Heparin therapy in COVID-19: Call for randomized controlled trials (RCTs).

To the Editor: Coronavirus disease 2019 (COVID-19) is widely spread and poses a critical threat to global health.1 Prominent changes in coagulation function in severe patients of COVID-19 have been reported in a recent study.2 Therefore, we conducted this quantitative meta-analysis to explore the difference in blood coagulation parameters between severe and mild cases of COVID-19. Literature published from December 1, 2019 to March 30, 2020 was searched systematically using PubMed and Embase without language limits. The keywords were: coronavirus, laboratory, clinical manifestations, clinical characteristics, and clinical features. All documents comparing information on coagulation parameters between mild and severe cases of COVID-19 patients were finally referred to in our meta-analysis. The pooled standardised mean difference (SMD) and 95% confidence interval (CI) were computed by applying the random-effect model using Stata software (STATA 14.0, Stata Corp, College Station, TX, USA). The study quality was measured by adopting an 11-item checklist, which was suggested by the Agency for Healthcare Research and Quality (AHRQ). Table I displays the main characteristics of the included studies. Nine studies, including one study from medRxiv, with 1105 patients were eventually included for detailed evaluation. Platelet count (PLT), activated partial thromboplastin time (APTT), prothrombin time (PT) and D-dimer (D-D) levels were available in five, six, six and eight studies, respectively. All the studies were conducted in China. Quality score varied from 3 to 7 points, with a mean of 5·4 (Table I). All the studies were of moderate quality, except one of low quality. The main difference in coagulation function between severe and mild COVID-19 patients is shown in Fig 1. Pooled results revealed that PT and D-D levels were significantly higher in patients with severe COVID-19 (0·68, 95% CI = 0·43–0·93, I2 = 53·7%; 0·53, 95% CI = 0·22–0·84, I2 = 78·9%, respectively). However, no significant difference in PLT and APTT values between severe and mild patients was observed (−0·08, 95% CI = −0·34 to 0·18, I2 = 60·5%; −0·03, 95% CI = −0·40 to 0·34, I2 = 79·5%, respectively). Increasing values of D-D and PT support the notion that disseminated intravascular coagulation (DIC) may be common in COVID-19 patients.2 In addition, the rise of D-D level also indicates secondary fibrinolysis conditions in these patients. According to Berri et al.,3 fibrin clot formation helps people to fight against influenza virus infections. Hence, fibrinolysis may potentially induce following severe COVID-19 infection. Future studies should aim to discover more biomarkers of severe cases of COVID-19, and studies exploring the underlying mechanism of deranged coagulation function in COVID-19 are urgently needed. The haemostatic system might be explored for underlying treatment against coronavirus. Due to the lack of sufficient study data, we cannot perform a more thorough analysis to prove beneficial screening parameters for PLT, APTT, PT and D-D for prediction of severity of COVID-19. However, we suggest that clinical practitioners pay attention to the changes in coagulation function in COVID-19 patients on a daily basis.

In Reply–Use of Famotidine and Risk of Severe Course of Illness in Patients With COVID-19: A Meta-analysis

Perioperative Cardiac Research Considerations During the Coronavirus Disease 2019 (COVID-19) Pandemic

Better design leads to better results - Importance of virological outcome design in clinical trials for antiviral treatment of coronavirus disease 2019.

Lianhua Qingwen prescription for Coronavirus disease 2019 (COVID-19) treatment: Advances and prospects

Sharpening the global focus on ethnicity and race in the time of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic constitutes a global health emergency. Currently, there are no completely effective therapeutic medications for the management of this outbreak. The cytokine storm is a hyperinflammatory medical condition due to excessive and uncontrolled release of pro-inflammatory cytokines in patients suffering from severe COVID-19, leading to the development of acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) and even mortality. Understanding the pathophysiology of COVID-19 can be helpful for the treatment of patients. Evidence suggests that the levels of tumor necrosis factor alpha (TNF-α) and interleukin (IL)-1 and IL-6 are dramatically different between mild and severe patients, so they may be important contributors to the cytokine storm. Several serum markers can be predictors for the cytokine storm. This review discusses the cytokines involved in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, focusing on interferons (IFNs) and ILs, and whether they can be used in COVID-19 treatment. Moreover, we highlight several microRNAs that are involved in these cytokines and their role in the cytokine storm caused by COVID-19.

Asthma, biologics, corticosteroids, and coronavirus disease 2019

Abnormal blood coagulation often occurs in critically ill patients, which seriously affects their prognosis. This retrospective study investigated the implications of changes in blood coagulation in patients with coronavirus disease 2019 (COVID-19). Records were reviewed for patients admitted with COVID-19 between February 4 and 16, 2020. The primary outcome was in-hospital death. A total of 85 patients were included, of whom 12 died in the hospital. The admission prothrombin time (PT), international normalized ratio (INR), and levels of D-dimer and fibrin/fibrinogen degradation products (FDP) were significantly higher in non-survivors than in survivors, while the reverse was true for prothrombin time activity (PT-act) and PaO2/FiO2. Multivariate logistic regression showed that PT-act < 75% was independently associated with mortality. The area under the receiver operating characteristic curves for PT-act, D-dimer, and FDP at admission could significantly predict mortality. The AUCs for PT-act were larger than those for D-dimer and FDP; however, there was no significant difference. After 2 weeks of treatment, the coagulation parameters of the surviving patients improved. COVID-19 is often accompanied by abnormal coagulation. PT-act at admission is able to predict mortality in patients with COVID-19 as can D-dimer and FDP levels. PT-act < 75% is independently associated with mortality.

After the World Health Organisation declared Coronavirus Disease 2019 (COVID-19) a global pandemic on March 11, 2020, it became clear that health professionals worldwide were facing a severe and unprecedented challenge. On March 28, the FDA issued an emergency use authorisation order for use of chloroquine and hydroxychloroquine in COVID-19 patients, and on May 1, 2020, the agency gave the same authorisation for use of remdesivir. Even though different treatment strategies are undergoing evaluation, particularly for severe COVID-19 cases requiring intensive care, the consensus regarding best treatment approach has not yet been reached. Earlier this year, Zhe Xu and colleagues provided a detailed case report of a 50-year-old man with COVID-19 in the Lancet Respiratory Medicine journal.1 This case is particularly interesting since it provides a detailed day-to-day account of the hospitalisation, laboratory parameters and histological findings in a patient who neither belonged to a very high-risk age group, nor did he have any other co-morbidity.2 The patient's assessment revealed an overactivation of T cells manifested by an increase in the Th17 subset of CD4+ T cells leading to increased production of IL-17 and IL-22 cytokines which in turn caused the cytokine release storm (CRS) with a rapid and severe deterioration of the patient's condition.1 Pathologic postmortem lung analysis revealed a high number of Th17 lymphocytes in alveolar spaces. Besides the referenced case report, there is emerging body of evidence supporting the role of IL-17 in the pathogenesis of severe COVID-19 disease, including two recent publications reviewing the immune response in patients with COVID-19, that further emphasise the Th17-type cytokine storm in pathogenesis of the disease.3, 4 Wu and Yang highlighted the Th17 response in CRS of COVID-19 and proposed using fedratinib, a Janus kinase 2 (JAK2) inhibitor which blocks downstream cellular Th17 signalling pathway, in the treatment of CRS of COVID-19 patients.3 However, in our view, JAK inhibition of intracellular enzymes would also be associated with significant disadvantages entailing unintended and/or off-target effects leading to difficulty in predicting JAK2 inhibitors' biological effects.5 Since the increase in Th17 CD4+ T cells is also found in several inflammatory diseases, such as in severe plaque psoriasis,6 we hypothesise that the use of IL-17 blocking agents could be beneficial in the treatment of severe COVID-19 cases. The ligation of IL-17 to IL-17RA initiates activation of transcription factors NFκB, IκBζ, API and C-EBP, which potentiate IL-17–induced transcription of the most potent proinflammatory cytokines (TNF-α, IL-1β, IL-6, IL-8, G-CSF and GM-CSF), chemokines involved in attracting and further recruitment of immune infiltrates (IL-8, CXCL1, CXCL2, CXCL5, CCL2, CCL7 and CCL20), and matrix metalloproteinases involved in tissue damage (MMP1, MMP3, MMP9, MMP12 and MMP13).5, 7 IL-17 has been demonstrated in blood and affected tissues of patients with COVID-19, and IL-6 levels were significantly increased on Days 2 and 3 of the patient's hospitalisation1; thus, IL-17 inhibitors, which block IL-6 and IL-8 secretion from innate immune system, like neutrophils, mast cells, γδ T cells and innate lymphoid cells (ILC3), could prove as safe and effective therapy for severe COVID-19 (Figure 1). A recent study by Liu et al. also revealed an increased IL-6 level as well as increased levels of several other proinflammatory Th1, Th2 and Th17 cytokines (e.g., IL-2, 4, 6, 7, 10, 12 and 17) in patients with severe COVID-19.8 Blockade of IL-17 alone has been shown as clinically effective in many circumstances and diseases, despite the presence of myriad of proinflammatory cytokines; nevertheless, relevance of mediators crucial for the CRS response remains to be elucidated.9, 10 IL-17 specifically boosts proinflammatory, but not antiviral gene expression in human cells infected with respiratory viruses by stimulating non immune cells (fibroblasts and epithelial cells) to produce increased amounts of proinflammatory cytokines and chemokines in response to viral infections that attract other immune cell types (for example, neutrophils) which can lead to increased morbidity while simultaneously remaining inefficient in preventing the pathogen's spread.11 To date, there have been three IL-17 blocking agents available: secukinumab, ixekizumab and brodalumab.5 Secukinumab and ixekizumab are monoclonal IgG1 antibodies that bind specifically to IL-17A and that have been demonstrated to be very effective in the treatment of severe plaque psoriasis.12 Both drugs have a quick onset of action, high efficacy, tolerability and a well-established safety profile which does not include a decrease in the lymphocyte count.5 The substantial decrease in the total number of lymphocytes was found in patients with severe COVID-19, and this seems to facilitate viral replication.13 In contrast to TNF-α inhibitors, IL-17 blocking agents are not associated with a decrease in lymphocyte count.14 Brodalumab, a human monoclonal IgG2κ antibody against IL-17 receptor A (IL-17RA), was shown to be superior to placebo and ustekinumab for psoriasis treatment, due to complete blockade of key mediators of the T helper 17 pathway.5 Brodalumab as an IL-17 receptor blocker could potentially offer improved efficacy; however, patient suicides reported during the AMAGINE trial involving brodalumab raised some concerns regarding the safety of this agent, even though causal relationship was not unequivocally demonstrated.5 We believe that secukinumab, a fully human monoclonal antibody which exhibits significantly lower immunogenicity potential in patients with moderate-to-severe plaque psoriasis compared to ixekizumab (a humanised monoclonal antibody), would be best suitable for the treatment of severe COVID-19 patients.15, 16 IL-17 blocking agents can suppress the production of several Th17 signature cytokines (including the effects of IL-6 and TNF-α on other types of cells), thus theoretically offering significant therapeutic potential for Th17-associated CRS in COVID-19. Owing to their parenteral administration, these drugs could also be used concomitantly with other antiviral drugs as well as in patients on ventilator support. Preclinical studies demonstrated that the response to severe swine-origin influenza A virus H1N1 (S-OIV) in mice was boosted by introduction of IL-17 blocking agents, which led to reduction in cell and fluid infiltrates and an improvement in severity of acute lung injury.8 Crowe et al. found IL-17RA signalling crucial for acute lung injury in response to pulmonary influenza infection. This finding suggests that therapeutic modulation of IL-17 signalling might be beneficial in treating immunopathology associated with pulmonary viral infections.17 Li et al. demonstrated that pandemic H1N1 influenza virus caused acute lung injury in an IL-17-dependent manner in mice.18 They also reported that the response to pandemic H1N1 influenza virus in mice was improved by IL-17-blocking agents, which reduced disease duration, as well as cellular and fluid infiltrates. IL-17 blocking agents decreased pulmonary recruitment of inflammatory cells, cytokine production by T cells and the formation of lung oedema without preventing virus clearance in mice.18 These broad beneficial effects support further the idea that IL-17 blocking agents might be tested as potential treatment in severe COVID-19 patients. Tocilizumab, a recombinant human monoclonal IgG1 antibody that specifically binds to soluble and membrane-bound IL-6 receptors, has been shown to be effective in the treatment of severe COVID-19 by blocking IL-6 signalling and its proinflammatory response.19, 20 Until now, several clinical trials have been registered in order to assess safety and efficacy of tocilizumab in the treatment of severe COVID-19 pneumonia in adult patients.19, 20 Since IL-17 inhibitors and tocilizumab share the common Th17 signalling pathway, IL-17 blocking agents could also prove as safe and effective therapy for severe COVID-19. They might be even more effective than tocilizumab, since IL-17 precedes synthesis of potent proinflammatory cytokines IL-6 and TNF-α. Moreover, subcutaneous route of administration of IL-17 blocking agents could prove more convenient than intravenous administration of tocilizumab. In the treatment of severe plaque psoriasis, secukinumab is administered subcutaneously in the dose of 300 mg once weekly during the first month of treatment, followed by a dose of 300 mg every 4 weeks. Ixekizumab is also administered subcutaneously 160 mg every 2 weeks during the first 3 months, followed by a dose of 160 mg every 4 weeks. The recommended brodalumab dose in the treatment of severe plaque psoriasis is 210 mg once weekly during the first 2 weeks of treatment, followed by a dose of 210 mg every 2 weeks administered subcutaneously. It is worth noting that IL-17 blocking agents have not yet been evaluated in clinical trials for severe COVID-19 and patients would not receive the same dosage as patients with severe plaque psoriasis. Also, the timing of IL-17 blocking agent administration to severe COVID-19 patients would be crucial. It would perhaps be best to begin the treatment in the middle stage of CRS, when a significant increase in IL-6 levels is to be expected.1, 21 While we currently do not have a vaccine or highly effective antiviral treatments for COVID-19, repurposing certain immunomodulators, such as IL-17 blocking agents, might help to prevent CRS in severe COVID-19 cases, thereby further improving patients' outcomes. Finally, in our new, COVID-19 directed worldwide reality and with the constraints of limited experimental evidence regarding IL-17 blocking agents in mind, the importance of drug repurposing and effective dosing scheme investigation through conduct of well designed, randomised and double blind controlled clinical trials cannot be overstated enough. There are no competing interests to declare. All authors have made equal contributions to the article.

BackgroundIn March 2020, the World Health Organization declared the coronavirus disease 2019 as a global pandemic. Though antiviral drugs and antimalarial drugs are considered treatment options for treating coronavirus disease 2019 (COVID-19), no specific antivirals are currently available for its treatment. Efficient use of drug discovery approaches including repurposing or repositioning of drugs used in the treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV) is considered recently. The widespread application of corticosteroid therapy in COVID-19 should be backed with careful documented pragmatic research of its use in this context.Main bodyThis article aims to analyze various trials registered across the globe providing an overall picture of the use of corticosteroids in the treatment of COVID-19. An extensive search was conducted on the clinical trial registries around the world to identify all the trials reporting information regarding the use of corticosteroids in COVID-19. Our initial search returned 231 trials, out of which 60 trials were finally included in the analysis. Fifty-six studies were interventional trials, and all the trials had clearly defined primary and secondary outcomes of interest, of which only 11 trials had evaluation of respiratory rate as one of their outcomes.ConclusionFew preliminary trial findings show promising results and recommend the use of methylprednisolone and dexamethasone in the severe form of the disease; however, there is insufficient data to prove its benefits over its risks. Routine use of corticosteroids should be favored only after a better insight is obtained, with the completion of these trials.

With great interest, we have read the article by Lang et al. on the use of extracorporeal organ support (ECOS) for patients with severe coronavirus disease 2019 (COVID-19).1 We agree with the authors that there is an important role for ECOS in the treatment of severe COVID-19. Furthermore, we welcome the attempt to define criteria for the use of ECOS in COVID-19. However, currently, we question whether there is sufficient evidence available to support some of the authors’ suggestions and criteria. We would urge caution to initiate extracorporeal membrane oxygenation (ECMO) therapy in COVID-19 earlier than in other forms of acute respiratory distress syndrome (ARDS). Evidence for the use of ECMO is insufficient—this applies equally to COVID-19 and other forms of ARDS. Besides, ECMO treatment can come along with serious complications and deleterious side effects. Recently, the results from the treatment of 83 COVID-19 patients with ECMO revealed similar outcome compared to the outcome in previous trials on the use of ECMO for other forms of ARDS using the same criteria for initiation of ECMO.2 Therefore, ECMO still should be considered as a last-resort treatment option and should only be used when all other forms of treatment are not successful.3 We also agree that there may be a role for extracorporeal cytokine adsorption in COVID-19.4 Initial experience with cytokine adsorption in combination with ECMO in severe COVID-19 yielded promising results.5 Even more so than for ECMO alone, evidence for the use of cytokine adsorption is scarce. Currently, there is no evidence supporting specific levels of interleukin-6 (IL-6) as a trigger for initiation of cytokine adsorption in the treatment of COVID-19. Therefore, this therapeutic option should primarily be used within clinical trials—like the randomized controlled CYCOV-II study to examine the use of cytokine adsorption in combination with ECMO in COVID-19 (NCT04385771). Furthermore, we would disagree that the expression of blood cytokines or the elevation of IL-6 above a predefined threshold could be a suitable criterion for initiation continuous renal replacement therapy. Even though COVID-19 has emerged only few months ago and we had only limited time to get to know this novel disease and to develop specific treatment strategies, over the past months a vast amount of evidence has been collected. We should proceed on this quest for evidence, promote preclinical research and develop, design, and initiate appropriate clinical trials that will help generate new evidence to guide our therapies. A Supady designed the paper and prepared the first draft based on preceding discussions with all co-authors. All authors reviewed the draft and approved the final version of the manuscript.

We thank Kow et al. [1] for their response to the findings of the RECEDE-C19 study on clinical outcomes between people living with and without HIV hospitalized with coronavirus disease 2019 (COVID-19) [2]. The authors suggest the inclusion of antiretroviral therapy (ART) in the multivariable model, particularly those who received tenofovir-based ART, to investigate the effectiveness of these medications in patients with COVID-19. As only five (7.4%) people living with HIV not receiving ART were included, this study was not powered to compare the effect of ART on clinical outcomes in hospitalized patients. Tenofovir disoproxil fumarate (TDF) is associated with renal and bone density-related adverse effects, and UK national guidelines [3] recommend avoiding TDF in people with impaired renal function or osteoporosis. As a result, the population receiving TDF is biased, and its inclusion in the multivariable model risks multicollinearity with the comorbidities, frailty and age factors that were already included. The small sample size and lack of a suitable denominator for people living with HIV across all clinics receiving tenofovir-based ART were other limitations in evaluating the effectiveness of tenofovir in the prevention of severe COVID-19 hospitalisation outcomes. Therefore, we considered that inclusion of tenofovir-based ART in the multivariable model would be of limited value, and the antiretroviral data were presented descriptively to avoid overinterpretation in this paper. As the authors have summarized, tenofovir has been hypothesized to be potentially effective against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); however, evidence to support the use of tenofovir-based strategies for the treatment or prevention of COVID-19 remains sparse. Evidence from two open-labelled randomized trials have provided mixed results. Participants randomized to TDF/emtricitabine following a recent diagnosis (<7 days) of non-severe COVID-19 showed a mean real-time polymerase chain reaction cycle threshold difference of 2.9 (95% confidence interval [CI] 0.1–5.2, p = 0.044) but no difference in time to symptom recovery, and the study was not powered to collect other clinical outcomes [4]. Although a larger pragmatic randomized trial of TDF/emtricitabine, rosuvastatin plus colchicine, or a combination of the four medications showed lower mortality in participants receiving all four medications (hazard ratio [HR] 0.53; 95% CI 0.29–0.96; p = 0.038), TDF/emtricitabine alone was not associated with a reduction in 28-day mortality in the TDF/emtricitabine arm compared with standard of care (HR 0.69; 95% CI 0.39–1.20; p = 0.187) [5]. Two ongoing randomized controlled trials investigating TDF/emtricitabine as treatment for COVID-19 are registered in the clinicaltrials.gov database at the time of writing (NCT04712357, NCT04890626). Effective treatments for COVID-19 are available, but the search continues for effective, lower cost, alternative treatments and remains relevant, particularly for settings with limited resources and/or access to vaccines. However, we advise caution in the interpretation of the effectiveness of ART including tenofovir for the treatment of COVID-19 from retrospective cohorts because of the contribution of confounding overlapping factors that may not be possible to adequately adjust for. The findings of the ongoing suitably powered and blinded randomized controlled trials are anticipated to provide more robust answers as to whether tenofovir is effective in the treatment of COVID-19. The authors would like to thank the RECEDE study group staff and patients for their contributions to this work. MJL drafted the letter, AN, SF, RK, JF, CS reviewed and contributed to the final draft.

COVID-19 and Gastrointestinal Tract Symptoms: Recognition, Containment, and Learning From the Past

Background: The coronavirus disease 2019 (COVID-19) pandemic is a distinct public health issue that calls for the quick development of novel treatments and viral detection. Due to their high specificity and reliability, monoclonal antibodies (mAbs) have emerged as useful diagnostic and therapeutic tools for a variety of diseases. As a result, several scientists have jumped right into developing Ab-based assays for the identification of SARS-CoV-2 and Ab drugs for use as COVID-19 therapy agents. Since the receptor-binding domain (RBD) of the SARS-CoV-2 spike protein is essential for viral infection and has a known precise structure, it has become a key target for the creation of therapeutic antibodies. The use of Ab cocktails is anticipated to be a key component of an efficient COVID-19 treatment plan since SARS-CoV-2 is an RNA virus with a high mutation rate, particularly when subjected to the selection pressure of aggressively applied preventive vaccinations and neutralizing Abs. Furthermore, SARS-CoV-2 infection could provoke an overzealous immune response, leading to a cytokine storm that accelerates the onset of a severe disease. Abs to counteract cytokine storms are also actively being researched as COVID-19 therapies. Abs are now used in SARS-CoV-2 detection assays, including immunoglobulin and antigen tests, in addition to their use as medicines. In order to stop the spread of COVID-19, such Ab-based detection tests are essential surveillance tools. In this article, we’ll go over several important ideas related to mAb-based COVID-19 pandemic detection tests and treatments. Objective: To understand the role of hybridoma technology in therapeutic implications. 1) To study the basic concepts and options in hybridoma technology; 2) To study the applications of hybridoma technology; 3) To explore how hybridoma technology is applied in diagnostic histopathology. Method: For this method generally there is use of mouse or mammals are transfect with the Ags to find out the formation of antibody afterwards isolate the antibody which has been formed after injecting the antigens for a number of weeks. Following are the steps for mAbs: Step 1: In this step immunization of mouse is done; Step 2: Spleen is used for the isolation of B cells; Step 3: Cultivation of cancerous cells; Step 4: Merging of B cells with Myeloma cells; Step 5: This step cell lines are separated; Step 6: in the next step screening the suitable cell lines; Step 7: observation of multiplication in vitro as well as in vivo; Step 8: Harvesting. Discussion: Now a day there are many diseases which has been cured easily at the mean time it’s very difficult to diagnose and get the treatment. Due to advancement of monoclonal antibodies are used in the diagnosis and treatments such as COVID-19, SARS and SARS COV-2. Therefore important part of the monoclonal antibodies are its used in the diagnosis as well as in the treatment tools.