procurement and use of medicines by bypassing primary healthcare services and without consulting a physician, usually to manage acute symptoms of self-diagnosed illnesses. Due to the limited availability of primary healthcare services and the anxiety associated with the COVID-19 pandemic, the compulsion to SM by the public has increased considerably. The study aimed to assess the characteristics, practices, and associated factors of SM by the public during the COVID-19 pandemic in Sargodha, Pakistan. χ2-tests and univariable analyses were conducted to explore the identification of characteristics and the potential contributing factors for SM during COVID-19, while multivariable logistic regression models were run to study the effect of variables that maintained a significant association. The study was performed during July−September 2021, with n = 460 questionnaires returned overall (response rate: 99.5%). The majority of respondents were males (58.7%, n = 270) who live in the periphery of the town (63.9%, n = 294), and most of the respondents belonged to the age group of 18−28 years (73.3%, n = 339). A large number, 46.1% (n = 212), of the participants were tested for COVID-19 during the pandemic, and among them, 34.3% (n = 158) practiced SM during the pandemic; the most common source of obtaining medicines was requesting them directly from a pharmacy (25.0%; n = 127). The chances of practicing SM for medical health professionals were 1.482 (p-value = 0.046) times greater than for non-medical health personnel. The likelihood of practicing SM in participants whose COVID-19 test was positive was 7.688 (p-value < 0.001) times more than who did not test for COVID-19. Allopathic medicines, acetaminophen (23.6%), azithromycin (14,9%), and cough syrups (13%), and over the counter (OTC) pharmaceuticals, vitamin oral supplements, such as Vitamin C (39.1%), folic acid (23.5%), and calcium (22.6%), were the most commonly consumed medicines and supplements, respectively; being a healthcare professional or having a COVID-test prior showed a significant association with the usage of Vitamin C (p < 0.05 in all cases). Respondents who mentioned unavailability of the physician and difficulty in travelling/reaching healthcare professionals were found 2.062-times (p-value = 0.004) and 1.862-times (p-value = 0.021) more likely to practice SM, respectively; SM due to fear of COVID was more common in individuals who had received COVID-tests prior (p = 0.004). Practices of SM were observed at alarming levels among our participants. Consciousness and understanding about the possible adverse effects of SM must be established and validated on a continuous level; in addition, on a commercial level, collaboration from pharmacists not to sell products (especially prescription-only medicines) without a certified prescription must be developed and implemented.

The failure of drug repurposing for COVID-19 as an effect of excessive hypothesis testing and weak mechanistic evidence

The current strategy of searching for an effective treatment for COVID-19 relies mainly on repurposing existing therapies developed to target other diseases. Conflicting results have emerged in regard to the efficacy of several tested compounds but later results were negative. The number of conducted and ongoing trials and the urgent need for a treatment pose the risk that false-positive results will be incorrectly interpreted as evidence for treatments' efficacy and a ground for drug approval. Our purpose is twofold. First, we show that the number of drug-repurposing trials can explain the false-positive results. Second, we assess the evidence for treatments' efficacy from the perspective of evidential pluralism and argue that considering mechanistic evidence is particularly needed in cases when the evidence from clinical trials is conflicting or of low quality. Our analysis is an application of the program of Evidence Based Medicine Plus (EBM+) to the drug repurposing trials for COVID. Our study shows that if decision-makers applied EBM+, authorizing the use of ineffective treatments would be less likely. We analyze the example of trials assessing the efficacy of hydroxychloroquine as a treatment for COVID-19 and mechanistic evidence in favor of and against its therapeutic power to draw a lesson for decision-makers and drug agencies on how excessive hypothesis testing can lead to spurious findings and how studying negative mechanistic evidence can be helpful in discriminating genuine from spurious results.

Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis

BACKGROUND

Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients.

METHODS

We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions.

RESULTS

Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively).

CONCLUSIONS

The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.

Identification of Suitable Drug Combinations for Treating COVID-19 Using a Novel Machine Learning Approach: The RAIN Method

Simple Summary

This study follows an improved approach to systematic reviews, called the Systematic Review and Artificial Intelligence Network Meta-Analysis (RAIN), registered within PROSPERO (CRD42021256797), in which, the PRISMA criterion is still considered. Drugs used in the treatment of COVID-19 were searched in the databases of ScienceDirect, Web of Science (WoS), ProQuest, Embase, Medline (PubMed), and Scopus. In addition, using artificial intelligence and the measurement of the p-value between human genes affected by COVID-19 and drugs that have been suggested by clinical experts, and reported within the identified research papers, suitable drug combinations are proposed for the treatment of COVID-19. During the systematic review process, 39 studies were selected. Our analysis shows that most of the reported drugs, such as azithromycin and hydroxyl-chloroquine on their own, do not have much of an effect on the recovery of COVID-19 patients. Based on the result of the new artificial intelligence, on the other hand, at a significance level of less than 0.05, the combination of the two drugs therapeutic corticosteroid + camostat with a significance level of 0.02, remdesivir + azithromycin with a significance level of 0.03, and interleukin 1 receptor antagonist protein + camostat with a significance level 0.02 are considered far more effective for the treatment of COVID-19 and are therefore recommended.

Abstract

COVID-19 affects several human genes, each with its own p-value. The combination of drugs associated with these genes with small p-values may lead to an estimation of the combined p-value between COVID-19 and some drug combinations, thereby increasing the effectiveness of these combinations in defeating the disease. Based on human genes, we introduced a new machine learning method that offers an effective drug combination with low combined p-values between them and COVID-19. This study follows an improved approach to systematic reviews, called the Systematic Review and Artificial Intelligence Network Meta-Analysis (RAIN), registered within PROSPERO (CRD42021256797), in which, the PRISMA criterion is still considered. Drugs used in the treatment of COVID-19 were searched in the databases of ScienceDirect, Web of Science (WoS), ProQuest, Embase, Medline (PubMed), and Scopus. In addition, using artificial intelligence and the measurement of the p-value between human genes affected by COVID-19 and drugs that have been suggested by clinical experts, and reported within the identified research papers, suitable drug combinations are proposed for the treatment of COVID-19. During the systematic review process, 39 studies were selected. Our analysis shows that most of the reported drugs, such as azithromycin and hydroxyl-chloroquine on their own, do not have much of an effect on the recovery of COVID-19 patients. Based on the result of the new artificial intelligence, on the other hand, at a significance level of less than 0.05, the combination of the two drugs therapeutic corticosteroid + camostat with a significance level of 0.02, remdesivir + azithromycin with a significance level of 0.03, and interleukin 1 receptor antagonist protein + camostat with a significance level 0.02 are considered far more effective for the treatment of COVID-19 and are therefore recommended. Additionally, at a significance level of less than 0.01, the combination of interleukin 1 receptor antagonist protein + camostat + azithromycin + tocilizumab + oseltamivir with a significance level of 0.006, and the combination of interleukin 1 receptor antagonist protein + camostat + chloroquine + favipiravir + tocilizumab7 with corticosteroid + camostat + oseltamivir + remdesivir + tocilizumab at a significant level of 0.009 are effective in the treatment of patients with COVID-19 and are also recommended. The results of this study provide sets of effective drug combinations for the treatment of patients with COVID-19. In addition, the new artificial intelligence used in the RAIN method could provide a forward-looking approach to clinical trial studies, which could also be used effectively in the treatment of diseases such as cancer.

Hydroxychloroquine blocks SARS-CoV-2 entry into the endocytic pathway in mammalian cell culture

Hydroxychloroquine (HCQ), a drug used to treat lupus and malaria, was proposed as a treatment for SARS-coronavirus-2 (SARS-CoV-2) infection, albeit with controversy. In vitro, HCQ effectively inhibits viral entry, but its use in the clinic has been hampered by conflicting results. A better understanding of HCQ’s mechanism of actions in vitro is needed. Recently, anesthetics were shown to disrupt ordered clusters of monosialotetrahexosylganglioside1 (GM1) lipid. These same lipid clusters recruit the SARS-CoV-2 surface receptor angiotensin converting enzyme 2 (ACE2) to endocytic lipids, away from phosphatidylinositol 4,5 bisphosphate (PIP₂) clusters. Here we employed super-resolution imaging of cultured mammalian cells (VeroE6, A549, H1793, and HEK293T) to show HCQ directly perturbs clustering of ACE2 receptor with both endocytic lipids and PIP₂ clusters. In elevated (high) cholesterol, HCQ moves ACE2 nanoscopic distances away from endocytic lipids. In cells with resting (low) cholesterol, ACE2 primarily associates with PIP₂ clusters, and HCQ moves ACE2 away from PIP₂ clusters—erythromycin has a similar effect. We conclude HCQ inhibits viral entry through two distinct mechanisms in high and low tissue cholesterol and does so prior to inhibiting cathepsin-L. HCQ clinical trials and animal studies will need to account for tissue cholesterol levels when evaluating dosing and efficacy.

Super-resolution microscopy in cultured cells is employed to dissect the effect of hydroxychloroquine (HCQ) at the plasma membrane and HCQ directly perturbs clustering of the SARS-CoV-2 receptor ACE2 with endocytic lipids and PIP2 clusters.

The Impact of Landscape Changes on Data and Safety Monitoring Board Oversight of Clinical Trials

Impact of Landscape Changes on DSMB OversightThis Clinical Trials Workshop describes how external factors (or landscape changes) can affect monitoring of an ongoing clinical trial and discusses issues to consider to avoid stopping a trial too early while maintaining equipoise for enrolled participants. Three clinical trials in which DSMBs had to consider the effects of landscape changes on the continued performance of the monitored trial are reviewed.

Pharmacotherapy prescribing pattern and outcome for hospitalized patients with severe and critical COVID-19

There are many treatment modalities for COVID-19 – with varied outcome. Therefore, authors designed this study to assess prescribing patterns and the clinical outcome for hospitalized patients with severe and critical COVID-19 so as to determine the most effective approach.

Authors conducted a retrospective observational study on 346 adult patients with either severe or critical COVID-19, who were admitted to public hospitals in Al-Najaf city, Iraq from June to September 2020. Patients’ information, medications and outcomes were collected from their medical records in the registered office of the hospital.

A total of 346 patients were enrolled, with a majority of patients being adults above 35 years old and male (70.2%). Most patients (81%) received corticosteroid as dexamethasone, and about 45% of all patients were given convalescent plasma therapy, while a few patients were prescribed antiviral favipiravir (23%) and lopinavir/ritonavir (19%). As supportive care medications, anticoagulant such as enoxaparin was administered to most of the patients (93%) and more than half of all patients received the broad-spectrum antibiotic, meropenem.

The majority of the patients recovered and were discharged alive (66%), however, the in- hospital mortality rate was 26%. Interestingly, patients treated with enoxaparin alone or in combination with hydroxychloroquine were associated with better outcome.

The prescribing pattern of COVID-19 specific medications and supportive care is aligned with guideline recommendations and associated with a beneficial therapeutic outcome.

The association of antiviral drugs with COVID-19 morbidity: The retrospective analysis of a nationwide COVID-19 cohort

Background and objectives

Although several repurposed antiviral drugs have been used for the treatment of COVID-19, only a few such as remdesivir and molnupiravir have shown promising effects. The objectives of our study were to investigate the association of repurposed antiviral drugs with COVID-19 morbidity.

Methods

Patients admitted to 26 different hospitals located in 16 different provinces between March 11–July 18, 2020, were enrolled. Case definition was based on WHO criteria. Patients were managed according to the guidelines by Scientific Board of Ministry of Health of Turkey. Primary outcomes were length of hospitalization, intensive care unit (ICU) requirement, and intubation.

Results

We retrospectively evaluated 1,472 COVID-19 adult patients; 57.1% were men (mean age = 51.9 ± 17.7years). A total of 210 (14.3%) had severe pneumonia, 115 (7.8%) were admitted to ICUs, and 69 (4.7%) were intubated during hospitalization. The median (interquartile range) of duration of hospitalization, including ICU admission, was 7 (5–12) days. Favipiravir (n = 328), lopinavir/ritonavir (n = 55), and oseltamivir (n = 761) were administered as antiviral agents, and hydroxychloroquine (HCQ, n = 1,382) and azithromycin (n = 738) were used for their immunomodulatory activity. Lopinavir/ritonavir (β [95% CI]: 4.71 [2.31–7.11]; p = 0.001), favipiravir (β [95% CI]: 3.55 [2.56–4.55]; p = 0.001) and HCQ (β [95% CI]: 0.84 [0.02–1.67]; p = 0.046) were associated with increased risk of lengthy hospital stays. Furthermore, favipiravir was associated with increased risks of ICU admission (OR [95% CI]: 3.02 [1.70–5.35]; p = 0.001) and invasive mechanical ventilation requirement (OR [95% CI]: 2.94 [1.28–6.75]; p = 0.011).

Conclusion

Our findings demonstrated that antiviral drugs including lopinavir, ritonavir, and favipiravir were associated with negative clinical outcomes such as increased risks for lengthy hospital stay, ICU admission, and invasive mechanical ventilation requirement. Therefore, repurposing such agents without proven clinical evidence might not be the best approach for COVID-19 treatment.