Non-severe Coronavirus Disease 2019 Research Articles

Predicting roles of IL-27 and IL-32 in determining the severity and outcome of COVID-19.

Immune changes play fundamental roles in the pathogenesis and severity of coronavirus disease 2019 (COVID-19). Previous studies have revealed alterations in immune responses of patients with non-severe and severe COVID-19. Therefore, this study investigated whether interleukin-27 (IL-27) and interleukin-32 (IL-32) levels may be considered as predicting factors for determining the severity and outcome of COVID-19. The blood samples were collected from 50 non-severe and severe patients infected with COVID-19 and 25 healthy subjects. The serum samples were isolated from the whole blood. The levels of IL-27 and IL-32 were measured by enzyme-linked immunosorbent assay and percentages of some immune cells were studied by cell counter. The levels of IL-27 and IL-32 were significantly higher in COVID-19 patients than healthy subjects (p < 0.0001-0.01). IL-27 was significantly reduced in severe COVID-19 patients who needed to undergo ICU therapy (p < 0.05). Disease severity was significantly associated with IL-27 level in patients with COVID-19 (p < 0.05), unlike IL-32 level. There was a significant association between IL-27 and IL-32 in participants (p < 0.0001, odds ratio (OR) = 0.9873; 95% confidence interval (CI) = 0.9998 to 1.000; p < 0.05, OR = 0.4462; 95% CI = 0.08,579 to 0.7802; p < 0.01, OR = 0.6640, 95% CI = 0.3007-0.8590). IL-27 level was significantly higher in the recovered subjects than dead cases (p < 0.0001). IL-27 and IL-32 levels in patients who had fever were significantly higher than those who did not have (p < 0.01-0.05), unlike patients who suffered from cough (p < 0.001-0.01). The IL-27 level in patients with non-severe COVID-19 was directly correlated with CRP value (p < 0.05, OR = 0.5,722,357, 95% CI = 0.06,807,176-0.8,435,928). IL-27 and IL-32 levels in non-severe patients were positively associated with NLR (p < 0.01, OR = 0.7292; 95% CI = 0.2809 to 0.9163; p < 0.01, OR = 0.6537, 95% CI = 0.1425-0.8896). Patients with severe COVID-19 had a significant increase in NLR (p < 0.0001-0.05). NLR was significantly correlated with the disease severity (p < 0.0001-0.05). Survivors had a significant reduction in NLR compared with those who succumbed to COVID-19 (p < 0.05). Change in IL-27 level along with the frequencies of some immune cells may serve as a predictor of the severity and outcome of COVID-19.

The effect of vitamin E and vitamin C in patients with COVID-19 pneumonia;a randomized controlled clinical trial

Introduction: Cytokine storm and oxidative stress play a key role in the pathogenesis of coronavirus disease 2019 (COVID-19). Vitamins C and E are two known antioxidants with possible theoretical beneficial effects in COVID-19 patients. Objectives: This study aimed to clinically evaluate the effects of the combination of these agents as adjunctive therapy with the standard treatment in the outcome of COVID-19 patients. Patients and Methods: Hospitalized non-severe COVID-19 patients were randomly divided into two groups of intervention (n=38) and control (n=34) to receive either oral vitamin C 1000 mg daily plus oral vitamin E 400 IU daily in addition to the national standard treatment regimen (hydroxychloroquine) or standard regimen alone, respectively, during the hospitalization period until hospital discharge or ICU admission. The clinical response of patients at the end of treatment (either cure, improvement, or failure), the duration of hospitalization, and the mortality rate were recorded and compared between the groups. Results: During the study, three patients in the intervention group (7.89%) and five patients in the control group (14.71%) had treatment failure, while all other patients had clinical improvement (P = 0.380). The duration of hospitalization was shorter in the intervention group (7.95 ± 3.18 days) compared to the control group (8.03 ± 2.83 days); however, the difference was not statistically significant (P = 0.821). Furthermore, no patients in both groups died during the study. Conclusion: The combination of oral vitamins C (1000 mg daily) and E (400 IU daily) has no beneficial effect in COVID-19 patients. Trial Registration: Registration of trial protocol has been approved in Iranian registry of clinical trials (identifier: IRCT20180425039414N3; https://www.irct.ir/trial/48083, ethical# IR.MUI.MED.REC.1399.047).

The Assessment of Complement Proteins in Patients With Severe COVID-19

Introduction: The complement system, consisting of more than 20 soluble proteins, has a crucial role in innate immunity and inflammation and eliminates pathogens and viral infections. Therefore, we investigated the titers of C3, C4, and total IgG in the sera of non-severe and severe coronavirus disease 2019 (COVID-19) patients. Methods: For this purpose, peripheral blood samples were collected from 30 non-severe and 30 severe COVID-19 patients and 30 healthy individuals with similar age and sex as the control group. The serum levels of total IgG, C3, and C4 were analyzed. Also, white blood cells, platelets (PLTs), and lymphocytes were counted by an auto-analyzer. Results: White blood cell count showed no difference between COVID-19 patients and the control group. The results showed a significant decrease in lymphocyte and PLT counts in COVID-19 patients compared to the control. Complement proteins, including C3 and C4, were increased in non-severe COVID-19 patients (C3; P=0.017 and C4; P=0.012) compared to other groups. Total IgG showed a notable decrease in severe COVID-19 patients. Conclusion: The decrease in C3 and C4 complement factors in severe COVID-19 patients may be due to further consumption secondary to the formation of immune complexes. By clarifying the role of complement proteins of C3 and C4 in different stages of the disease, our results can be helpful in designing therapeutic and diagnostic measures for the disease.

Proposed subtypes of post-COVID-19 syndrome (or long-COVID) and their respective potential therapies.

The effects of coronavirus disease 2019 (COVID-19), a highly transmissible infectious respiratory disease that has initiated an ongoing pandemic since early 2020, do not always end in the acute phase. Depending on the study referred, about 10%-30% (or more) of COVID-19 survivors may develop long-COVID or post-COVID-19 syndrome (PCS), characterised by persistent symptoms (most commonly fatigue, dyspnoea, and cognitive impairments) lasting for 3 months or more after acute COVID-19. While the pathophysiological mechanisms of PCS have been extensively described elsewhere, the subtypes of PCS have not. Owing to its highly multifaceted nature, this review proposes and characterises six subtypes of PCS based on the existing literature. The subtypes are non-severe COVID-19 multi-organ sequelae (NSC-MOS), pulmonary fibrosis sequelae (PFS), myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), post-intensive care syndrome (PICS) and medical or clinical sequelae (MCS). Original studies supporting each of these subtypes are documented in this review, as well as their respective symptoms and potential interventions. Ultimately, the subtyping proposed herein aims to provide better clarity on the current understanding of PCS.

Gene Expression Risk Scores for COVID-19 Illness Severity.

BackgroundThe correlates of COVID-19 illness severity following infection with SARS-Coronavirus 2 (SARS-CoV-2) are incompletely understood.MethodsWe assessed peripheral blood gene expression in 53 adults with confirmed SARS-CoV-2-infection clinically adjudicated as having mild, moderate or severe disease. Supervised principal components analysis was used to build a weighted gene expression risk score (WGERS) to discriminate between severe and non-severe COVID.ResultsGene expression patterns in participants with mild and moderate illness were similar, but significantly different from severe illness. When comparing severe versus non-severe illness, we identified >4000 genes differentially expressed (FDR<0.05). Biological pathways increased in severe COVID-19 were associated with platelet activation and coagulation, and those significantly decreased with T cell signaling and differentiation. A WGERS based on 18 genes distinguished severe illness in our training cohort (cross-validated ROC-AUC=0.98), and need for intensive care in an independent cohort (ROC-AUC=0.85). Dichotomizing the WGERS yielded 100% sensitivity and 85% specificity for classifying severe illness in our training cohort, and 84% sensitivity and 74% specificity for defining the need for intensive care in the validation cohort.ConclusionThese data suggest that gene expression classifiers may provide clinical utility as predictors of COVID-19 illness severity.

Impact of Latent Tuberculosis on Severity and Outcomes in Admitted COVID-19 Patients.

BackgroundThere is limited data on coronavirus disease 2019 (COVID-19) and latent tuberculosis infection (LTBI).MethodologyWe analyzed data of admitted COVID-19 patients evaluated for LTBI to examine the impact of LTBI on severity, laboratory parameters, and COVID-19 outcome. Prospectively collected data were analyzed for 60 patients who were administered the Mantoux tuberculosis skin test (TST) using five tuberculin units of purified protein derivative. All patients were administered TST irrespective of Bacille Calmette-Guérin (BCG) vaccination status. Comorbidities, clinical features, radiologic involvement, laboratory parameters, and clinical course were analyzed concerning LTBI.ResultsThe mean age was 45.9 (±15.2) years, and 35 (58.3%) patients had non-severe disease. The vast majority (n = 56/60; 93.3%) had been vaccinated with single-dose BCG in infancy or early childhood, as per national immunization guidelines. LTBI was diagnosed in 15 (25%) patients. LTBI prevalence was lower in severe (n = 1/25; 4%) than non-severe (n = 14/35; 40%) COVID-19 (p = 0.01) patients. LTBI patients had lower percentage neutrophil count, higher lymphocyte percentage, higher monocyte count, lower neutrophil-lymphocyte (NL) ratio, lower alanine aminotransferase, lower C-reactive protein, and lesser radiologic involvement compared to those without LTBI (p < 0.05). Similarly, among the mild COVID-19 subgroup, those with LTBI had higher lymphocyte and monocyte counts and lesser radiologic involvement than those without LTBI (p < 0.05).ConclusionsLTBI patients appear to have milder disease, higher lymphocyte and monocyte count, higher NL ratio, and lesser radiographic involvement. This observation needs to be studied in larger studies using interferon release assays.

Long-Term Effects of COVID-19 on Adolescents

Long-term effects are increasingly reported in adult patients with coronavirus disease-2019 (COVID-19) but there are not enough studies in adolescents. This study aimed to evaluate the long-term effects of COVID-19 in the adolescent population. Adolescent patients diagnosed with non-severe COVID-19 between October 2020 and January 2021 in our center were questioned in terms of long-term effects by telephone call. A total of 109 adolescent patients with non-severe COVID-19 were evaluated. In five of them at least of one myalgia/fatigue, cough, chest pain, palpitation, sleep disorderand psychiatric problems are seen as long‐term effects of COVID-19. These five patients had a median age of 16.4 years (range 11.5-17) and three of them are boys. The mean time that we evaluate these patients after diagnosis is 121.6±13.1 days. All of them categorized as ‘mild’ COVID-19 infection and none of them were hospitalized. Only one patient has the underlying disease ‘asthma’. Long-term COVID-19 symptoms can also be seen in otherwise healthy children after mild disease. Especially psychiatric complaints should not be ignored and pediatricians should be more careful in terms of these effects.

ESCMID COVID-19 living guidelines: drug treatment and clinical management

ScopeIn January 2021, the ESCMID Executive Committee decided to launch a new initiative to develop ESCMID guidelines on several COVID-19-related issues, including treatment of COVID-19. MethodsAn ESCMID COVID-19 guidelines task force was established by the ESCMID Executive Committee. A small group was established, half appointed by the chair, and the remaining selected with an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the PICO (population, intervention, comparison, outcome) format was developed at the beginning of the process. For each PICO, two panel members performed a literature search with a third panellist involved in case of inconsistent results. Voting was based on the GRADE approach. Questions addressed by the guideline and recommendationsA synthesis of the available evidence and recommendations is provided for each of the 15 PICOs, which cover use of hydroxychloroquine, bamlanivimab alone or in combination with etesevimab, casirivimab combined with imdevimab, ivermectin, azithromycin and empirical antibiotics, colchicine, corticosteroids, convalescent plasma, favipiravir, remdesivir, tocilizumab and interferon β-1a, as well as the utility of antifungal prophylaxis and enoxaparin. In general, the panel recommended against the use of hydroxychloroquine, ivermectin, azithromycin, colchicine and interferon β-1a. Conditional recommendations were given for the use of monoclonal antibodies in high-risk outpatients with mild–moderate COVID-19, and remdesivir. There was insufficient evidence to make a recommendation for use of favipiravir and antifungal prophylaxis, and it was recommended that antibiotics should not be routinely prescribed in patients with COVID-19 unless bacterial coinfection or secondary infection is suspected or confirmed. Tocilizumab and corticosteroids were recommended for treatment of severe COVID-19 but not in outpatients with non-severe COVID-19. ScopeThe aim of the present guidance is to provide evidence-based recommendations for management of adults with coronavirus disease 2019 (COVID-19). More specifically, the goal is to aid clinicians managing patients with COVID-19 at various levels of severity including outpatients, hospitalized patients, and those admitted to intensive care unit. Considering the composition of the panel, mostly clinical microbiologists or infectious disease specialists with no pulmonology or intensive care background, we focus only on pharmacological treatment and do not give recommendations on oxygen supplement/support. Similarly, as no paediatricians were included in the panel; the recommendations are only for adult patients with COVID-19. Considering the current literature, no guidance was given for special populations such as the immunocompromised.

SARS-CoV-2-specific Humoral and Cellular Immunities in Kidney Transplant Recipients and Dialyzed Patients Recovered From Severe and Nonsevere COVID-19.

Background.Kidney transplantation and dialysis are two major risk factors for severe forms of coronavirus disease 2019 (COVID-19). The dynamics of the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this population remain largely unknown.Methods.We report here the analysis of anti–SARS-CoV-2 antibody– and T cell–mediated immune responses in 26 kidney transplant recipients (KTRs) and 11 dialyzed patients (DPs) who recovered from COVID-19.Results.After a mean time of 83 ± 26 d post–symptom onset for KTRs and 97 ± 31 d for DPs, 20 KTRs (76.9%) and 10 DPs (90.9%) displayed anti-S1 immunoglobulin G SARS-CoV-2 antibodies (P = 0.34), at similar titers in both groups. SARS-CoV-2–specific interferon-γ–producing T cells were evidenced in 26 KTRs (100%) and 10 DPs (90.9%). Total numbers of SARS-CoV-2–reactive T cells were high and not statistically different between the 2 groups. No correlation between the severity of the disease and the number of reactive T cells was found in KTRs. In 5 KTRs, also evaluated 10 mo after COVID-19, weak or absent antibody response was observed, whereas specific memory T-cell response was detected in all cases.Conclusion.T-cell response persisted up to 3 mo post–symptom onset, even in KTRs in whom full immunosuppressive regimen was reinstated at recovery, and seems to be present up to 10 mo after infection. Our findings have implications in the understanding of the natural course of the disease in transplant patients and DPs.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19.

ABSTRACTIntroductionThere is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.MethodsA modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for “very important” on Likert-scale questions in the final round.ResultsTwenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients’ selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5–10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any “red-flag” signs.ConclusionThe experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5–10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.How to cite this articleHow to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280–1285.

Association between thrombocytopenia and platelet profile with morbidity/mortality of severe and non-severe COVID-19 patients.

Coronavirus disease 2019 (COVID-19) is a novel infectious viral disease that can be associated with changes in platelet counts. Thrombocytopenia is a risk factor for increased mortality and morbidity among these patients. In this study, we aimed to measure the platelet count of COVID-19 patients and find the association with morbidity and mortality after following up. This study was conducted on 1,320 confirmed COVID-19 patients who were admitted to the Ayatollah Taleghani and Shohada Tajrish Hospital in Tehran, Iran. The diagnosis of COVID-19 was confirmed by standard protocols. The data on the platelet profile were retrospectively extracted from patients' electronic medical records consisted of platelet counts on admission, the next 7 days during the hospital stay, and on discharge. Patients were categorized into two groups, namely, "non-severe presentation" and "severe presentation" based on clinical signs. There was no significant difference in platelet counts and thrombocytopenia between severe and non-severe, survivors and non-survivors, and severe survivors and severe non-survivors groups at the time of admission to the hospital. After 7 days, a trend toward an increase in platelet counts was seen in non-severe patients, survivors, and severe compared with severe patients, non-survivors, and severe non-survivors, respectively. Thrombocytopenia and thrombotic complications in COVID-19 patients are common and lead to a higher mortality rate.

Hepatic and gastrointestinal disturbances in Egyptian patients infected with coronavirus disease 2019: A multicentre cohort study.

BACKGROUNDVarious liver and gastrointestinal involvements occur in patients with coronavirus disease 2019 (COVID-19) at variable prevalence. Most studies report mild liver function disturbances correlated with COVID-19 severity, though liver failure is unusual.AIMTo study liver and gastrointestinal dysfunctions in Egyptian patients with COVID-19 and their relation to disease outcomesMETHODSThis multicentre cohort study was conducted on 547 Egyptian patients from April 15, 2020 to July 29, 2020. Consecutive polymerase chain reaction-confirmed COVID-19 cases were included from four quarantine hospitals affiliated to the Egyptian ministry of health. Demographic information, laboratory characteristics, treatments, fibrosis-4 (FIB-4) index, COVID-19 severity, and outcomes were recorded and compared according to the degree of liver enzyme elevation and the presence of gastrointestinal symptoms. Follow-ups were conducted until discharge or death. Regression analyses were performed to determine the independent factors affecting mortality.RESULTSThis study included 547 patients, of whom 53 (9.68%) died during hospitalization and 1 was discharged upon his request. Patients’ mean age was 45.04 ± 17.61 years, and 21.98% had severe or critical COVID-19. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were available for 430 and 428 patients, respectively. In total, 26% and 32% of patients had elevated ALT and AST, respectively. Significant liver injury with ALT or AST elevation exceeding 3-fold was recorded in 21 (4.91%) and 16 (3.73%) patients, respectively. Male gender, smoking, hypertension, chronic hepatitis C, and lung involvement were associated with elevated AST or ALT. AST was elevated in 50% of patients over 60-years-old. FIB-4 was significantly higher in patients admitted to the intensive care unit (ICU), those with more severe COVID-19, and non-survivors. The independent variables affecting outcome were supplementary vitamin C intake (1 g daily capsules) [odds ratio (OR): 0.05, 95% confidence interval (CI): 0.008–0.337]; lung consolidation (OR: 4.540, 95%CI: 1.155–17.840); ICU admission (OR: 25.032, 95%CI: 7.110–88.128); and FIB-4 score > 3.25 (OR: 10.393, 95%CI: 2.459-43.925). Among 60 (13.98%) patients with gastrointestinal symptoms, 52 (86.67%) had diarrhoea. Patients with gastrointestinal symptoms were predominantly females with higher body mass index, and 50 (83.40%) patients had non-severe COVID-19. CONCLUSIONFew Egyptian patients with COVID-19 developed a significant liver injury. The independent variables affecting mortality were supplementary vitamin C intake, lung consolidation, ICU admission, and FIB-4 score.

Clinical use of antiviral, antibiotic and immunomodulatory drugs in hospitalized COVID-19 patients: a retrospective study in Bandung, Indonesia

Background: Evidence of highly effective repurposed drugs for coronavirus disease 2019 (COVID-19) is insufficient. However, empirical therapy using antiviral, antibiotic and immunomodulatory drugs is massive. Studies evaluating the clinical use of these drugs in Indonesia are sparse. Methods: We performed a retrospective study using medical records of hospitalized COVID-19 patients from July 2020 to March 2021 in Bandung, Indonesia. Data were collected at relevant timelines: age, sex, comorbid condition, peripheral oxygen saturation (SpO2), and hematology at admission; antiviral, antibiotic, and immunomodulator treatment during hospitalization; length of stay hospitalization (LOS) and death at discharge. Clinical use of the drug regimens included dose, frequency, and duration of therapy. The main outcome of hospitalization care was LOS and death. Results: Out of 249 patients, 43.3% had a comorbid condition, 74.7% had non-severe COVID-19 (SpO2 ≥ 90%), and almost all received antiviral or antibiotic agents. Remdesivir was the most frequent drug composing various antiviral regimens. Patients receiving a combination of remdesivir and favipiravir had lower SpO2 compared to those receiving oseltamivir (p=0.01). The short LOS was associated with remdesivir alone (p=0.03), the combination of favipiravir and oseltamivir (p=0.01), and the combination of intravenous levofloxacin and ceftriaxone (p&lt;0.0001). Immunomodulatory drugs (methylprednisolone, dexamethasone, tocilizumab) were used in 47.1% of patients with low SpO2 (p=0.001). Its use was associated with prolonged LOS (p=0.0043). The increased risk of death in patients treated with the combination of remdesivir and favipiravir (OR 4.1;95%CI 1.4-12.2), and immunomodulatory drugs (OR 6.2; 95%CI 1.7-23.3) was confounded by the baseline characteristics of older age, comorbid condition, SpO2 level, and low lymphocyte number. Conclusions: Some treatment regimens were associated with short LOS, but there were drug regimens which might increase the risk of death. Further study should control the clinical conditions of COVID-19 patients at admission to confirm the outcome of death following drug therapy.

Evaluation of early antibiotic use in patients with non‐severe COVID‐19 without bacterial infection

ObjectivesThe use of antibiotics was common in some countries during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, but adequate evaluation remains lacking. This study aimed to evaluate the effect of early antibiotic use in patients with non-severe COVID-19 admitted without bacterial infection.MethodsThis multi-centre retrospective cohort study included 1,373 inpatients with non-severe COVID-19 admitted without bacterial infection. Patients were divided into two groups according to their exposure to antibiotics within 48 h of admission. The outcomes were progression to severe COVID-19, length of stay >15 days and mortality rate. A mixed-effect Cox model and random effect logistic regression were used to explore the association between early antibiotic use and outcomes.ResultsDuring the 30-day follow-up period, the proportion of patients who progressed to severe COVID-19 in the early antibiotic use group was almost 1.4 times that of the comparison group. In the mixed-effect model, the early use of antibiotics was associated with higher probability of developing severe COVID-19 and staying in hospital for >15 days. However, there was no significant association between early use of antibiotics and mortality. Analysis with propensity-score-matched cohorts displayed similar results. In subgroup analysis, patients receiving any class of antibiotic were at increased risk of adverse health outcomes. Azithromycin did not improve disease progression and length of stay in patients with COVID-19.ConclusionsIt is suggested that antibiotic use should be avoided unless absolutely necessary in patients with non-severe COVID-19, particularly in the early stages.

The K18-Human ACE2 Transgenic Mouse Model Recapitulates Non-severe and Severe COVID-19 in Response to an Infectious Dose of the SARS-CoV-2 Virus.

ABSTRACTA comprehensive analysis and characterization of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection model that mimics non-severe and severe coronavirus disease 2019 (COVID-19) in humans is warranted for understating the virus and developing preventive and therapeutic agents. Here, we characterized the K18-hACE2 mouse model expressing human (h)ACE2 in mice, controlled by the human keratin 18 (K18) promoter, in the epithelia, including airway epithelial cells where SARS-CoV-2 infections typically start. We found that intranasal inoculation with higher viral doses (2 × 103 and 2 × 104 PFU) of SARS-CoV-2 caused lethality of all mice and severe damage of various organs, including lung, liver, and kidney, while lower doses (2 × 101 and 2 × 102 PFU) led to less severe tissue damage and some mice recovered from the infection. In this hACE2 mouse model, SARS-CoV-2 infection damaged multiple tissues, with a dose-dependent effect in most tissues. Similar damage was observed in postmortem samples from COVID-19 patients. Finally, the mice that recovered from infection with a low dose of virus survived rechallenge with a high dose of virus. Compared to other existing models, the K18-hACE2 model seems to be the most sensitive COVID-19 model reported to date. Our work expands the information available about this model to include analysis of multiple infectious doses and various tissues with comparison to human postmortem samples from COVID-19 patients. In conclusion, the K18-hACE2 mouse model recapitulates both severe and non-severe COVID-19 in humans being dose-dependent and can provide insight into disease progression and the efficacy of therapeutics for preventing or treating COVID-19.IMPORTANCE The pandemic of coronavirus disease 2019 (COVID-19) has reached nearly 240 million cases, caused nearly 5 million deaths worldwide as of October 2021, and has raised an urgent need for the development of novel drugs and therapeutics to prevent the spread and pathogenesis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To achieve this goal, an animal model that recapitulates the features of human COVID-19 disease progress and pathogenesis is greatly needed. In this study, we have comprehensively characterized a mouse model of SARS-CoV-2 infection using K18-hACE2 transgenic mice. We infected the mice with low and high doses of SARS-CoV-2 to study the pathogenesis and survival in response to different infection patterns. Moreover, we compared the pathogenesis of the K18-hACE2 transgenic mice with that of the COVID-19 patients to show that this model could be a useful tool for the development of antiviral drugs and therapeutics.

Adverse Outcome in Non-Severe COVID-19: Potential Diagnostic Coagulation Tests

COVID-19-associated coagulopathy (CAC) identifies the coagulation changes in coronavirus disease 2019 (COVID-19) and is responsible for thrombosis. CAC has been studied in critical and severe stage COVID-19 disease through tests including the D-Dimer (DD), prothrombin time (PT), thromboplastin partial time (PTT), platelet count, fibrinogen (Fib), and platelet factor 4 (PF4) tests. However, these tests have some limitations. The aim of this study was to identify more accurate warning tests for early recognition of CAC and to prevent its deterioration to disseminated intravascular coagulation (DIC). First, we measured Interleukin-1α (IL-1α) and IL-8, and tissue factor pathway inhibitor (TFPI) as inflammation and endothelial damage markers, respectively. Second, we measured thrombin antithrombin complex (TAT), β-Thromboglobulin (β-TG), and thromboelastometric parameters including clotting time (CT), clot formation time (CFT), clot firmness (MCF), and clot lysis at 30 min (LY-30), as markers of coagulation and platelet activation. This study included 100 non-severe patients with COVID-19 that developed pulmonary embolism (PE) compared to 80 healthy patients. IL-1α and IL-8, and TFPI were higher as well as TAT and β-TG and thromboelastometric parameters, indicating hypercoagulability. If confirmed in other studies, these results could help in predicting the deterioration of non-severe COVID-19 disease, thereby reducing hospitalizations and health costs.

Value of the Neutrophil-Lymphocyte Ratio in Predicting COVID-19 Severity: A Meta-analysis.

Background Coronavirus disease 2019 (COVID-19) is highly contagious and continues to spread rapidly. However, there are no simple and timely laboratory techniques to determine the severity of COVID-19. In this meta-analysis, we assessed the potential of the neutrophil-lymphocyte ratio (NLR) as an indicator of severe versus nonsevere COVID-19 cases. Methods A search for studies on the NLR in severe and nonsevere COVID-19 cases published from January 1, 2020, to July 1, 2021, was conducted on the PubMed, EMBASE, and Cochrane Library databases. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and area under the curve (AUC) analyses were done on Stata 14.0 and Meta-disc 1.4 to assess the performance of the NLR. Results Thirty studies, including 5570 patients, were analyzed. Of these, 1603 and 3967 patients had severe and nonsevere COVID-19, respectively. The overall sensitivity and specificity were 0.82 (95% confidence interval (CI), 0.77-0.87) and 0.77 (95% CI, 0.70-0.83), respectively; positive and negative correlation ratios were 3.6 (95% CI, 2.7-4.7) and 0.23 (95% CI, 0.17-0.30), respectively; DOR was 16 (95% CI, 10-24), and the AUC was 0.87 (95% CI, 0.84-0.90). Conclusion The NLR could accurately determine the severity of COVID-19 and can be used to identify patients with severe disease to guide clinical decision-making.

Philadelphia-Negative Myeloproliferative Neoplasms Around the COVID-19 Pandemic.

Purpose of ReviewCoronavirus disease 2019 (COVID-19) is associated with a high rate of respiratory failure, thromboembolism, bleeding, and death. Patients with myeloproliferative neoplasms (MPNs) are prone to both thrombosis and bleeding, calling for special care during COVID-19. We reviewed the clinical features of MPN patients with COVID-19, suggesting guidance for treatment.Recent FindingsOne study by the European LeukemiaNet collected 175 MPN patients with COVID-19 during the first wave of the pandemic, from February to May 2020. Patients with primary myelofibrosis (PMF) were at higher risk of mortality (48%) in comparison with essential thrombocythemia (ET) (25%) and polycythemia vera (19%); the risk of death was higher in those patients who abruptly discontinued ruxolitinib. In patients followed at home, in regular wards, or in ICU, the thrombosis rate was 1.0%, 2.8%, and 18.4%, respectively. Independent risk factors for thrombosis were ET phenotype, transfer to ICU, and neutrophil/lymphocyte ratio; major bleeding occurred in 4.3% of patients, particularly those with PMF.SummaryMPN patients with non-severe COVID-19 treated at home should continue their primary or secondary antithrombotic prophylaxis with aspirin or oral anticoagulants. In the case of hospitalization, patients assuming aspirin should add low molecular weight heparin (LMWH) at standard doses. In contrast, LMWH at intermediate/therapeutic doses should replace oral anticoagulants prescribed for atrial fibrillation or previous venous thromboembolism. Intermediate/high doses of LMWH can also be considered in ICU patients with ET, particularly in the case of a rapid decline in the number of platelets and progressive respiratory failure.

Lower plasma calcium associated with COVID-19, but not with disease severity: a two-centre retrospective cohort study

Background Previous studies indicate hypocalcaemia as a potential diagnostic and prognostic marker of corona-virus disease 2019 (COVID-19). Our aim was to investigate these relations in more detail in a large test cohort and an independent validation cohort. Methods We retrospectively included 2792 COVID-19 suspected patients that presented to the emergency department (ED) of two hospitals. Plasma calcium and ionized plasma calcium levels were compared between COVID-19 positive and negative patients, and between severe and non-severe COVID-19 patients using univariate and multivariate analyses in the first hospital (N = 1363). Severe COVID-19 was defined as intensive care unit (ICU) admission or death within 28 d after admission. The results were validated by repeating the same analyses in the second hospital (N = 1429). Results A total of 693 (24.8%) of the enrolled patients were COVID-19 positive, of whom 238 (34.3%) had severe COVID-19. In both hospitals, COVID-19 positive patients had lower plasma calcium levels than COVID-19 negative patients, regardless of correction for albumin, in univariate and multivariate analysis (Δ0.06–0.13 mmol/L, p < .001). Ionized plasma calcium concentrations, with and without correction for pH, were also lower in COVID-19 positive patients in multivariate analyses (Δ0.02–0.05 mmol/L, N = 567, p < .001). However, we did not find a significant association between COVID-19 disease severity and plasma calcium in multivariate analyses. Conclusions Plasma calcium concentrations were lower in COVID-19 positive than COVID-19 negative patients but we found no association with disease severity in multivariate analyses. Further understanding of plasma calcium perturbation may facilitate the development of new preventive and therapeutic modalities for the current pandemic.

Efficacy and safety of current medications for treating severe and non-severe COVID-19 patients: an updated network meta-analysis of randomized placebo-controlled trials.

Background: Many recent studies have investigated the role of drug interventions for coronavirus disease 2019 (COVID-19) infection. However, an important question has been raised about how to select the effective and secure medications for COVID-19 patients. The aim of this analysis was to assess the efficacy and safety of the various medications available for severe and non-severe COVID-19 patients based on randomized placebo-controlled trials (RPCTs).Methods: We did an updated network meta-analysis. We searched the databases from inception until July 31, 2021, with no language restrictions. We included RPCTs comparing 49 medications and placebo in the treatment of severe and non-severe patients (aged 18 years or older) with COVID-19 infection. We extracted data on the trial and patient characteristics, and the following primary outcomes: all-cause mortality, the ratios of virological cure, and treatment-emergent adverse events. Odds ratio (OR) and their 95% confidence interval (CI) were used as effect estimates.Results: From 3,869 publications, we included 61 articles related to 73 RPCTs (57 in non-severe COVID-19 patients and 16 in severe COVID-19 patients), comprising 20,680 patients. The mean sample size was 160 (interquartile range 96–393) in this study. The median duration of follow-up drugs intervention was 28 days (interquartile range 21–30). For increase in virological cure, we only found that proxalutamide (OR 9.16, 95% CI 3.15–18.30), ivermectin (OR 6.33, 95% CI 1.22–32.86), and low dosage bamlanivimab (OR 5.29, 95% CI 1.12–24.99) seemed to be associated with non-severe COVID-19 patients when compared with placebo, in which proxalutamide seemed to be better than low dosage bamlanivimab (OR 5.69, 95% CI 2.43–17.65). For decrease in all-cause mortality, we found that proxalutamide (OR 0.13, 95% CI 0.09–0.19), imatinib (OR 0.49, 95% CI 0.25–0.96), and baricitinib (OR 0.58, 95% CI 0.42–0.82) seemed to be associated with non-severe COVID-19 patients; however, we only found that immunoglobulin gamma (OR 0.27, 95% CI 0.08–0.89) was related to severe COVID-19 patients when compared with placebo. For change in treatment-emergent adverse events, we only found that sotrovimab (OR 0.21, 95% CI 0.13–0.34) was associated with non-severe COVID-19 patients; however, we did not find any medications that presented a statistical difference when compared with placebo among severe COVID-19 patients.Conclusion: We conclude that marked variations exist in the efficacy and safety of medications between severe and non-severe patients with COVID-19. It seems that monoclonal antibodies (e.g., low dosage bamlanivimab, baricitinib, imatinib, and sotrovimab) are a better choice for treating severe or non-severe COVID-19 patients. Clinical decisions to use preferentially medications should carefully consider the risk-benefit profile based on efficacy and safety of all active interventions in patients with COVID-19 at different levels of infection.