Efficacy and Safety of 5-Day Oral Ensitrelvir for Patients With Mild to Moderate COVID-19: The SCORPIO-SR Randomized Clinical Trial

Importance

Treatment options for COVID-19 are warranted irrespective of the presence of risk factors for severe disease.

Objective

To assess the efficacy and safety of ensitrelvir in patients with mild to moderate COVID-19.

Design, Setting, and Participants

This phase 3 part of a phase 2/3, double-blind, placebo-controlled randomized clinical trial was conducted from February 10 to July 10, 2022, with a 28-day follow-up period, at 92 institutions in Japan, Vietnam, and South Korea. Patients (aged 12 to <70 years) with mild to moderate COVID-19 within 120 hours of positive viral test results were studied.

Interventions

Patients were randomized (1:1:1) to receive 125 mg of once-daily ensitrelvir (375 mg on day 1), 250 mg of once-daily ensitrelvir (750 mg on day 1), or placebo for 5 days.

Main Outcomes and Measures

The primary end point was the time to resolution of the composite of 5 characteristic symptoms of SARS-CoV-2 Omicron infection, assessed using a Peto-Prentice generalized Wilcoxon test stratified by vaccination history. Virologic efficacy and safety were also assessed.

Results

A total of 1821 patients were randomized, of whom 1030 (347 in the 125-mg ensitrelvir group, 340 in the 250-mg ensitrelvir group, and 343 in the placebo group) were randomized in less than 72 hours of disease onset (primary analysis population). The mean (SD) age in this population was 35.2 (12.3) years, and 552 (53.6%) were men. A significant difference was observed between the 125-mg ensitrelvir group and the placebo group (P = .04 with a Peto-Prentice generalized Wilcoxon test). The difference in median time was approximately 1 day between the 125-mg ensitrelvir group and the placebo group (167.9 vs 192.2 hours; difference, -24.3 hours; 95% CI, -78.7 to 11.7 hours). Adverse events were observed in 267 of 604 patients (44.2%) in the 125-mg ensitrelvir group, 321 of 599 patients (53.6%) in the 250-mg ensitrelvir group, and 150 of 605 patients (24.8%) in the placebo group, which included a decrease in high-density lipoprotein level (188 [31.1%] in the 125-mg ensitrelvir group, 231 [38.6%] in the 250-mg ensitrelvir group, and 23 [3.8%] in the placebo group). No treatment-related serious adverse events were reported.

Conclusions and Relevance

In this randomized clinical trial, 125-mg ensitrelvir treatment reduced the time to resolution of the 5 typical COVID-19 symptoms compared with placebo in patients treated in less than 72 hours of disease onset; the absolute difference in median time to resolution was approximately 1 day. Ensitrelvir demonstrated clinical and antiviral efficacy without new safety concerns. Generalizability to populations outside Asia should be confirmed.

Trial Registration

Japan Registry of Clinical Trials Identifier: jRCT2031210350.

The Effect of Phloroglucinol in Patients With Diarrhea-predominant Irritable Bowel Syndrome: A Randomized, Double-blind, Placebo-controlled Trial

Background/Aims

We aim to evaluate the efficacy and safety of phloroglucinol in patients with diarrhea-predominant irritable bowel syndrome (IBS-D).

Methods

Seventy-two patients with IBS-D who met Rome III criteria were 1:1 randomized in a parallel, double-blind design to receive phloroglucinol or placebo for 2 weeks. Patients were followed for 1 week after the end of treatment. The primary outcome was the proportion of responders, defined as those who answered “moderate or more of improvement” to the subject global assessment for at least 1 week of the 2-week treatment period. Secondary outcomes included the proportion of these patients during the 3-week period including 1 week of follow-up, IBS symptoms (abdominal pain/discomfort, diarrhea, urgency, mucus in stool, bloating, and passage of gas), stool frequency and consistency, and IBS quality of life (IBS-QOL).

Results

The proportion of responders during 2-week treatment period tended to be higher in the phloroglucinol group than in the placebo group, although the difference did not reach statistical significance (55.6% vs 30.6%, P = 0.056). The proportion of responders during the 3-week period was significantly higher in the phloroglucinol group than in the placebo group (61.6% vs 30.6%, P = 0.013). Individual symptom scores, IBS-QOL, stool frequency and consistency tended to improve in the phloroglucinol group, but there were no statistical significances compared to those of the placebo group. No serious adverse events were reported in both groups.

Conclusions

Phloroglucinol could be a safe and beneficial option for the management of overall IBS symptoms in patients with IBS-D. Further large scaled studies are warranted.

Dermatomyositis associated with hepatitis B virus-related hepatocellular carcinoma

Dermatomyositis is an idiopathic inflammatory myopathy with typical cutaneous manifestations. It has been proposed that dermatomyositis may be caused by autoimmune responses to viral infections. Previous studies have shown an association between dermatomyositis and malignant tumors such as ovarian cancer, lung cancer, and colorectal cancer. However, a chronic hepatitis B virus (HBV) infection associated with dermatomyositis and hepatocellular carcinoma (HCC) has been very rarely reported. Here, we report a rare case of dermatomyositis coinciding with HBV-associated HCC. A 55-year-old male was confirmed to have HCC and dermatomyositis based on proximal muscle weakness, typical skin manifestations, elevated muscle enzyme levels, and muscle biopsy findings. This case suggests that HCC and/or a chronic HBV infection may be factors in the pathogenesis of dermatomyositis through a paraneoplastic mechanism.

A case of acute myocarditis as the initial presentation of Crohn's disease

We experienced a case of acute myocarditis as the initial presentation of Crohn's disease. A 19-year-old woman was admitted with impaired consciousness, shock, and respiratory failure. She had suffered from frequent diarrhea and abdominal pain for several years. Cardiac troponin I and creatine kinase-MB fraction levels were elevated to 5.32 and 16.66 ng/mL, respectively. A 12-lead electrocardiogram showed sinus tachycardia, and a chest radiograph revealed interstitial pulmonary edema. An echocardiogram showed dilated ventricles with akinesia of the basal to apical inferoseptal, anteroseptal, anterior, and inferior left ventricular walls and severely impaired systolic function. Intensive care with inotropic support was effective, and her clinical condition gradually improved. Two weeks later, a colonoscopy revealed ulceration with stenosis in the terminal ileum and multiple aphthous ulcers in the rectum. A biopsy of the rectum revealed non-caseating granulomatous inflammation. She was diagnosed with Crohn's disease presenting with acute myocarditis.

Simultaneous emergence of entecavir resistance mutations in a nucleoside-naive chronic hepatitis B patient

BACKGROUND

Entecavir (ETV) has potent antiviral activity against hepatitis B virus (HBV), and the emergence of drug resistance is rare in nucleoside-naive patients. Resistance requires simultaneous appearance of three mutations which account for the very low resistance profile of ETV. We experienced one case of genotypic ETV resistance with viral rebound during ETV treatment of nucleoside-naive patients with chronic hepatitis B (CHB).

CASE

A 50-year-old HBV e antigen-positive man received ETV 0.5 mg/day for 120 weeks. The level of HBV DNA was 9.0 log(10) copies/ml at baseline, declined to a nadir of 2.7 at week 60 and then rebounded to 6.0 at week 108 and 7.5 at week 120. The serum alanine aminotransferase level did not increase during ETV treatment. The ETV resistance-related substitution (T184A) and lamivudine resistance-related substitutions (L180M and M204V) were detected by sequence analysis at week 96.

CONCLUSIONS

The three substitutions associated with ETV and lamivudine resistance developed simultaneously without complete suppression in a nucleoside-naive CHB patient after extended therapy. In spite of the extremely rare chance of viral mutation during ETV treatment, treatment-naive patients with high pretreatment viral loads and detectable HBV DNA during treatment should be carefully monitored or undergo targeted surveillance for resistance.

Outcomes and efficiency of national gastric cancer screening program in Korea: Single-center, large-scale study

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Background: Gastric cancer is a major cause of death and a substantial socioeconomic burden in Korea. The National Cancer Screening Program for Medicaid recipients was initiated in 1999 and has contributed to reduction of cancer-related mortality in Korea. Endoscopy may be cost-effective screening tool in Korea, where the cost of endoscopy and UGIS are similar and the incidence of gastric cancer is high. Most of Japanese studies on the efficiency of mass screening for gastric cancer have dealt with photoflurography as a screening tool. Although biennial gastric cancer screening by endoscopy has been increasing in Korea as part of the National Cancer Screening Program, few studies have evaluated its efficiency. Therefore, we analyzed the outcomes and efficiency of the National Gastric Cancer Screening Program using endoscopy in Korea.

Methods: We reviewed medical records from the National Gastric Cancer Screening Program at Chung-Ang University hospital in Korea from January 2007 to December 2010. The study population was comprised of Medicaid recipients ≥ 40 years of age who were taken from the National Health Insurance Corporation.

Results: A total of 41,150 asymptomatic subjects underwent endoscopy for gastric cancer screening. The mean age of the screened subjects was 56.3 years for men and 48.9 years for women. The male to female ratio of the screened subjects was 1.57:1. Gastric cancer was diagnosed in 102 (0.24%) of 41,150 subjects (60 men and 42 women). Their mean age was 54.4 years. Of these, 76 subjects (0.18%) were diagnosed as early gastric cancer and 26 subjects (0.06%) as advanced gastric cancer. The proportion of early gastric cancer among total gastric cancers was 74.5%. During the period, only 6,586 (16.0%) subjects participated in the biennial gastric cancer screening (59% for men and 49% for women).

Conclusions: Despite accomplishments of the National Gastric Cancer Screening Program in Korea, low compliance to the screening program remains an issue. Furthermore, its cost-effectiveness analysis will be needed for successful progression.

The Frequency and Risk Factors of Colorectal Adenoma in Health-Check-up Subjects in South Korea: Relationship to Abdominal Obesity and Age

BACKGROUND/AIMS

Obesity is associated with the risk of colorectal cancer. However, there is a lack of information about the relationship between obesity and colorectal adenoma. We investigated whether general and abdominal obesity are risk factors for colorectal adenoma.

METHODS

Subjects who received health check-ups, including colonoscopy, from April 2006 to September 2007 in Chung-Ang University Hospital were included (n=1,316). The frequency and characteristics of colorectal adenomas were analyzed according to demographic features, past history, blood tests, body mass index, and components of metabolic syndrome. Abdominal obesity was defined as a waist circumference of >/=80 cm in women and >/=90 cm in men.

RESULTS

The sex ratio of the subjects was 1.9:1 (male:female) and their age was 47.7+/-10.0 years (mean+/-SD). In univariate analysis, abdominal obesity was significantly associated with the frequency of colorectal adenoma (26.5% "yes" vs 16.9% "no"; p<0.001). The frequency of colorectal adenoma was significantly higher among males, older patients, current smokers, and subjects with fasting hyperglycemia (>/=100 mg/dL) or fatty liver (p<0.05). Multivariate analysis identified that male sex (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0-2.2), old age (age >/=60 years; OR, 6.7; 95% CI, 3.5-12.5), and abdominal obesity (OR, 1.5; 95% CI, 1.0-2.2) were independent risk factors for colorectal adenoma (p<0.05). The frequency of multiple adenomas (more than two sites) was also significantly higher in subjects with abdominal obesity. However, the effect of abdominal obesity on the development of colorectal adenoma decreased in elderly people.

CONCLUSIONS

Abdominal obesity is an independent risk factor for colorectal adenoma and its multiplicity, especially in younger people in South Korea.

Fragment-specific fracture fixation and double-column plating of unstable distal radial fractures using AO mini-fragment implants and Kirschner wires

OBJECTIVE

To evaluate the efficacy of AO mini-fragment implants and 1.25-mm Kirschner wires using fragment-specific fracture fixation and double-column plating for displaced or unstable distal radial fractures.

DESIGN

prospective and consecutive.

SETTING

level II trauma hospital.

PARTICIPANTS

28 people with 30 fractures and an average follow-up of 21.1 (range 12-41) months, treated with fragment-specific fracture fixation.

OUTCOME MEASUREMENTS

anatomical assessment using anteroposterior and lateral radiographs, graded according to Sarmiento's modification of Lidstrom's scoring system. CLINICAL OUTCOME ASSESSMENT: DASH and Modified Gartland and Werley scores.

RESULTS

There were 24 excellent and 6 good radiological results. Final mean grip strength was 83% of uninjured side, and mean wrist range of motion was 61 degrees dorsiflexion, 54 degrees palmar flexion, 85 degrees supination and 83 degrees pronation. Gartland and Werley's demerit point system revealed 13 (43%) excellent, 12 (40%) good, 5 (17%) fair and no poor results. The mean DASH score was 18, with a standard deviation of +/-18.

CONCLUSION

This fixation method is a reliable and low-cost alternative with good clinical and anatomical results, particularly useful in open reduction and internal fixation of comminuted intra-articular distal radial fractures.

Applications of three-dimensionally scanned models in orthodontics

The purpose of this study was to investigate clinical applications of the three-dimensional reverse engineering technologies for the analysis of orthodontic models. The measuring accuracy and the process of the 3D model scanning technique were evaluated with respect to linear, surface and volumetric parameters. Orthodontically induced dentoalveolar changes, which have been traditionally evaluated by cephalometric analysis, were assessed by the registration function of Rapidform 2002, a 3D-reverse modeling software in scanned maxillary casts. Three-dimensional digital models are valuable alternatives to conventional casts for model analysis and also yield information which could previously be gathered only by cephalometric superimposition.

[Is immunohistochemistry for MLH1 and MSH2 proteins a useful method for detection of microsatellite instability in sporadic colorectal cancer?]

BACKGROUND/AIMS

In order to identify microsatellite instability (MSI), the test based on the polymerase chain reaction (PCR) can be used. However, PCR is not routinely performed in all hospital laboratories. Recently, immunohistochemistry (IHC) for MLH1 and MSH2 proteins has been reported as a rapid and useful method for MSI. However, the efficacy of IHC in the detection of the MSI has not been well established. The aim of this study was to evaluate the usefulness of IHC in the detection of the MSI by comparing it with the test results using PCR in colorectal cancer (CRC).

METHODS

Paraffin-embedded normal and tumor tissues from seventy-five patients who underwent surgical resection of CRC were used. Abnormal expression of MLH1 and MSH2 protein was determined by IHC using MLH1 and MSH2 antibodies. Normal and tumor DNAs were obtained from thirty CRC tissues that showed abnormal expression of MLH1 and MSH2 proteins by IHC. The MSI status was confirmed by PCR using five markers.

RESULTS

Thirty tumors showed abnormal expression of MLH1 and MSH2 proteins by IHC, but only three tumors out of them were confirmed to have MSI by PCR.

CONCLUSIONS

This result suggests that IHC with MLH1 and MSH2 antibodies does not seem to be a useful method to identify MSI in CRC, therefore PCR is required for detection of the MSI.

Effects of green tea catechin on hepatic microsomal phospholipase A2 activities and changes of hepatic phospholipid species in streptozotocin-induced diabetic rats

In this study, male Sprague-Dawley rats weighing 70 +/- 5 g were divided into a control (normal) group and three different diabetes mellitus (DM) groups that were supplemented with catechin-free (DM-0C), 0.5% catechin dietary (DM-0.5C), and 1% catechin (DM-1.0C). The animals were maintained on an experimental diet for four weeks. At this point, they were injected with streptozotocin (STZ) to induce diabetes, and they were sacrificed on the 6th day to determine the activities of phospholipase A2 (PLA2) and the changes of phospholipid species by catechin supplementation. In liver tissues, no significant differences were found between the PC hydrolysis of a normal group and a diabetic group; however, PE hydrolysis of the DM-0C, DM-0.5C, and DM-1.0C groups increased by 68.9%, 34.01%, and 26.9%, respectively, compared with the normal group. Although the PLA2 activity of the DM-0C group in the liver tissues increased 91% compared with the normal group, the PLA2 activity of DM-0.5C and DM-1.0C, which were fed catechin, increased 50% and 56%, respectively, compared with the normal group. In the liver tissues, peroxide values of the DM-0C, the DM-0.5C, and the DM-1.0C groups were increased 109%, 32.8%, and 46.7%, respectively, compared with the normal group. Based on these results for STZ-induced diabetic rats, lipid peroxidation seems to be accelerated specifically with the increased PLA2 activities. Thus if antioxidants like catechin were supplementation, the activity of PLA2 and PE hydrolysis can be altered and the accumulation of lipid peroxide would be decreased. Therefore we concluded that the antioxidant catechin for diabetic animals can significantly reduce PLA2 activities and lipid peroxide formation.

Solar Photovoltaic Power Systems: Will They Reduce Utility Peaking Requirements?

From an analysis of the long-run electric generating requirements of several representative utilities, it is concluded that the energy supplied by solar photovoltaic power devices will displace primarily base-load, and to a lesser extent intermediate, generating plants, even at relatively modest penetrations corresponding to several percent of the utility peak load. Attaching photovoltaic devices to the utility grid will not yield significant fuel oil savings over the long run, in which utilities approach the economic optimum generating mix, and will increase peak plant requirements. Utility capacity and fuel savings of photovoltaic devices are reported both for the case without storage and for the case in which the utility has access to load-leveling storage.