The proportion and effect of corticosteroid therapy in patients with COVID-19 infection: A systematic review and meta-analysis

COVID-19 Infection in Pediatric Patients Presenting to a Tertiary Center in Jordan: Clinical Characteristics and Age-Related Patterns

Objectives: This study assessed the clinical characteristics of pediatric COVID-19 patients across different age groups during the first and second pandemic waves in Jordan. Methods: A retrospective analysis was conducted at Jordan University Hospital, involving 485 patients aged 1 month to 18 years from September 2020 to July 2021. Patients were categorized into preschool (≤5 years), school-aged (6-10 years), and teenagers (>10 years). Patients' clinical characteristics were analyzed using R (version 2.3.3). Results: The mean age for participants was 10.7 ± 5.7 years. Shortness of breath, abdominal pain, and headaches were significantly more likely among older participants (all p < 0.01). Conversely, younger patients were more likely to experience nasal congestion, decreased activity, and reduced feeding (all p < 0.05). The majority of patients had mild symptom severity. Analysis of physiologic and laboratory parameters demonstrated significant differences among age groups in terms of heart rate, respiratory rate, hemoglobin, neutrophils, lymphocytes, platelets, CRP, and creatinine (all p < 0.05). Respiratory support was mainly observed among younger patients. Antibiotics was the most commonly received medication. In terms of outcomes, two patients had complications during their stay, both of which belonged to the <5 years age group. We observed significant differences in incidence of symptoms and laboratory markers among different pediatric age groups. While younger patients experienced severe complications, their older counterparts exhibited more alarming symptoms and worse counts of immune cells. Conclusions: These findings highlight the importance of age-specific management strategies for COVID-19, emphasizing the need for tailored approaches in both treatment and prevention.

A meta-analysis of the efficacy and safety of immunomodulators in the treatment of severe COVID-19

ObjectiveTo evaluate the efficacy and adverse events of immunomodulators in the treatment of severe coronavirus disease 2019 (COVID-19).MethodsA literature search for the meta-analysis was performed using PubMed, The Cochrane Library, Embase, Wanfang Data, CNKI, and Web of Science to identify randomized controlled trials assessing the outcomes of patients treated with corticosteroids alone and/or interleukin-6 receptor antagonists for COVID-19. The risk of bias was assessed using the Cochrane method. The protocol was registered with PROSPERO (registry number: CRD42022356904).ResultsCompared with patients receiving standard of care, patients treated with corticosteroids alone had an increased risk of 14-day in-hospital death, whereas those treated with interleukin-6 receptor antagonists alone or in combination with corticosteroids had a lower risk of 14-day in-hospital death. Corticosteroid therapy alone was associated with increased risk of several adverse events, including intensive care unit admission and non-invasive ventilation, whereas interleukin-6 receptor antagonists alone or in combination with corticosteroids were not linked to adverse effects.ConclusionsThe findings supported the safety and efficacy of interleukin-6 receptor antagonists, either alone or together with corticosteroids, in patients with severe COVID-19; evidence supporting the efficacy and safety of corticosteroids monotherapy is lacking.

Calcifediol or Corticosteroids in the Treatment of COVID-19: An Observational Study

Medical treatment of coronavirus 19 disease (COVID-19) is a therapeutic challenge. The available data strongly suggest that calcifediol treatment may reduce the severity of COVID-19, and corticosteroids are the treatment of choice worldwide for severe COVID-19. Both have a very similar action profile, and their combined use in patients may modify the contribution of each administered compound.

OBJECTIVE

To evaluate how treatment with calcifediol and/or corticosteroids in medical practice modified the need for ICU admission, death, or poor prognosis of patients hospitalized with COVID-19 during the first outbreaks.

DESIGN, PATIENTS AND SETTING

A retrospective observational cohort study of patients admitted for COVID-19 to the Pneumology Unit of the Hospital Universitario Reina Sofía (Córdoba, Spain).

INTERVENTIONS

Patients were treated with calcifediol or/and corticosteroids with the best available therapy and standard care, according to clinical practice guidelines.

MEASUREMENTS

Admission to the intensive care unit (ICU) or death during hospitalization and poor prognosis.

RESULTS

Seven hundred and twenty-eight patients were included. According to the treatment received, they were included in four groups: calcifediol (n = 68), glucocorticoids (n = 112), both (n = 510), or neither (n = 38). Of the 578 patients treated with calcifediol, 88 were admitted to the ICU (15%), while of the 150 not treated with calcifediol, 39 required ICU admission (26%) (p < 0.01). Among the patients taking calcifediol without glucocorticoids, only 4 of 68 (5.8%) required ICU admission, compared to 84 of 510 (16.5%) treated with both (p = 0.022). Of the 595 patients who had a good prognosis, 568 (82.01%) had received treatment with calcifediol versus the 133 patients with a poor prognosis, of whom 90 (67.66%) had received calcifediol (p < 0.001). This difference was not found for corticosteroids.

INTERPRETATION

The treatment of choice for hospitalized patients with moderate or mild COVID-19 could be calcifediol, not administering corticosteroids, until the natural history of the disease reaches a stage of hyperinflammation.

Nigella sativa, Anthemis hyaline and Citrus sinensis extracts reduce SARS-CoV-2 replication by fluctuating Rho GTPase, PI3K-AKT, and MAPK/ERK pathways in HeLa-CEACAM1a cells

Traditional remedies have long utilized Anthemis hyaline, Nigella sativa, and Citrus sinensis peel extracts as treatments for microbial infections. This study aimed to investigate the influence of Anthemis hyaline, Nigella sativa, and Citrus sinensis extracts on coronavirus replication and apoptosis-related pathways. HeLa-CEACAM1a cells were exposed to mouse hepatitis virus-A59. After viral inoculation, the mRNA levels of 36 genes were quantified using a Fluidigm Dynamic Array nanofluidic chip. IL-8 level and intracellular Ca2+ concentration was measured, and viral titer was assessed by the TCID50/ml assay to detect the extent of infection. Treatment with Nigella sativa extract surged the inflammatory cytokine IL-8 level at both 24 and 48-hour. Changes in gene expression were notable for RHOA, VAV3, ROCK2, CFL1, RASA1, and MPRIP genes following treatment with any of the extracts. The addition of Anthemis hyaline, Nigella sativa, or Citrus sinensis extracts to coronavirus-infected cells reduced viral presence, with Anthemis hyaline extract leading to a virtually undetectable viral load at 6- and 8-hours after infection. While all treatments influenced IL-8 production and viral levels, Anthemis hyaline extract displayed the most pronounced reduction in viral load. Consequently, Anthemis hyaline extract emerges as the most promising agent, harboring potential therapeutic compounds.

Factors Associated with Adverse Outcomes among SARS-CoV-2 Positive Children in a Tertiary Government COVID-19 Referral Hospital in the Philippines

Background and Objective

Pediatric COVID-19 epidemiology and factors associated with adverse outcomes - mortality, need for invasive mechanical ventilation, and ICU admission, are largely unstudied. We described the clinico-demographic characteristics of Filipino pediatric COVID-19 patients and determined the factors associated with adverse outcomes.

Methods

This is a retrospective cohort study of 180 hospitalized SARS-CoV-2-confirmed cases 0-18 years old from April 2020 to August 2021 in a tertiary COVID-19 referral hospital in Manila, National Capital Region. Crude associations were determined using chi-squared or Fisher's exact tests; and medians were compared using the Mann-Whitney test. Factors predictive of mortality were determined using Cox proportional hazards regression analysis. The survivor functions were depicted in graphs.

Results

About 41.67% had mild disease, 58.33% were males, 39.4% aged 0-4 years, and 69.44% had at least one comorbidity. About 9.44% died (adjusted 9.2 persons per 1000 patient-days, 95% CI 5.5%-15.2%), 17.78% needed invasive mechanical ventilation, and 20% needed ICU admission. Independently, severe-critical COVID-19 (HRc 11.51, 95% CI 3.23, 41.06), retractions (HRc 10.30, 95% CI 3.27, 32.47), alar flaring (HRc 4.39, 95% CI 1.53, 12.58), cyanosis (HRc 4.39, 95% CI 1.72, 14.11), difficulty of breathing (HRc 7.99, 95% CI 2.25, 28.71), poor suck/appetite (HRc 4.46, 95% CI 1.59, 12.40), ferritin (HRc 1.01, 95% CI 1.00, 1.01), IL-6 (HRc 1.01, 95% CI 1.00, 1.01), aPTT (HRc 1.05, 95% CI 1.01, 1.10), IVIg (HRc 4.00, 95% CI 1.07, 14.92) and corticosteroid (HRc 6.01, 95% CI 2.04, 17.67) were significant hazards for mortality. In adjusted Cox analysis, only retractions (HRa 34.96, 95% CI 3.36, 363.79), seizure (HRa 9.98, 95% CI 1.76, 56.55), and corticosteroids (HRa 8.21, 95% CI 1.12, 60.38) were significantly associated with mortality while alar flaring appeared to be protective (HRa 0.10, 95% CI 0.01, 0.95). Several clinical characteristics were consistently associated with adverse outcomes.

Conclusions

Majority of hospitalized pediatric COVID-19 patients were very young, males, had mild disease, and had at least one comorbidity. Mortality, invasive mechanical ventilation, and ICU admission were relatively low. Except for alar flaring which appeared to be protective, retractions, seizure, and use of corticosteroids were associated with adverse outcomes.

Short-term inhalation of sargramostim with concomitant high-dose steroids does not hasten recovery in moderate COVID-19 pneumonia: a double-blind, randomised, placebo-controlled trial

BACKGROUND

Granulocyte-macrophage colony stimulating factor (GM-CSF) inhalation may alleviate pulmonary inflammation caused by viral pneumonia. To investigate this, we evaluated its efficacy on COVID-19 pneumonia.

METHODS

This double-blind, randomised, placebo-controlled study (ClinicalTrials.gov: NCT04642950) evaluated patients in the first half of 2021 at seven Japanese hospitals. Hospitalised patients with COVID-19 pneumonia with moderate hypoxaemia inhaled sargramostim or placebo for 5 days. The primary endpoint was days to achieve a ≥ 2-category improvement from baseline on a modified 7-category ordinal scale. Secondary endpoints included degree of oxygenation, defined by amount of oxygen supply, and serum CCL17 level.

RESULTS

Seventy-five patients were randomly assigned in a 2:1 ratio to receive sargramostim or placebo, of which 47 and 23 were analysed, respectively. No difference was observed between groups regarding the primary endpoint (8.0 and 7.0 days for sargramostim and placebo, respectively) or in the secondary endpoints, except for CCL17. A post hoc sub-analysis indicated that endpoint assessments were influenced by concomitant corticosteroid therapy. When the cumulative corticosteroid dose was ≤500 mg during Days 1-5, recovery and oxygenation were faster in the sargramostim group than for placebo. Bolus dose corticosteroids were associated with temporarily impaired oxygenation and delayed clinical recovery. The increase in serum CCL17, a candidate prognostic factor, reflected improvement with sargramostim inhalation. The number of adverse events was similar between groups. Two serious adverse events were observed in the sargramostim group without causal relation.

CONCLUSIONS

Inhaled sargramostim was likely to be effective for COVID-19 pneumonia unless the concomitant corticosteroid dose was high.

Novel Risks of Unfavorable Corticosteroid Response in Patients with Mild-to-Moderate COVID-19 Identified Using Artificial Intelligence-Assisted Analysis of Chest Radiographs

The prediction of corticosteroid responses in coronavirus disease 2019 (COVID-19) patients is crucial in clinical practice, and exploring the role of artificial intelligence (AI)-assisted analysis of chest radiographs (CXR) is warranted. This retrospective case-control study involving mild-to-moderate COVID-19 patients treated with corticosteroids was conducted from 4 September 2021, to 30 August 2022. The primary endpoint of the study was corticosteroid responsiveness, defined as the advancement of two or more of the eight-categories-ordinal scale. Serial abnormality scores for consolidation and pleural effusion on CXR were obtained using a commercial AI-based software based on days from the onset of symptoms. Amongst the 258 participants included in the analysis, 147 (57%) were male. Multivariable logistic regression analysis revealed that high pleural effusion score at 6-9 days from onset of symptoms (adjusted odds ratio of (aOR): 1.022, 95% confidence interval (CI): 1.003-1.042, p = 0.020) and consolidation scores up to 9 days from onset of symptoms (0-2 days: aOR: 1.025, 95% CI: 1.006-1.045, p = 0.010; 3-5 days: aOR: 1.03 95% CI: 1.011-1.051, p = 0.002; 6-9 days: aOR; 1.052, 95% CI: 1.015-1.089, p = 0.005) were associated with an unfavorable corticosteroid response. AI-generated scores could help intervene in the use of corticosteroids in COVID-19 patients who would not benefit from them.

Structure-based virtual screening, molecular docking, molecular dynamics simulation and MM/PBSA calculations towards identification of steroidal and non-steroidal selective glucocorticoid receptor modulators

Glucocorticoids have been used in the treatment of many diseases including inflammatory and autoimmune diseases. Despite the wide therapeutic effects of synthetic glucocorticoids, the use of these compounds has been limited due to side effects such as osteoporosis, immunodeficiency, and hyperglycaemia. To this end, extensive studies have been performed to discover new glucocorticoid modulators with the aim of increasing affinity for the receptor and thus less side effects. In the present work, structure-based virtual screening was used for the identification of novel potent compounds with glucocorticoid effects. The molecules derived from ZINC database were screened on account of structural similarity with some glucocorticoid agonists as the template. Subsequently, molecular docking was performed on 200 selected compounds to obtain the best steroidal and non-steroidal conformations. Three compounds, namely ZINC_000002083318, ZINC_000253697499 and ZINC_000003845653, were selected with the binding energies of -11.5, -10.5, and -9.5 kcal/mol, respectively. Molecular dynamic simulations on superior structures were accomplished with the glucocorticoid receptor. Additionally, root mean square deviations, root mean square fluctuation, radius of gyration, hydrogen bonds, and binding-free energy analysis showed the binding stability of the proposed compounds compared to budesonide as an approved drug. The results demonstrated that all the compounds had suitable binding stability compared to budesonide, while ZINC_000002083318 showed a tighter binding energy compared to the other compounds.Communicated by Ramaswamy H. Sarma.

A Comparison of the Effects of Dexamethasone and Methylprednisolone, Used on Level-3 Intensive Care COVID-19 Patients, on Mortality: A Multi-Center Retrospective Study

BACKGROUND

Coronavirus disease 2019 (COVID-19) is often a mild disease, usually manifesting with respiratory complaints, and is sometimes mortal due to multiple organ failure. Hyperinflammation is a known COVID-19 component and is associated with organ dysfunction, disease severity and mortality. Controlling hyperinflammatory response is crucial in determining treatment direction. An important agent in providing this control is corticosteroids. This study aimed to determine whether dexamethasone and methylprednisolone, doses, administration time and duration in COVID-19 treatment are associated with improved treatment outcomes.

METHODS

This retrospective multicenter study was conducted with participation of 6 healthcare centers which collected data by retrospectively examining files of 1,340 patients admitted to intensive care unit due to COVID-19 between March 2020 and September 2021, diagnosed with polymerase chain reaction (+) and/or clinically and radiologically.

RESULTS

Mortality in the pulse methylprednisolone group was statistically significantly higher than that in the other 3 groups. Mortality was higher in older patients with comorbidities such as hypertension, diabetes mellitus, chronic kidney failure, coronary artery disease, and dementia. Pulse and mini-pulse steroid doses were less effective than standard methylprednisolone and dexamethasone doses, pulse steroid doses being associated with high mortality. Standard-dose methylprednisolone and dexamethasone led to similar effects, but standard dose methylprednisolone was more effective in severe patients who required mechanical ventilation (MV). Infection development was related to steroid treatment duration, not cumulative steroid dose.

CONCLUSION

Corticosteroids are shown to be beneficial in critical COVID-19, but the role of early corticosteroids in mild COVID-19 patients remains unclear. The anti-inflammatory effects of corticosteroids may have a positive effect by reducing mortality in severe COVID-19 patients. Although dexamethasone was first used for this purpose, methylprednisolone was found to be as effective at standard doses. Methylprednisolone administered at standard doses was associated with greater PaO₂/FiO₂ ratios than dexamethasone, especially in the severe group requiring MV. High dose pulse steroid doses are closely associated with mortality and standard methylprednisolone dose is recommended.

COVID-19 Therapeutic Potential of Natural Products

Despite the fact that coronavirus disease 2019 (COVID-19) treatment and management are now considerably regulated, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still one of the leading causes of death in 2022. The availability of COVID-19 vaccines, FDA-approved antivirals, and monoclonal antibodies in low-income countries still poses an issue to be addressed. Natural products, particularly traditional Chinese medicines (TCMs) and medicinal plant extracts (or their active component), have challenged the dominance of drug repurposing and synthetic compound libraries in COVID-19 therapeutics. Their abundant resources and excellent antiviral performance make natural products a relatively cheap and readily available alternative for COVID-19 therapeutics. Here, we deliberately review the anti-SARS-CoV-2 mechanisms of the natural products, their potency (pharmacological profiles), and application strategies for COVID-19 intervention. In light of their advantages, this review is intended to acknowledge the potential of natural products as COVID-19 therapeutic candidates.

Factors Influencing the Length of Hospital Stay Among Pediatric COVID-19 Patients at Queen Rania Al Abdullah Hospital for Children: A Cross-Sectional Study

Background COVID-19 caused by SARS-CoV-2 is a worldwide epidemic. Children are less commonly infected and have less severe symptoms than adults. However, they are at risk for COVID-19-associated severe sickness and hospitalization. The duration of stay is a major driver of effective health treatment during hospitalization; thus, it is only logical to attempt to comprehend the factors influencing the length of stay (LOS) for these patients, particularly in light of the ongoing pandemic caused by the new SARS-CoV-2 virus. As predictors of hospital LOS, several variables, including age, gender, disease severity, hospital mortality, insurance type, and hospital location, have been discovered. In our study, we focused on the severity of the patient's condition, the presence of comorbidities, and the necessary therapeutic regimen to predict the duration of stay. This study aimed to answer the following questions: If a patient has comorbidity and has COVID-19 requiring hospital treatment, will the patient's comorbidity elongate the duration of stay at the hospital for further management in the pediatric age group? What are the risk factors that play a significant role in the hospital stay duration in pediatrics? Methodology We gathered data from 100 hospitalized children aged up to 14 years who tested positive for COVID-19, which was not specific to variants of SARS-CoV-2, over 24 months (February 2020-February 2022) at Queen Rania Al Abdullah Hospital for Children, one of the Health Care Accreditation Council accredited facilities. Clinical symptoms, signs, oxygen demand, imaging study results, laboratory data, and usage of corticosteroid and antiviral medication were all taken from patients' medical records. There were no limitations in taking the sample of patients. All patients in the duration mentioned were included. Results Clinical data of 100 COVID-19-positive pediatric patients were analyzed; 52% of the patients had associated chronic illnesses, while 48% were medically free. The longest duration of LOS was 28 days, the shortest was one day, the median was eight days, and five days was the most frequent among patients owing to 21% of patients, using mean descriptive statistics. We compared LOS to having or not having comorbidities. The mean LOS of patients with the comorbid disease was 6.15 days, with a maximum of 28 days, while for patients without chronic illnesses, the mean was 4.81 days with a maximum of 14 days. The significance was 0.07. Our results also showed a significant correlation between using steroids and LOS, as it had an advantageous effect by decreasing it with a significance value of 0.04. Having abnormal findings on chest computed tomography (CT) scan was also associated with increased LOS with a significant value of 0.00. Conclusions According to our research, there was no direct association between comorbidity and hospital LOS, which is counterintuitive, as it was influenced by multiplayers of variables such as using steroids, which decreased the LOS, and abnormal findings on chest CT, which resulted in lengthening of the hospital stay. Our findings cannot be proven without further research and a larger patient sample.

Targeting TLR-4 Signaling to Treat COVID-19-induced Acute Kidney Injury

The newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has turned into a potentially fatal pandemic illness. Numerous acute kidney injury (AKI) cases have been reported, although diffuse alveolar destruction and acute respiratory failure are the major symptoms of SARS-CoV-2 infection. The AKI, often known as a sudden loss of kidney function, carries a greater risk of mortality and morbidity. AKI was the second most frequent cause of death after acute respiratory distress syndrome (ARDS) in critically ill patients with coronavirus disease 2019 (COVID-19). While most patients with COVID-19 have moderate symptoms, some have severe symptoms, such as septic shock and ARDS. Also, it has been proven that some patients have severe symptoms, such as the failure of several organs. The kidneys are often affected either directly or indirectly. The major signs of kidney involvement are proteinuria and AKI. It is hypothesized that multiple mechanisms contribute to kidney injury in COVID-19. Direct infection of podocytes and proximal tubular cells in the kidneys may lead to acute tubular necrosis and collapsing glomerulopathy. SARS-CoV2 may also trigger a cascade of immunological responses that lead to AKI, including cytokine storm (CS), macrophage activation syndrome, and Toll-like receptor type-4 activation (TLR-4). Other proposed processes of AKI include interactions between organs, endothelial failure, hypercoagulability, rhabdomyolysis, and sepsis.

Furthermore, ischemic damage to the kidney might result from the decreased oxygen supply. This article focuses on kidney injury’s epidemiology, etiology, and pathophysiological processes. Specifically, it focuses on the CS and the role of TLR-4 in this process. To effectively manage and treat acute kidney damage and AKI in COVID-19, it is crucial to understand the underlying molecular pathways and pathophysiology.

Immuno-Modulatory Effects of Dexamethasone in Severe COVID-19-A Swedish Cohort Study

Dexamethasone (Dex) has been shown to decrease mortality in severe coronavirus disease 2019 (COVID-19), but the mechanism is not fully elucidated. We aimed to investigate the physiological and immunological effects associated with Dex administration in patients admitted to intensive care with severe COVID-19. A total of 216 adult COVID-19 patients were included-102 (47%) received Dex, 6 mg/day for 10 days, and 114 (53%) did not. Standard laboratory parameters, plasma expression of cytokines, endothelial markers, immunoglobulin (Ig) IgA, IgM, and IgG against SARS-CoV-2 were analyzed post-admission to intensive care. Patients treated with Dex had higher blood glucose but lower blood lactate, plasma cortisol, IgA, IgM, IgG, D-dimer, cytokines, syndecan-1, and E-selectin and received less organ support than those who did not receive Dex (Without-Dex). There was an association between Dex treatment and IL-17A, macrophage inflammatory protein 1 alpha, syndecan-1 as well as E-selectin in predicting 30-day mortality. Among a subgroup of patients who received Dex early, within 14 days of COVID-19 debut, the adjusted mortality risk was 0.4 (95% CI 0.2-0.8), i.e., 40% compared with Without-Dex. Dex administration in a cohort of critically ill COVID-19 patients resulted in altered immunological and physiologic responses, some of which were associated with mortality.

[Post-Covid osteomyelitis of the facial bones]

The pandemic of coronavirus infection existed from 2019 to 2023. The World Health Organization (WHO) has announced on May 5, 2023 that the pandemic had ended. However, it does not cease to have an adverse effect on the health of the world population. Necrotic lesions of the bones of the facial skeleton are now a characteristic sign of a severe coronavirus infection. We conducted a review of scientific publications that reflected the relationship between coronavirus and necrotic processes of the skull bones, methods of treatment, prevention and the latest developments in this direction. The purpose of this article is to review existing studies on Post-Covid osteomyelitis of facial bones, its impact, features of the clinical picture of this disease, analysis of methods and means of treatment of this group of patients. Analysis of literature data has shown that the search for an ideal dressing material continues, especially the developments of native developers stand emphasized. The advantages of modern materials over traditional ones have become unquestionable, but further research in this direction is required.

COVID-19 immunopathology: From acute diseases to chronic sequelae

The clinical manifestation of coronavirus disease 2019 (COVID-19) mainly targets the lung as a primary affected organ, which is also a critical site of immune cell activation by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, recent reports also suggest the involvement of extrapulmonary tissues in COVID-19 pathology. The interplay of both innate and adaptive immune responses is key to COVID-19 management. As a result, a robust innate immune response provides the first line of defense, concomitantly, adaptive immunity neutralizes the infection and builds memory for long-term protection. However, dysregulated immunity, both innate and adaptive, can skew towards immunopathology both in acute and chronic cases. Here we have summarized some of the recent findings that provide critical insight into the immunopathology caused by SARS-CoV-2, in acute and post-acute cases. Finally, we further discuss some of the immunomodulatory drugs in preclinical and clinical trials for dampening the immunopathology caused by COVID-19.

Corticosteroids: A boon or bane for COVID-19 patients?

Several drugs and antibodies have been repurposed to treat COVID-19. Since the outcome of the drugs and antibodies clinical studies have been mostly inconclusive or with lesser effects, therefore the need for alternative treatments has become unavoidable. However, corticosteroids, which have a history of therapeutic efficacy against coronaviruses (SARS and MERS), might emerge into one of the pandemic's heroic characters. Corticosteroids serve an immunomodulatory function in the post-viral hyper-inflammatory condition (the cytokine storm, or release syndrome), suppressing the excessive immunological response and preventing multi-organ failure and death. Therefore, corticosteroids have been used to treat COVID-19 patients for more than last two years. According to recent clinical trials and the results of observational studies, corticosteroids can be administered to patients with severe and critical COVID-19 symptoms with a favorable risk-benefit ratio. Corticosteroids like Hydrocortisone, dexamethasone, Prednisolone and Methylprednisolone has been reported to be effective against SARS-CoV-2 virus in comparison to that of non-steroid drugs, by using non-genomic and genomic effects to prevent and reduce inflammation in tissues and the circulation. Clinical trials also show that inhaled budesonide (a synthetic corticosteroid) increases time to recovery and has the potential to reduce hospitalizations or fatalities in persons with COVID-19. There is also a brief overview of the industrial preparation of common glucocorticoids.

Corticosteroids use for COVID-19: an overview of systematic reviews

PURPOSE

A reappraisal of the validity of the conclusions of systematic reviews (SRs) and meta-analyses related to corticosteroids use for the treatment of COVID-19.

MATERIAL AND METHODS

An overview of SRs (umbrella review). The methodological quality of the SRs was assessed using tha AMSTAR-2 checklist; quality of the evidence was appraised following the GRADE approach.

RESULTS

35 SRs were included in this overview. Data were from 307 overlapping reports, based on 121 individual primary studies (25 randomized clinical trials (RCTs), 96 non-RCTs. In critically ill patients the use of steroids significantly reduced mortality compared to standard of care in 80% of the SRs, more often with moderate/high level of certainty; however, in patients not requiring oxygen supplementation the use of steroids increased the overall mortality in 2/3 of the comparisons. Clinical progression of diseases (need for mechanical ventilation, or for intensive care admission) was more commonly observed among controls compared to steroids recipients (in 9 out of 14 comparisons; certainty of evidence from very-low to moderate). The occurrence of adverse events was similar among steroids recipients and controls. Other outcomes (i.e., viral clearance, length of hospital stay) or issue related to optimal dose and type of steroids were addressed in a minority of SRs, with a high level of uncertainty, so that no definitive conclusions can be drawn.

CONCLUSIONS

There is moderate certainty of evidence that corticosteroids reduce mortality and progression of disease in critically ill COVID-19 patients compared to standard of care, without increasing the occurrence of adverse events.

Systematic review and meta-analysis of the efficacy and safety of oseltamivir (Tamiflu) in the treatment of Coronavirus Disease 2019 (COVID-19)

Efforts are ongoing by researchers globally to develop new drugs or repurpose existing ones for treating COVID-19. Thus, this led to the use of oseltamivir, an antiviral drug used for treating influenza A and B viruses, as a trial drug for COVID-19. However, available evidence from clinical studies has shown conflicting results on the effectiveness of oseltamivir in COVID-19 treatment. Therefore, this systematic review and meta-analysis was performed to assess the clinical safety and efficacy of oseltamivir for treating COVID-19. The study was conducted according to the PRISMA guidelines, and the priori protocol was registered in PROSPERO (CRD42021270821). Five databases were searched, the identified records were screened, and followed by the extraction of relevant data. Eight observational studies from four Asian countries were included. A random-effects model was used to pool odds ratios (ORs), mean differences (MD), and their 95% confidence intervals (CI) for the study analysis. Survival was not significantly different between all categories of oseltamivir and the comparison groups analysed. The duration of hospitalisation was significantly shorter in the oseltamivir group following sensitivity analysis (MD -5.95, 95% CI -9.91--1.99 p = 0.003, heterogeneity I2 0%, p = 0.37). The virological, laboratory and radiological response rates were all not in favour of oseltamivir. However, the electrocardiographic safety parameters were found to be better in the oseltamivir group. However, more studies are needed to establish robust evidence on the effectiveness or otherwise of oseltamivir usage for treating COVID-19.

Effect of methylprednisolone therapy on hospital stay and viral clearance in patients with moderate COVID-19

Background

The benefits and harms of methylprednisolone treatment in patients with moderate coronavirus disease 2019 (COVID-19) remain controversial. In this study, we investigated the effect of methylprednisolone on mortality rate, viral clearance, and hospitalization stay in patients with moderate COVID-19.

Methods

This retrospective study included 4827 patients admitted to Wuhan Huoshenshan and Wuhan Guanggu hospitals from February to March 2020 diagnosed with COVID-19 pneumonia. The participants' epidemiological and demographic data, comorbidities, laboratory test results, treatments, outcomes, and vital clinical time points were extracted from electronic medical records. The primary outcome was in-hospital death; secondary outcomes were time from admission to viral clearance and hospital stay. Univariate and multivariate logistic or linear regression analysis were used to assess the roles of methylprednisolone in different outcomes. The propensity score matching (PSM) method was used to control for confounding factors.

Results

A total of 1320 patients were included in this study, of whom 100 received methylprednisolone. Overall, in-hospital mortality was 0.91% (12/1320); the 12 patients who died were all in the methylprednisolone group, though multivariate logistic regression analysis showed methylprednisolone treatment was not a risk factor for in-hospital death in moderate patients before or after adjustment for confounders by PSM. Methylprednisolone treatment was correlated with longer length from admission to viral clearance time and hospital stay before and after adjustment for confounders.

Conclusions

Methylprednisolone therapy was not associated with increased in-hospital mortality but with delayed viral clearance and extended hospital stay in moderate COVID-19 patients.

COVID-19 in Russia: Evolution of Views on the Pandemic. Report II

Over the two years of the novel coronavirus infection (COVID-19) pandemic, there has been an evolution of views in various fields of medicine, which has led to a powerful development of scientific research in the field of epidemiology, clinic, diagnosis and therapy of COVID-19. This article discusses the evolution of views and approaches to the study of the clinic and therapy of COVID-19. The symptoms and aggravation of the course of cardiovascular diseases with COVID-19 have been established. The main strategy for organizing surgical care for patients with COVID-19 is indicated. The main criteria for the treatment of COVID-19, the need to prescribe SGCS on an individual basis, and the need to search for new methods of anti-inflammatory therapy for COVID-19, one of which may be the use of alkylating drugs in ultra-low doses, are described.

Effect of corticosteroid therapy on mortality in COVID-19 patients-A systematic review and meta-analysis

The effect of corticosteroid therapy is still controversial on prevention of mortality in coronavirus disease‐2019 (COVID‐19). The objective of this study is to investigate the effect of corticosteroids on mortality. This systematic review was performed as per preferred reporting items for systematic reviews and meta‐analyses guidelines. A systematic search was performed at different databases namely Medline/PubMed, Cochrane and Google scholar on 10 February 2022. A pooled estimate for effect of corticosteroid therapy on mortality was calculated as outcome of study. Risk bias analysis and Newcastle Ottawa Scale were used to assess the quality of randomized control trial (RCT) and cohort studies, respectively. Cochran's Q test and the I² statistic were conducted for heterogeneity and accordingly study model was applied. A total 43 studies were included, having sample size of 96,852 patients. Amongst them, 19,426 and 77,426 patients received corticosteroid therapy (intervention group) or standard treatment without corticosteroid (control group), respectively. Mortality observed in the intervention and control group was 14.2% (2749) and 7.1% (5459), respectively. The pooled estimate 2.173 (95% CI: 2.0690–2.2820) showed significantly increased mortality in intervention as compared to control. The pooled estimate of methyprednisolone 1.206 (95% CI: 1.0770–1.3500) showed significantly increased mortality while the pooled estimate of dexamethasone 1.040 (95% CI: 0.9459–1.1440) showed insignificantly increased mortality as compared to control. In conclusion, corticosteroid therapy produced a negative prognosis as depicted by increased mortality among COVID‐19 patients. The possible reasons might be delay in virus clearance and secondary infections due to corticosteroids initiated at high dose in the early stage of infection.

Efficacy and safety of corticosteroid regimens for the treatment of hospitalized COVID-19 patients: a meta-analysis

Aim

To evaluate the efficacy and safety of corticosteroids for treating hospitalized COVID-19 patients.

Materials & methods

Efficacy outcomes included time to negative SARS-CoV-2 tests, length of stay, duration and incidence of intensive unit care stay, incidence of mortality and duration and incidence of mechanical ventilation. Safety outcomes included the incidence of adverse events and severe adverse events, incidence of hyperglycemia and incidence of nosocomial infections.

Results

Ninety-five randomized controlled trials (RCTs) and observational studies (n = 42,205) were included. Corticosteroids were associated with increased length of stay (based on RCT only), increased time to negative tests, decreased length of mechanical ventilation and increased odds of hyperglycemia.

Conclusion

Corticosteroids should be considered in patients requiring mechanical ventilation, and glycemic monitoring may be needed when administering corticosteroids.

Post-COVID-19 related osteonecrosis of the jaw (PC-RONJ): an alarming morbidity in COVID-19 surviving patients

Purpose

The recent coronavirus disease (COVID-19) pandemic mainly affects the respiratory system; however, several oral and maxillofacial post-COVID-19 complications have also been observed. This series reports the growing number of osteonecrosis cases associated with post-COVID-19 patients.

Materials and methods

This is a retrospective, multi-center case series that reports cases with maxillary osteonecrosis after various periods of SARS-CoV-2 infection in the period between January and August 2021 based on the PROCESS guidelines.

Results

Twelve cases were reported with post-COVID-19 manifestation of spontaneous osteonecrosis of the maxillary jaw. Five patients were hospitalized during COVID-19 management and all of the twelve cases had at least one systematic Co-morbidity, and undertake corticosteroids prescription based on the COVID-19 disease treatment protocol. The mean onset of osteonecrosis symptoms appearance was 5.5 ± 2.43 weeks calculated from the day of the negative PCR test. The management was successfully done through surgical debridement and pre and post-operative antibiotics. No anti-fungal medications were prescribed as the fungal culture and the histopathological report were negative.

Conclusion

Post-COVID-related osteonecrosis of the jaw (PC-RONJ) could be now considered as one of the potential post-COVID-19 oral and maxillofacial complications that occurs unprovokedly and mainly in the maxilla.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07518-9.

Evaluation of Antibacterial and Antiviral Drug Effectiveness in COVID-19 Therapy: A Data-Driven Retrospective Approach

The clinical manifestations associated with COVID-19 disease is mainly due to a dysregulated host response related to the overexpression of inflammatory markers. Until recently, only remdesivir had gained FDA approval for COVID-19 hospitalized patients and there are currently no evidence-based therapeutic options or options for prevention of complications that have been established. Some medical treatments such as antivirals, antibacterials, antithrombotics, antipyretics, corticosteroids, interleukin inhibitors, monoclonal antibodies, convalescent plasma, immunostimulants, and vitamin supplements have been utilized. However, there are limited data to support their effectiveness. Hence, this study was attempted to identify and evaluate the effectiveness of antibacterials and antivirals used for COVID-19 using a retrospective cross-sectional approach based on the medical records of adult patients in four hospitals. The number of antibacterials was calculated in defined daily dose (DDD) per 100 bed-days unit. Both mixed-logit regression and analysis of covariance were used to determine the effectiveness of the aforementioned agents in relation to COVID-19 outcome and patients' length of stay. The model was weighed accordingly and covariates (e.g., age) were considered in the model. Heart disease was found to be the most common pre-existing condition of COVID-19 hospitalized patients in this study. Azithromycin, an antibacterial in the Watch category list, was used extensively (33-65 DDD per 100 bed-days). Oseltamivir, an antiviral approved by the FDA for influenza was the most prescribed antiviral. In addition, favipiravir was found to be a significant factor in improving patients' COVID-19 outcomes and decreasing their length of stay. This study strongly suggests that COVID-19 patients' received polypharmacy for their treatment. However, most of the drugs used did not reach statistical significance in improving the patients' condition or decreasing the length of stay. Further studies to support drug use are needed.

The Role of Cytochrome P450 Enzymes in COVID-19 Pathogenesis and Therapy

Coronavirus disease 2019 (COVID-19) has become a new public health crisis threatening the world. Dysregulated immune responses are the most striking pathophysiological features of patients with severe COVID-19, which can result in multiple-organ failure and death. The cytochrome P450 (CYP) system is the most important drug metabolizing enzyme family, which plays a significant role in the metabolism of endogenous or exogenous substances. Endogenous CYPs participate in the biosynthesis or catabolism of endogenous substances, including steroids, vitamins, eicosanoids, and fatty acids, whilst xenobiotic CYPs are associated with the metabolism of environmental toxins, drugs, and carcinogens. CYP expression and activity are greatly affected by immune response. However, changes in CYP expression and/or function in COVID-19 and their impact on COVID-19 pathophysiology and the metabolism of therapeutic agents in COVID-19, remain unclear. In this analysis, we review current evidence predominantly in the following areas: firstly, the possible changes in CYP expression and/or function in COVID-19; secondly, the effects of CYPs on the metabolism of arachidonic acid, vitamins, and steroid hormones in COVID-19; and thirdly, the effects of CYPs on the metabolism of therapeutic COVID-19 drugs.

Systemic administration of glucocorticoids, cardiovascular complications and mortality in patients hospitalised with COVID-19, SARS, MERS or influenza: A systematic review and meta-analysis of randomised trials

BACKGROUND

Administration of glucocorticoids might reduce mortality in patients with severe COVID-19 but have adverse cardiometabolic effects.

OBJECTIVES

to investigate the effect of systemic administration of glucocorticoids on cardiovascular complications and all-cause mortality in patients hospitalised with respiratory viral infections, including COVID-19, SARS, MERS and influenza.

METHODS

We identified randomised trials published prior to July 28th, 2021. The Mantel-Haenszel random effects method and the Hartung and Knapp adjustment were used to obtain pooled estimates of treatment effect with 95% confidence intervals.

RESULTS

No randomised trials of glucocorticoids for SARS, MERS or influenza reported relevant outcomes. We included eleven COVID-19 randomised trials (8109 patients). Overall, compared to placebo or standard care, glucocorticoids were not associated with a reduction of in-hospital mortality (p = 0.09). In a pre-specified sub-analysis, in-hospital mortality was reduced by 19% when follow-up was restricted to 14 days from randomisation (5/11 trials, 1329 patients, p = 0.02). With longer follow-up (9/11 trials, 7874 patients), administration of glucocorticoids was associated with a trend to benefit for those requiring mechanical ventilation (RR 0.86; 95% CI 0.57-1.27) but possible harm for those not receiving oxygen at randomisation (RR 1.27; 95% CI 1.00 - 1.61), an effect that was significantly different amongst subgroups (p = 0.0359). Glucocorticoids reduced the risk of worsening renal function by 37% (4/11 trials); reported rate of other cardiovascular complications was low.

CONCLUSIONS

Administration of systemic glucocorticoids to patients hospitalised with COVID-19 does not lower mortality overall but may reduce it in those requiring respiratory support and increase it in those who do not.

Use of steroids in COVID-19 patients: A meta-analysis

BACKGROUND

Emerging reports have shown the benefits of steroids in hospitalized COVID-19 patients as life-saving drugs. However, the use of steroids in COVID-19 patients is confusing among many physicians.

AIM

The aim of the current study was to find out the exact association of steroids in the deaths of COVID-19 patients.

METHODS

The relevant studies were searched in PubMed, Google scholar, and Clinical trials registries till May 25, 2021 and sorted out based on inclusion and exclusion criteria. The quality of studies was assessed using a standard scale. The pooled odds ratio was calculated with a 95% confidence interval. The sensitivity and sub-group analyses were also done. The publication bias was assessed qualitatively. The Rev Man 5 was used for all analyses with a random-effect model.

RESULTS

The quantitative analysis was done with 9922 patients (6265-male and 3657-females) from 21 relevant studies. The pooled estimate results i.e. 0.52 [0.34, 0.80] have shown a significant reduction in deaths of COVID-19 patients in the steroidal group as compared to the non-steroidal group. The sensitivity analyses did not alter our conclusions. In subgroup analysis, methylprednisolone has shown a significant reduction in deaths of COVID-19 patients as compared to the non-steroidal group, however, more clinical evidence is required for dexamethasone and hydrocortisone.

CONCLUSION

The use of steroids in hospitalized COVID-19 patients is useful to reduce deaths.

The rise in cases of mucormycosis, candidiasis and aspergillosis amidst COVID19

The Coronavirus outbreak globally has changed the medical system and also led to a shortage of medical facilities in both developing and underdeveloped countries. The COVID19 disease, being novel in nature along with high infectivity and frequent mutational rate, has been termed to be fatal across the globe. The advent of infection by SARS-CoV-2 has brought a myriad of secondary complications and comorbidities resulting in additional challenges to the health care system induced by novel therapeutic procedures. The emerging variant with respect to the Indian subcontinent and the associated genetic mutations have worsened the situation at hand. Proper clinical management along with epidemiological studies and clinical presentations in scientific studies and trials is necessary in order to combat the simultaneous waves of emerging strains. This article summarizes three of the major fungal outbreaks in India namely mucormycosis, candidiasis and aspergillosis, and elaborates their subtypes, pathogenesis, symptoms and treatment and detection techniques. A detail of future therapeutics under consideration are also elaborated along with a general hypothesis on how COVID19 is related to immunological advances leading to major widespread fungal infection in the country. The factors that contribute in promoting virus proliferation and invasive fungal infections include cell-mediated immunity, associated immunocompromised conditions and treatment protocols that slows down immune mechanisms. To better comprehend a fungal or bacterial outbreak, it is very important to conduct audits mediated through multicenter national and state research teams for recognizing patterns and studying current cases of fungal infection in both healthy and comorbid groups of COVID19 patients.

The role and place of pathogenetic therapy with glucocorticosteroid hormones in the treatment of patients with novel coronavirus infection (COVID-19)

In December 2019, in Wuhan (PRC), there was an outbreak of a new coronavirus infection (COVID-19) caused by coronavirus type 2 (SARS-CoV-2), which has a zoonotic origin. The World Health Organization announced the COVID-19 pandemic on March 11, 2020. In most cases, the disease is asymptomatic or mild. However, up to 15% of patients require hospitalization, and 5% develop a critical condition. To date, no effective antiviral drug COVID-19 has been found that can reduce mortality. Pathological changes in the lungs are manifested by diffuse alveolar damage, which is clinically manifested by increasing respiratory failure, accompanied by a decrease in saturation and oxygen concentration in arterial blood. It is assumed that autoimmune reactions play an important role in the development of multiple organ failure. Generalized inflammation is characterized by an increase in the concentration of C-reactive protein, ferritin, interleukin-1 and interleukin-6, and other markers. At the stage of development of infection in the form of a cytokine storm, proinflammatory cytokines can themselves become pathogenetic factors in the development of critical conditions, multiple organ failure and deaths. Therefore, a key challenge in treating hospitalized patients with COVID-19 is to control generalized inflammation. Glucocorticosteroid hormones (GCS) are widely used as anti-inflammatory drugs in the clinic of infectious diseases. However, until recently, there was no convincing data on the effectiveness of GCS in patients with COVID-19. Recently published results of a large randomized clinical trial (RECOVERY) showing the efficacy of GCS (dexamethasone) in the treatment of critically ill patients with COVID-19. At the same time, the feasibility and effectiveness of GCS in patients with COVID-19 outside critical conditions, the pathogenetic mechanisms that determine the effectiveness/ineffectiveness of these drugs and the validity of their use remain insufficiently studied.

Corticosteroids for COVID-19: worth it or not?

Pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induced COVID-19 implied the presence of excessive proinflammatory cytokines and chemokines in patients causing significant morbidity and mortality. To diminish systemic hyper inflammation, a few physicians and researchers have utilized corticosteroids. Corticosteroid implementation has increased after the publication of interim guidelines regarding corticosteroid use in COVID-19 patients by WHO, despite the remaining controversies regarding long-term side effects and disease progression capability of corticosteroids. In different studies, the implementation of corticosteroids on COVID-19 patients revealed controversial results, which require further intensive research. This review will present the current outcomes and possibilities of using corticosteroids to treat COVID-19 patients.

Case Report: Successful Treatment of Five Critically Ill Coronavirus Disease 2019 Patients Using Combination Therapy With Etoposide and Corticosteroids

Acute respiratory distress syndrome (ARDS) is the leading cause of mortality in hospitalized patients with coronavirus disease 2019 (COVID-19) because of limited effective therapies. During infection, the accumulation and activation of macrophages and monocytes in the lungs induce inflammatory mediators and contribute to tissue injury, leading to ARDS. However, therapeutic strategies that directly target activated macrophage and monocytes have not been reported. Combination treatment with etoposide (a cytotoxic agent) and a corticosteroid has been widely used for treating hemophagocytic lymphohistiocytosis characterized by the systemic activation of macrophages with overwhelming inflammation. Herein, we present five cases of COVID-19-associated ARDS treated with etoposide and corticosteroids. Three of the five patients were over 65 years of age and had various underlying diseases, including multiple myeloma. Four patients required invasive mechanical ventilation (MV), and one patient refused to be placed on MV due to underlying diseases. All patients were pre-treated with antiviral and/or other anti-inflammatory agents, but their condition deteriorated and hyperinflammation was noted. All five patients responded well to treatment and had an immediate response, as reflected by improvement in their respiratory condition and inflammatory marker levels and rapid resolution of fever after etoposide administration; however, some patients required a second dose of etoposide and longer course of steroids. All patients recovered, and there were no severe adverse events related to the drugs. Following successful treatment in these five patients, we plan to conduct a clinical trial to evaluate the efficacy and safety of combination therapy with etoposide and corticosteroid for treating COVID-19 patients in Japan.

Phase I dose-escalation single centre clinical trial to evaluate the safety of infusion of memory T cells as adoptive therapy in COVID-19 (RELEASE)

BACKGROUND

Effective treatments are still needed to reduce the severity of symptoms, time of hospitalization, and mortality of COVID-19. SARS-CoV-2 specific memory T-lymphocytes obtained from convalescent donors recovered can be used as passive cell immunotherapy.

METHODS

Between September and November 2020 a phase 1, dose-escalation, single centre clinical trial was conducted to evaluate the safety and feasibility of the infusion of CD45RA^- memory T cells containing SARS-CoV-2 specific T cells as adoptive cell therapy against moderate/severe cases of COVID-19. Nine participants with pneumonia and/or lymphopenia and with at least one human leukocyte antigen (HLA) match with the donor were infused. The first three subjects received the lowest dose (1 × 10⁵ cells/kg), the next three received the intermediate dose (5 × 10⁵ cells/kg) and the last three received the highest dose (1 × 10⁶ cells/kg) of CD45RA^- memory T cells. Clinicaltrials.gov registration: NCT04578210.

FINDINGS

All participants' clinical status measured by National Early Warning Score (NEWS) and 7-category point ordinal scales showed improvement six days after infusion. No serious adverse events were reported. Inflammatory parameters were stabilised post-infusion and the participants showed lymphocyte recovery two weeks after the procedure. Donor microchimerism was observed at least for three weeks after infusion in all patients.

INTERPRETATION

This study provides preliminary evidence supporting the idea that treatment of COVID-19 patients with moderate/severe symptoms using convalescent CD45RA^- memory T cells is feasible and safe.

FUNDING

Clinical Trial supported by Spanish Clinical Research Network PT17/0017/0013. Co-funded by European Regional Development Fund/European Social Fund. CRIS CANCER Foundation Grant to AP-M and Agencia Valenciana de Innovación Grant AVI-GVA COVID-19-68 to BS.