The Drug Repurposing Strategy in the Exscalate4CoV Project: Raloxifene Clinical Trials

Drug repurposing is a cost-effective process to identify therapeutic candidates during a medical crisis or pandemic. The supercomputing platform, EXaSCale smArt pLatform Against paThogEns for CoronaVirus (EXSCALATE4CoV;E4C), was used to identify drug candidates for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. E4C identified raloxifene as having great therapeutic potential, confirmed by in vitro data, which led to the progression of clinical trials to assess its efficacy. Raloxifene met the primary virologic endpoint in the treatment of early mild coronavirus disease 2019 (COVID-19), and although additional clinical trials are needed to confirm these results, there is evidence in support of in silico drug repurposing to provide cost-effective and rapid drug screening to identify treatment options for the pandemic and future pandemics. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

SARS-CoV-2 VIRAL LOAD CHANGE IN A RANDOMIZED TRIAL ON THREE DIFFERENT EARLY THERAPIES

Background: SARS-CoV-2 Omicron sublineages exhibit evolving escape to in vitro neutralization by monoclonal antibodies (mAbs), with an unclear impact on in vivo treatment response. Our aim is to assess the impact of SARS-Cov-2 variants on the decline of viral load (VL) after treatment with 3 different drugs approved in EU for the early treatment of patients with mild-moderate COVID-19. Method(s): Post-hoc analysis from MONET (EudraCT: 2021-004188-28), phase 4 open-label RCT to assess efficacy of 500 mg intravenous sotrovimab (SOT), 600 mg intramuscular tixagevimab/cilgavimab (TIX/CIL) and oral 5-days course of NMV/r 300/100 mg BID, in non-hospitalized high-risk patients (pts) with early COVID-19. Pts' features were analyzed as binary variables by Chi-squared test. SARS-Cov-2 VL in nasopharyngeal swabs was carried out at randomization (1d) and at day 7 (7d) by cycle threshold value (Ct). Variant sequencing was performed at 1d. Ct variation was assessed by mixed effect log-linear model including random intercept at pts' level, log of Ct as independent variable, time, arm, viral variant as dependent variables, and interaction between time and arm. Multiple comparisons were adjusted by Bonferroni. Result(s): Among the 320 pts included between 4 Mar and 16 Nov, 2022, 108 (33.75%) received NMV/r, 103 (32.19%) TIX/CIL, and 109 (34.06%) SOT. Main characteristics were balanced across arms. Most of the pts were infected either with BA.2 (N=194;60.63%) or BA.4/BA.5 (N=100;31.25%) (Fig1A). VL at 1d was similar across the arms. In contrast, mean 7d VL was significantly lower in pts receiving NMV/r than in those receiving TIX/ CIL or SOT (P< 0.001) No significant VL variation was observed between the mAb arms (Fig1B). The analysis of the impact of viral variants suggests that while VL was significantly affected by variants (P=0.034), the superior effect of NMV/r over mAbs was homogeneous across all variant groups (P=0.290 for interaction) (Fig1C). Conclusion(s): Our study provides for the first time strong in vivo evidence that, when used against Omicron lineages, NMV/r exerts a stronger antiviral effect than mAbs. These results confirm previous in vitro evidence suggesting that mAbs may not retain neutralizing activity against all Omicron sublineages and provide preliminary information on how to use VL variation as a surrogate marker of efficacy. Further studies are needed to investigate whether the superior virologic activity of NMV/r over mAbs is confirmed for newly emerging variants, including BQ.1.1 or XBB.

SARS-CoV-2 OMICRON VIRAL LOAD DECREASE AFTER MONOCLONAL ANTIBODIES OR ANTIVIRALS

Background: Omicron subvariants questioned the efficacy of the approved therapies for the early COVID-19. In vitro data show that remdesivir (RDV), molnupiravir (MLN), and nirmatrelvir/ritonavir (NMV/r) all retained activity against all sub-lineages, while poor neutralizing activity was observed for Sotrovimab (SOT) and Tixagevimab/cilgavimab (TIX/CIL). No data about the risk of clinical failure or even in vivo antiviral activity are available. Method(s): Single-center observational comparison study enrolling all consecutive patients (pts) seen for care with a confirmed SARS-CoV-2 Omicron diagnosis and who met the AIFA criteria for eligibility for treatment with RDV, MLN, NMV/r, TIX/CIL, or SOT. Treatment allocation was subject to drug availability, time from symptoms onset, and comorbidities. Nasopharyngeal swab (NPS) VL was measured on day 1 (D1) and D7 and was expressed by log2 cycle threshold (CT) scale. Comparisons between treatment groups were made by Chi-square, and Wilcoxon paired tests. Primary endpoint was D1-D7 VL variation. Potential decrease in VL and average treatment effect (ATE) were calculated from fitting marginal linear regression models weighted for calendar month of drug initiation, duration of symptoms, and immunodeficiency using NMV/r as the comparator trial arm. Result(s): A total of 971 pts received treatments (SOT 321, MLN 231, NMV/r 211, TIX/CIL 70, and RDV 138): female 457 (47%), median age 67 yrs (IQR 56-78), 93% vaccinated;12% with negative baseline serology. At D1, median time from symptoms onset was 3 days (IQR 2,4). 379 (39%) pts were infected with BA.1, 215 (22%) with BA.2, 372 with BA.4/5 (38%), and 5 with BQ.1 (0,5%). D1 mean viral load was 4.02 log2. Adjusted analysis (ATE) showed that NMV/r significantly reduced VL compared to all the other drugs in pts infected with all sublineages, (Fig.1A-B) while less evidence for a difference vs. TIX/CIL was seen in those infected with BA.2 (p=0.05) (Fig.1 C-D). Conclusion(s): In this analysis of in vivo early VL reductions, NMV/r appears to be the drug showing the greatest antiviral activity, regardless of the underlying subvariant, perhaps with the exception of TIX/CIL in people infected with BA.2 for which there was less evidence for a difference. In the Omicron era, due to the high prevalence of vaccinated people and in absence of clinical events, VL is one of the possible alternative endpoints which guarantees adequate statistical power. Fig 1 SARS-CoV-2 RNA levels at D1 and D7 in patients treated with Nirmatrelvir/ ritonavir, Sotrovimab, Molnupiravir, Remdesivir, and Tixagevimab/cilgavimab. Dot-plots showing the comparison of viral loads detected at D1 and D7 and the variation of RNA levels observed between the two time-points by intervention in (A) all patients treated with Nirmatrelvir/ritonavir (n=211), Sotrovimab (n=321), or Molnupiravir (n=231), or Remdesivir (n=138), or Tixagevimab/ cilgavimab (n=136);(C) patients with Omicron BA.2 infection treated with Nirmatrelvir/ritonavir (n=58), Sotrovimab (n=81), or Molnupiravir (n=21), or Remdesivir (n=37), or Tixagevimab/cilgavimab (n=18);(D) patients with Omicron BA.4/5 infection treated with Nirmatrelvir/ritonavir (n=102), Sotrovimab (n=92), or Molnupiravir (n=110), or Remdesivir (n=16), or Tixagevimab/cilgavimab (n=52). Viral RNA levels are expressed as log2 CT values. The horizontal dashed line represents the limit of detection (CT: 40.0), values >=40 are considered negative. Mean of log2 CT values, and SD are shown in the graph. Statistical analysis of the differences in viral loads by intervention as compared to Nirmatrelvir/ritonavir was performed by Mann-Whitney test. Potential decrease in VL and average treatment effect (ATE) were calculated from fitting marginal linear regression models weighted for calendar month of drug initiation, duration of symptoms, and immunodeficiency using NMV/r as the comparator trial arm. Results are shown (B) for patients infected with all Omicron sublineages and (D) for those infected with Omicron BA.2 sublineage.

A Randomized Trial on Early Therapy in Covid-19 High-Risk Outpatients in Omicron Era

Background: Antivirals and monoclonal antibodies (mAbs) were approved for early treatment of COVID-19 based on data from trials conducted in unvaccinated people before the Omicron era. The comparative effectiveness of different treatments is unknown. We present the results of the interim analysis of MONET trial (EudraCT: 2021-004188-28). Method(s): In this ongoing multicenter, open-label, phase 4 trial, we randomly assigned, in a 1:1:1 ratio, non-hospitalized patients with early symptomatic Covid-19 (<=5 days after symptoms onset) and >=1 risk factor for disease progression, to receive 500 mg of intravenous sotrovimab (SOT) or 600 mg of intramuscular tixagevimab/cilgavimab (TIX/CIL) or oral 5-days course of NMV/r 300/100 mg BID. Primary outcome was hospitalization or death for any cause within 29 days after randomization, reported as cumulative incidence per 100 (95% CI), and P-value calculated by Fisher's exact test. Inflammatory marker (CRP, d-dimer, and neutrophils-to-lymphocytes ratio) and antibody level (serum anti-S IgG and anti-N IgG) analysed by mixed linear regression with random intercept and P-values for time trend calculated by ANOVA-style test with Bonferroni correction. Result(s): Prespecified interim analysis, including 400 patients (SOT =133, TIX/ CIL=130, NMV/r=137) enrolled from Mar 4 to Nov 16, 2022 (Fig.1A). Overall, 5 pts (3/5 immunosuppressed) had disease progression leading to hospitalization [1.25% (95% CI 0.4%-2.89%)], 1 in SOT (0.75%, 95% CI 0.01%-4.1%), 4 in TIX/CIL (3.08%, 95% CI 0.84%-7.69%) and none in NMV/r arm (P=0.030). No deaths or ICU admissions were observed. Among the hospitalized pts, 3 were infected with BA.2 (1 SOT, 2 TIX/CIL), one with BA.4/5, and one BQ.1.1 (both TIX/ CIL). No serious adverse events and no kidney or liver toxicity were reported. Temporal trend of inflammation markers was similar in the three arms, and their estimates are shown in Fig.1B. Kinetics of antibody was reported in Fig.1C. The plot shows a rapid increase of anti-S in both mAb arm and a linear increase of IgG in the NMV/r arm. Anti-N IgG kinetics was similar in the three arms. Conclusion(s): By these data the overall cumulative risk of clinical failure in mild Covid-19 occurring in the Omicron era is low. The hypothesis that differences in clinical progression among the three arms could be related to different activity against the Omicron subvariant observed in vitro should be further investigated. Type of treatment does not seem to influence the development of the natural antibody response.

Incidence and Predictors of Clinical Progression in an Early Treated Covid-19 Cohort

Background: Early treatment for preventing severe outcome of COVID-19 in high-risk not-hospitalized patients (pts) by monoclonal antibodies or antivirals represented a high-priority approach. Real-world evidence (RWE) from observational studies could give information on clinical effectiveness and predictors of treatment failure. Method(s): Single-center observational study on SARS-CoV-2 pts, not requiring hospital admission but having high-risk of severe outcome from COVID-19. All were selected for early treatment with monoclonal antibodies or antivirals from March 2021 to November 2022. Participants were classified according to whether they were hospitalized due to severe COVID-19 or died by day 30 from starting treatment in the outpatient setting (baseline). We conducted a logistic regression analysis with this binary endpoint and 4 main exposures of interest measured at baseline: i) age ( >75 years old) ii) vaccination status iii) VoC, and iv) immunosuppression or having received immunosuppressive therapy. We built a separate model for each of these exposures, which included a specific set of potential confounders. Result(s): 3,491 pts, female 48.6%, median age 67 yrs (IQR 55-77), fully vaccinated 83.7%;previous infection 4.6%;CVD 52.2%;cancer 24.6%;immunodeficiency 40.6%. Prevalence of SARS-CoV-2 VoC: delta 8.7%, BA.1 16.9%, BA.2 6.8%, BA.4/5 12.2, BQ 0.1%, other 3.0% (Tab.1A). Treatment exposure was BAM/ETE 569 (16.5%), CAS/IMD 262 (7.6%), SOT 935 (27.1%), TIX/CIL 79 (2.3%), NMV/r 555 (16.1%), MLP 684 (19.8%), RDV 356 (10.3%). Primary endpoint occurred in 80/3,491 pts with a day-30 incident risk of 2.3% (95%CI 1.8-2.9). Tab.1B shows the unadjusted and adjusted odds ratios (OR) of hospitalization due to COVID-19 or death by day 30. After controlling for potential confounders, higher risk was observed for the unvaccinated (OR 1.95;95%CI 1.03-3.71) and for those affected by immunodeficiency [1.73;1.04-2.89). Having delta as reference variant, an increased risk was observed for BA.2 [2.08;1.00-2.34]. No evidence for a difference was seen by age or other comorbidities. Conclusion(s): In this RWE study, largely represented by vaccinated people and prevalently observed in the Omicron era, the estimated risk of clinical failure of early treatment was slightly higher than that recorded in the experimental arms of randomized studies. The analysis confirms that among those eligible for early treatment, the unvaccinated and those with severe immunodeficiency are at higher risk of developing severe COVID-19. Table 1 -A. Main characteristics of 3,491 not-hospitalized people with mildto-moderate COVID-19 at high risk of severe disease observed between March 2021 to November 2022 according to reaching (n=80) or not reaching (3,411) primary clinical endpoint. B. Odds ratios (OR) of having a COVID-19-related hospitalization or death by different exposure factors.

NILMATREVIR-RITONAVIR TREATMENT IN CHILDREN WITH SARS-CoV-2 INFECTION

Background: Children seem to experience a less severe form of COVID-19 disease than adults, nevertheless, cases of severe infection have been described in a small proportion of patients, requiring hospitalization in 5-10% of cases. Among COVID-19 deaths 0,4% occurred in children and adolescents under 20 years of age. Most hospitalized children with acute COVID-19 had underlying conditions. Moreover, some children with previous COVID-19 infection, may later develop Multisystem Inflammatory Syndrome in Children (MIS-C), a rare but serious condition associated with COVID-19. These data suggest that a specific therapy is necessary in high-risk pediatric population, in order to prevent severe COVID-19, especially in children with underlying conditions. Antiviral paediatric data are currently very few Methods: We conducted a retrospective study on patients < 18 years of age who received Paxlovid (nirmatrelvir-ritonavir) for the treatment of mild-tomoderate COVID-19 at Bambino Gesu Children's Hospital from April 2022 to September 2022. Patients at high risk of progression to severe COVID-19 who had no need of supplemental oxygen received Paxlovid according to AIFA's indications for adults with the Informed Consent of relatives Results: 40 patients aged 1-18 years with confirmed SARS-CoV-2 infection were treated with Paxlovid (Tab 1)The average symptom duration was 4.2 days. No patient developed severe COVID-19 r All patients were treated within 5 days of symptom onset, Four patients received a longer course treatment (10 days) due to the persistence of symptoms combined with the presence of severe comorbidities .The mean time of viral shedding was 12.7 days, with a patient being persistently positive for 56 days. After Paxlovid initiation, only 5 patients (12.5%) experienced adverse reactions: Conclusion(s): Treatment with Paxlovid has proven to be safe. Further pharmacokinetic studies are required species for children < 5 years old.

Temporal evolution of humoral and T-cell specific immune response to COVID-19 mRNA vaccine in multiple sclerosis

Background: Although a full course of vaccine against Sars- Cov-2 is effective in most patients with MS (PwMS), the duration of the protection and the efficacy of a booster dose remain poorly explored, especially across different disease modifying treatments (DMTs). Aim(s): To characterize humoral and T-cell immune response along time and following third dose of COVID-19 vaccination in PwMS. Method(s): From an established cohort evaluated at baseline (T0), PwMS were recruited after 24 weeks (T1) from the first cycle of mRNA vaccine and 4 weeks after third dose (T2). At each timepoint we evaluated the serological response by measuring the anti- Region-Binding-Domain (RBD). Cell-mediated response was analyzed by computing interferon (IFN)-gamma in response to spike peptides. Result(s): The baseline cohort consisted of 134 PwMS [mean age 46.6+/-10.8 years;F:92;mean disease duration 15.1+/-9.4 years;26.9% ocrelizumab (OCR) 30.6% fingolimod (FTY), 16.4% cladribine (CLA), 26.1%IFN-s-1a (IFNB)]. Of them, 109 were reassessed at T1, 78 at T2 and 64 completed all evaluations. In the whole cohort there was a significant reduction (p<0.0001) in anti- RBD rate from T0 [76% positive, median 52.8 BAU/ml Interquartile Range (IQR) 1150.9] to T1 (57.8% positive, median 13.2 BAU/ml IQR 95.98] and a significant 20- and 5-fold increase in median titer at T2 (75% positive, median 272.3 BAU/ml IQR 4212.3) from T1 and T0 respectively (p<0.0001). Median IFN-gamma level at T2 was significantly higher than those evaluated at T1 (p<0.0001) and T0 (p=0.009). These latter results were consistent across all DMTs. At T1 the highest detectable anti-RBD response was found in CLA (100%, median 87.7 BAU/ml IQR 22) and IFNB (93.5%;median 126.3 BAU/ml IQR 149.2) cohort, while PwMS treated with FTY and OCR showed 60% (median 8.25 BAU/ml IQR 34.3) and 21% (median 0.8 BAU/ml IQR 6) rate of anti-RBD response respectively. At T2 100% PwMS showed positive anti-RBD response except those treated with OCR (23.8% positive, median 0.6 BAU/ml IQR 4.1). IFN-gamma-S-specific T-cell response was reduced in FTY cohort at both T1 and T2 (3.3 % positive, median 0.8 pg/ml IQR 3.1 and 0.6 pg/ml IQR 2.4 respectively). Conclusion(s): A third dose of COVID-19 vaccine reinforces both humoral and cell-mediated immune response in PwMS on DMTs. Despite vaccination, PwMS treated with OCR and FTY show lower humoral and T-cell specific immune response respectively, suggesting the need of specific treatment to halt COVID-19 in case of infection.

A REAL-WORLD COMPARISON of BAM/ETE VS CAS/IMD for COVID-19 CLINICAL PROGRESSION RISK

Background: Few data are available about comparison of different monoclonal antibodies (MAbs) for COVID-19 in the real-world setting. We aim to compare effectiveness of bamlanivimab/etesevimab (BAM/ETE) versus (vs) casirivimab/imdevimab (CAS/IMD) and to estimate predictors of hospitalization/death. Methods: Observational analysis of all consecutive outpatients (pts) with mild/moderate COVID-19 enrolled within the AIFA access program in a single center in Rome, from March to October, 2021. At first baseline (BL) visit, RT-PCR from nasopharyngeal swab with cycle thereshold (CT) measurement and viral sequencing was performed. Pts received intravenous BAM/ETE (700/1400 mg) or CAS/IMD (1200/1200 mg) and were followed through day 30. Primary endpoint was hospitalization/death due to severe COVID-19 by day 30. Average treatment effect (ATE) in the multiplicative scale of the odds was the chosen estimand to compare the two treatments, adjusted for age, obesity, time from onset to infusion, median C-reactive protein (CRP), vaccination, variant of concern (VOC) and BL-CT. Predictors of clinical failure were explored by two different models of multivariable logistic regression. Results: 242 pts receiving BAM/ETE (n=76) or CAS/IMD (n=166) were included (male 54%;median age 65 yrs;median SpO2 97%;diabetes 12%;hypertension 40%;CVD 17%;COPD 26%;autoimmune diseases 12%;immunodeficiency 18%). Median time from symptoms onset to infusion was 4 days (IQR 3-6). No differences were observed between the two MAbs for BL characteristics except for BMI>35 (BAM/ETE 24%, CAS/IMD 12%), CRP (BAM/ETE 1.8, CAS/IMD 1.2), vaccination (BAM/ETE 26%, CAS/IMD 46%) and distribution of VOC (Alpha 46% BAM/ETE vs 22% CAS/IMD;Gamma 20% vs 7%;Delta 5% vs 55%). Proportion of patients with COVID-related hospitalization/death by day 30 was 12/76 (15.8%) for BAM/ETE and 6/166 (3.6%) for CAS/IMD. Estimate of causal effect of BAM/ETE exposure compared to CAS/IMD on primary end point by ATE is reported in Table 1a. Factors associated with an increased risk of clinical failure by fitting multivariable logistic regression were BMI >35 and P1/Gamma VOC;higher BL-CT was associated with a reduced risk (Table 1b-1c). Conclusion: In a real-life setting, receiving BAM/ETE was associated with a 4-fold higher risk of COVID-19 progression to hospitalization/death than CAS/IMD. SARS-CoV-2 P.1/Gamma, but not B.1617.2/Delta VOC, obesity and higher BL viral load also predicted an increased risk of clinical worsening.

SARILUMAB PLUS STANDARD of CARE (SOC) VERSUS SOC for SEVERE COVID-19 (ESCAPE STUDY)

Background: We aimed to evaluate the efficacy of sarilumab, an IL-6 receptor inhibitor, combined with SOC, in patients (pts) affected by severe COVID-19 pneumonia. Methods: Open-label, Phase III, randomized trial assessing clinical efficacy and safety of intravenous sarilumab in pts with severe COVID-19, at 5 clinical centers in Italy. We included hospitalized pts with SARS-CoV-2 infection and pneumonia, in severe or critical condition (excluding mechanically ventilated). Pts were randomized 2:1 to receive sarilumab 400 mg plus SOC (armA) or to continue SOC (armB). The primary endpoint was time to clinical improvement of 2 points on a 7-point category ordinal scale, ranging from 1 (discharged with resumption of normal activities) to 7 (death). Pts were stratified according to baseline disease severity (PaO2/FiO2 ratio < or ≥ 200 mmHg), C reactive protein (CRP < or ≥ 7 mg/dL) and lymphocytes count (< or ≥ 870/mmc). The key secondary endpoint was time to death. Adverse events (AE) were evaluated as safety outcomes. We used chi square test to compare proportions between arms, and Cox regression stratified by clinical center to estimate the hazard risk (HR) of primary endpoint. Results: Of 191 pts screened, 176 were assigned to armA (121) and B (55). A similar proportion of pts were treated with steroids (44 armA vs 26 armB, p=0.170) and remdesivir (22 armA vs 8 armB, p=0.552). 58/121 (48%) pts underwent to a second dose of sarilumab 12 hours after the first dose. At day 30, no significant differences in the primary endpoint were found between the arms (Figure1). After stratifying for inflammatory parameters, the probability of improvement seemed greater in armA than B, for the strata with CRP <7 mg/dL (88% [95% CI 77-96] vs 79% [63-91], HR 1.55 [0.9-2.6];log-rank p=0.049) and with lymphocytes <870/mmc (90% [79-96]) vs (73% [55-89], HR 1.53 [0.9-2.7];log-rank p=0.058). Figure2 for interaction tests between strata. There were no significant differences in death probability (armA 5% [2.3-10.9]) and armB 3.6% [0.9-13.8] HR 1.30 [0.41-4.15];log-rank p=0.79) and in the rates of AE (armA 32% [39/121] and armB 23% [14/55], p=0.195) and serious AE (armA 18% [22/121] and armB 11% [7/55], p=0.244). Conclusion: In our population, efficacy of sarilumab in pts with severe COVID-19 was not confirmed, even if some benefits were shown in those treated at an early stage of the disease with lower inflammatory burden. Further trials are needed for identifying targeted subgroups for maximizing benefit of this treatment.

16S rRNA gene sequencing of rectal swab in patients affected by COVID-19

COronaVIrus Disease-2019 (COVID-19) is a pandemic respiratory infection caused by a new betacoronavirus, the Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-CoV-2). Few data are reported on the gut microbiota in COVID-19 patients. 16S rRNA gene sequencing was performed to reveal an altered composition of the gut microbiota in patients with COVID-19 pneumonia admitted in intensive care unit (ICU) (i-COVID19), or in infectious disease wards (w-COVID19) as compared to controls (CTRL). i-COVID19 patients showed a decrease of Chao1 index as compared to CTRL and w-COVID19 patients indicating that patients in ICU displayed a lower microbial richness while no change was observed as for Shannon Index. At the phylum level, an increase of Proteobacteria was detected in w-COVID19 patients as compared to CTRL. A decrease of Fusobacteria and Spirochetes has been found, with the latter decreased in i-COVID19 patients as compared to CTRL. Significant changes in gut microbial communities in patients with COVID-19 pneumonia with different disease severity compared to CTRL have been identified. Our preliminary data may provide valuable information and promising biomarkers for the diagnosis of the disease and, when validated in larger cohort, it could facilitate the stratification of patients based on the microbial signature.

Thyroid dysfunction in COVID-19 patients.

PURPOSE: "Non thyroidal illness syndrome" (NTIS) or "euthyroid sick syndrome" (ESS) is a possible biochemical finding in euthyroid patients with severe diseases. It is characterized by a reduction of serum T3 (fT3), sometimes followed by reduction of serum T4 (fT4). The relationship between thyroid hormones levels and mortality is well known and different studies showed a direct association between NTIS and mortality. The sudden spread of the 2019 novel coronavirus (SARS-CoV 2) infection (COVID-19) and its high mortality become a world healthcare problem. Our aim in this paper was to investigate if patients affected by COVID-19 presented NTIS and the relationship between thyroid function and severity of this infection. METHODS: We evaluated the thyroid function in two different groups of consecutive patients affected by COVID-19 with respect to a control group of euthyroid patients. Group A included patients hospitalized for COVID-19 pneumonia while patients requiring intensive care unit (ICU) for acute respiratory syndrome formed the group B. Group C identified the control group of euthyroid patients. RESULTS: Patients from group A and group B showed a statistically significant reduction in fT3 and TSH compared to group C. In group B, compared to group A, a further statistically significant reduction of fT3 and TSH was found. CONCLUSIONS: COVID-19 in-patients can present NTIS. FT3 and TSH serum levels are lower in patients with more severe symptoms.

Characteristics and outcomes of COVID-19-related hospitalization among plwh

Background: There is conflicting evidence on how HIV influences COVID19 infection. Aim of this study was to compare characteristics at presentation and clinical outcomes of people living with HIV (PLWH) versus HIV negative patients (non-PLWH) hospitalized with COVID-19. Methods: Patients ≥18 years with SARS-CoV-2 infection, defined as positive RT-PCR from nasal/oropharyngeal swab or positive serology, admitted at L. Spallanzani Institute (Italy) were included. Primary endpoint: time to invasive ventilation/death. Secondary endpoints: time to ventilation/death, time to symptoms resolution (resolution of fever or waning from oxygen). In order to control for measured confounders, Cox regression model was used. Results: A total of 905 hospitalized patients were included in the analysis (22 [2.4%] PLWH, 883 non-PLWH): 65% males, 66% with at least one comorbidity, median PaO2/FiO2 at admission 343 mmHg (260-405). PLWH were slightly younger (56 vs 62 years, p=0.057), less likely with pneumonia (59% vs 87%, p<0.001) and with PaO2/FiO2 <300 mmHg at admission (10% vs 31%, p=0.088), with less alterations in lymphocytes (1505 cells/mm vs 1170, p=0.025) and D-dimer (473 ng/mL vs 661, p=0.015) compared with non-PLWH. Symptoms at presentation were similar in the two groups apart from headache and myalgia that were more frequent in PLWH (both p<0.001). Among PLWH, nadir CD4 was 80 (33-284) cells/μl, CD4 at COVID19 diagnosis 350 cells/μl (138-515), all of them were on antiretroviral therapy and 94% had HIV-1 RNA < 50 copies/mL. The cumulative probability of invasive ventilation/death at day 14 was 9.1% (95% CI 2.4-31.7) in PLWH versus 14.7% (12.3-17.6) in non-PLWH (p=0.492). The cumulative probability of non-invasive or invasive ventilation/ death at day 14 was 14.3% (4.8-38.0) in PLWH versus 24.4% (21.4-27.8) in non-PLWH (p=0.372). Following adjustment for age, gender, comorbidities, PaO2/FiO2 and pneumonia at admission, adjusted hazard ratio (aHR) of mechanical ventilation/death of PLWH was 0.95 (95% CI 0.13-6.98, p=0.958) versus non-PLWH;similarly, aHR of non-invasive or invasive ventilation/death of PLWH was 1.05 (95% CI 0.26-4.28, p=0.947). The probability of symptoms resolution at day 14 was similar in the two groups (aHR 1.16;0.65-2.09;p=0.614). Conclusion: A less severe presentation and no difference in clinical outcomes with Covid-19 even in the adjusted models were observed in PLWH compared to non-PLWH, but further investigations are warranted due to the small sample size of HIV+ population. (Figure Presented).

SARS-CoV-2 Serum Neutralization Assay: A Traditional Tool for a Brand-New Virus

SARS-CoV-2 serum neutralization assay represents the gold standard for assessing antibody-mediated protection in naturally infected and vaccinated individuals. In the present study, 662 serum samples collected from February 2020 to January 2021 from acute and convalescent COVID-19 patients were tested to determine neutralizing antibody (NAb) titers using a microneutralization test (MNT) for live SARS-CoV-2. Moreover, anti-SARS-CoV-2 IgG, IgA, and IgM directed against different viral antigens were measured by high-throughput automated platforms. We observed higher levels of NAbs in elderly (>60 years old) individuals and in patients presenting acute respiratory distress syndrome. SARS-CoV-2 NAbs develop as soon as five days from symptom onset and, despite a decline after the second month, persist for over 11 months, showing variable dynamics. Through correlation and receiver operating characteristic (ROC) curve analysis, we set up a testing algorithm, suitable for the laboratory workload, by establishing an optimal cutoff value of anti-SARS-CoV-2 IgG for convalescent plasma donors to exclude from MNT samples foreseen to have low/negative NAb titers and ineligible for plasma donation. Overall, MNT, although cumbersome and not suitable for routine testing of large sample sizes, remains the reference tool for the assessment of antibody-mediated immunity after SARS-CoV-2 infection. Smart testing algorithms may optimize the laboratory workflow to monitor antibody-mediated protection in COVID-19 patients, plasma donors, and vaccinated individuals.

Safety of remdesivir vs standard care in patients with moderate COVID-19

Background: Remdesivir (RDV) has been shown to shorten recovery time and was well tolerated in patients with severe COVID-19. Here we report safety of RDV in patients with moderate COVID-19. Methods: We conducted an open-label, phase 3 trial (NCT04252664) in hospitalized patients with confirmed SARS-CoV-2 infection, evidence of pulmonary infiltrates, and oxygen saturation >94% on room air. Patients were randomly assigned to receive RDV (5 or 10 days) or standard of care (SOC). RDV was dosed intravenously at 200 mg on day 1, 100 mg daily thereafter. Adverse events (AEs) and laboratory abnormalities were evaluated through the day 11 data cut;safety data through day 28 will be presented at the meeting. Results: 584 patients were randomized and treated (5d RDV: n=191;10d RDV, n=193;SOC: n=200). Baseline characteristics were balanced among groups;median (range) age was 57y (12-95y), 39% were female and 19% Black, 39% had arterial hypertension, 15% hyperlipidemia, 11% asthma. Briefly, across both the 5d and 10d arms, RDV was well tolerated with a similar rate of Grade 3 or 4 AEs and fewer SAEs compared to SOC (Table). AEs more common with RDV vs SOC included nausea, headache, and hypokalemia. Overall, across the 3 arms, incidence of AEs leading to discontinuation and death were low and no clinically relevant changes in laboratory parameters were observed. In addition, median changes in renal and liver function tests from baseline were not statistically significant between the RDV 5d and RDV 10d groups compared to the SOC only group at d14 (Table 1). Conclusion: RDV given for 5d or 10d was well tolerated in patients with moderate COVID-19. No clinically significant safety signals were observed with RDV vs SOC. (Figure Presented).

An inflammatory profile correlates with decreased frequency of cytotoxic cells in coronavirus disease 2019. (COVID special issue #2.)

Increased production of inflammatory cytokines and myeloid-derived suppressor cells occurs in patients with coronavirus disease 2019. These inversely correlated with perforin-expressing natural killer (NK) and CD3⁺ T cells. We observed a lower number of perforin-expressing NK cells in intensive care unit (ICU) patients compared with non-ICU patients, suggesting an impairment of the immune cytotoxic arm as a pathogenic mechanism.