Nirmatrelvir and Molnupiravir Coadministration Modifies Preclinical Viral Exposure

Background: Implementation of vaccination programmes has had a transformational impact on control of the SARS-CoV-2 pandemic, but the need for effective antiviral drugs remains. Molnupiravir (MPV) targets viral RNA polymerase inhibiting replication via lethal mutagenesis and nirmatrelvir (NTV) is a protease inhibitor boosted with ritonavir when given clinically. This study aimed to assess the virological efficacy of NTV and MPV individually and in combination against the SARS-CoV-2 BA.1 Omicron variant in a K18-hACE2 mouse model. Method(s): K18-hACE2 mice were inoculated intranasally with 103 PFU of SARSCoV-2 BA.1 Omicron (B.1.1.529). After 24 hours, mice were orally dosed q12H, as outlined in Figure 1. At 2, 3, and 4-days post infection mice were sacrificed, and lung samples harvested. Animals were weighed and monitored daily throughout. Subsequently, viral replication in the lung was quantified using qRT-PCR to measure total (N-gene) and sub-genomic (E-gene) viral RNA. Data were normalized to 18S for quantitation. Viral exposures expressed as Areas Under viral load Curves (AUCs) were calculated by the trapezoidal method using mean values at each timepoint. Separate studies in Syrian golden hamsters using individual drugs were also conducted, and total serum IgG was measured by ELISA at 4-days post infection. Result(s): Mice gained weight in all groups post-treatment, with no significant difference between groups. A reduction in lung viral exposure was evident in all treatment groups compared to the vehicle control dosed mice (Figure 1). Coadministration of NTV with MPV displayed a trend towards lower lung viral exposure compared to the vehicle control with ~40-and ~45-fold reduction in AUC for N-and SgE-gene assays, respectively. Dosed individually, NTV and MPV reduced viral exposure 5.7-and 7.7-fold for the N-gene assay, respectively. Differences in total serum IgG concentrations were evident between vehicle and NTV-(34-fold reduction, P=0.018), and MPV-(4.2-fold reduction, P=0.053) treated hamsters. Conclusion(s): These data show virological efficacy of NTV and MPV against the SARS-CoV-2 BA.1 Omicron variant. The combination of NTV and MPV demonstrated a lower viral RNA exposure in the lung than either drug alone, albeit not statistically significant. Initial data indicate potential immune alterations in NTV and MPV dosed hamsters. Studies to clarify the utility of NTV/ MPV combinations and further characterize the impact of antiviral therapy on IgG are warranted.

NAFAMOSTAT AS NASAL CHEMOPROPHYLAXIS FOR SARS-CoV-2 IN HAMSTERS

Background: Chemoprophylaxis is a critical tool for many infectious diseases, and in COVID-19 may have particular benefit for vulnerable patients that do not maximally benefit from vaccination. Nafamostat inhibits TMPRSS2, which catalyses a critical cell entry pathway for SARS-CoV-2. This study sought to assess efficacy of intranasal nafamostat against airborne transmission of SARSCoV-2 in Syrian Golden hamsters. Method(s): Male hamsters were intranasally administered water or 5 mg/kg nafamostat in water twice daily for 5 days (sentinels). One day after treatment initiation, sentinels were co-housed with an untreated hamster that was intranasally inoculated with 1 x 104 PFU of Wuhan SARS-CoV-2 (donor). Sentinels were separated from the donor by a perforated divider, allowing airflow between zones but not contact. Hamsters were weighed and throat-swabbed throughout. At day 4, all animals were culled, and lung and nasal turbinates were harvested. N-RNA was quantified relative to 18S-RNA by qPCR. A 2-way ANOVA with Bonferroni correction was applied to compare weight changes in the nafamostat group to those in controls. An unpaired t-test was used to compare viral RNA in lung and nasal turbinate between groups. Result(s): SARS-CoV-2 viral RNA was significantly lower in the nasal turbinates of nafamostat-treated hamsters compared to water-treated controls (P = 0.012;Figure 1). Within the lung, SARS-CoV-2 RNA was undetectable in the nafamostat-treated hamsters, but was detectable in the water-treated controls. Viral RNA was undetectable in the swabs of the nafamostat-treated hamsters at all timepoints, but was quantifiable in the water-treated control group from day 3. Body weight of the nafamostat-treated hamsters was significantly lower (P = < 0.001) than in the water-treated animals throughout. SARS-CoV-2 viral RNA was detectable in the donor hamsters lung, nasal turbinate and swab samples confirming validity of the experiment. Conclusion(s): This study demonstrated a protective effect of intranasal nafamostat against airborne SARS-CoV-2 transmission in Syrian golden hamsters. A phase IIa study of intravenously administered nafamostat yielded no evidence of clinical efficacy in hospitalised patients, but further investigation of intranasally administered nafamostat in a prophylactic setting may be warranted.

FXR INHIBITION AS A NEW STRATEGY AGAINST COVID19 T Brevini1, M Maes2, GJ Webb3, CD Fuchs4, G Buescher5

Introduction: Vaccines revolutionised the management of COVID19. Nevertheless, they lack efficacy in high-risk or vulnerable groups (e.g., immunosuppressed patients), who may not mount an appropriate immune response. Monoclonal antibodies represent the gold-standard agents for such cases;but they are limited by availability, need for parenteral administration and the risk for viral escape because of spike protein mutations. Therefore, there is a pressing need for new prophylactic agents less prone to resistance.The viral receptor ACE2 represents an ideal target as it is essential for viral entry and transmission and because being a host protein it is not affected by viral mutations. However, the regulation of ACE2 remains elusive, due to the lack of appropriatein vitromodels. Cholangiocytes show one of the highest ACE2 expression levels in the body, representing an ideal platform for these studies. Here, we use cholangiocyte organoids as proof-of-principleto identify that the bile acid receptor FXR regulates ACE2 expression and SARS-CoV-2 infectionin vitro. We validate these findings in lung and gut organoids, animal models, human organs perfusedex situand patient cohorts. Aims & Methods: 1. Identify pathways controlling the transcriptional regulation of ACE2 2. Identify drugs modulating these pathways as novel prophylactic and therapeutic agents for COVID19. Organoids were propagated using established protocols. Marker expression was assessed using single-cell RNA sequencing, QPCR, and immunofluorescence. FXR binding on DNA was assessed with chromatin immunoprecipitation. SARS-CoV-2 was isolated from bronchoalveolar lavage of a COVID19 patient. Syrian golden hamsters were infected via direct inoculation and QPCR on oral swab, nasal turbinate and lung samples was used to measure SARS-CoV-2 infection. Human livers and lungs not used for transplantation were perfusedex-situusing normothermic perfusion. Nasopharyngeal swabs were used to measure ACE2 expression in nasal epithelial cells of healthy individuals taking UDCA at the standard therapeutic dose of 15 mg/kg/day. Patient registry data were compared using propensity score matching for sex, age, diabetes, NAFLD and Child- Turcotte-Pugh score. Result(s): We identified that FXR directly regulates ACE2 transcription in cholangiocyte organoids, while FXR inhibition with the approved drug ursodeoxycholic acid (UDCA), reduced ACE2 expression and SARS-CoV-2 infectionin vitro. We confirmed this mechanism in organoids from other COVID19-affected tissues, including the respiratory and intestinal systems. We validated our findingsin vivoin Syrian golden hamsters, showing that treatment with UDCA downregulates ACE2 and prevents SARS-CoV-2 infection. We confirmed that UDCA reduces ACE2 and SARS-CoV-2 infection in human lungs and livers perfusedex-situ. We performed a clinical study demonstrating that UDCA lowers ACE2 levels in the nasal epithelium of 6 healthy volunteers. Finally, we identified a correlation between UDCA and better clinical outcomes (hospitalisation, ICU admission and death) in COVID19 patients receiving UDCA for cholestatic diseases using the COVID-Hep and SECURELiver registry data. Conclusion(s): We identified FXR as a novel regulator of ACE2 expression. Using a bench-to-bedside approach combining in vitroand in vivomodels, exsituperfused human organs and clinical data we showed that FXR inhibition prevents or reduces SARS-CoV-2 infection and identified UDCA as an approved, cost-effective drug which could be repurposed for COVID19, paving the road for future clinical trials.

Management of Maxillofacial Trauma Emergency Department Presentations in an Evolving Pandemic. Did COVID-19 Change Our Practice?

Aim: Trauma encompasses a significant proportion of referrals to Oral Maxillofacial Surgery (OMFS). COVID-19 called for clinicians globally to tailor practice and follow-up patterns. Multiple government-imposed lock downs saw changes in patterns of emergency department (ED) attendances nationally. The aim of this audit was to examine the impact of COVID-19 on Maxillofacial trauma presentations, admissions, and existing practice in University Hospital of Wales (UHW). Method: Data was collected using an electronic patient database Team Talk. Patients filtered by pathology (Soft tissue trauma, fractures) and location (ED). Annual data collected for 2019, 2020 and 2021, to compare pre-pandemic (2019), evolving pandemic (2020) and established pandemic (2021) figures. Results: Trauma made up 74%, 73% and 78% of total OMFS referrals (2019, 2020, 2021). There was an 83% decrease in the number of trauma referrals between 2019 and 2020, despite UHW becoming a major trauma centre. No correlation identified between trauma presentations and lockdown events (2020) but lifting of restrictions (September 2021) showed an increase in presentations. 16.8%, 16.4% and 16.2% (2019, 2020 and 2021, respectively) of ED referrals were offered follow up follow up. Percentage of follow up appointments used for removal of sutures (ROS) decreased by 30% (2019-2020). Conclusions: 1) Overall decrease of trauma presentations during the COVID-19 pandemic, but trauma still comprised >70% of all OMFS referrals from ED. 2) Pandemic pressures did not change follow-up, discharge, or admission decisions for ED referrals. 3) Change to absorbable sutures can be taken forward to reduce percentage of follow up clinic appointments required for ROS.

Locked Up and Locked Down: How the Covid-19 Pandemic has Impacted the Mental Health of Male Prisoners and Support Staff

Background: The impact of the Covid-19 pandemic on prisons across the world has been of much concern due to the increased risk of virus spread among a particularly vulnerable population. Efforts made to prevent spread of the virus have resulted in a range of restrictive measures with the aim of reducing contact between prisoners and staff. Unfortunately, restrictions have also resulted in increased time confined to cells, reduced occupation, and restricted access to services. The potential impact of this on a population that already presents with high rates of mental health difficulties requires consideration. Male prisoners may be at particularly high risk of experiencing negative outcomes. Methods: This study evaluated the impact of the pandemic and related changes upon the mental health of prisoners and staff within a male urban prison in the United Kingdom. A mixed methods approach with a convergent parallel design was used. Correlational and feature selection analysis was conducted on quantitative data. Qualitative data were subject to a thematic analysis. Findings were integrated at the point of summary and interpretation. Results: Prisoners and staff reported finding it hard to cope with changes and stressors associated with the pandemic. For prisoners, time spent locked in one???s cell with limited access to activities and support was associated with poor mental health outcomes, and salient themes emerged of feeling trapped, isolated and neglected. For staff, concerns about prisoner welfare and worry about catching the virus was associated with increased anxiety and worry. Additionally finding it hard to cope with constant changes at work and reduced staffing resulted in unhealthy coping behaviours such as drinking and smoking. Conclusions: Findings suggest that the implementation of additional restrictions, within the already restricted prison environment, has had a significant negative impact on the mental health of both prisoners and staff. The potential long-term mental health difficulties resulting from this require further investigation, as does the likely negative impact on staff wellbeing and staff turnover. The effects of the pandemic appear to have heightened an already desperate need to consider the mental health and wellbeing of prisoners and prison

Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model.

We investigated the relationships between cognitive change following stroke, awareness of cognitive impairments, and mood to further understanding of change processes influencing psychological outcomes post-stroke in line with the "Y-shaped" process model. Patients (n = 143; Mage = 73 years, SD = 13.73; 74 males) were assessed at 3-weeks (T1) and 6-months (T2) post-stroke and had completed the Oxford Cognitive Screen (T1 and T2), the Cognitive Failures Questionnaire (CFQ; T2), and the Hospital Anxiety and Depression Scale (HADS; T2). An ANCOVA controlling for disability relating to activities of daily living (ADL) revealed that awareness of cognitive impairment was significantly lower in participants with moderate-severe cognitive impairment. Regression analysis indicated that greater awareness of cognitive impairment and reduced independence in ADL were associated with greater emotional distress at T2. Cognitive improvement was associated with lower emotional distressat T2. Contrary to the awareness hypothesis, moderation analyses suggest that this effect was largest for those most cognitively impaired at T1. Findings emphasize the importance of monitoring stroke patients' capacity to be self-aware when assessing and formulating long-term post-stroke distress and have potential implications for improving long-term emotional status in those most cognitively impaired post-stroke, e.g., through psychoeducation, cognitive rehabilitation, and emotional support.

Poor appetite and overeating reported by adults in Australia during the coronavirus-19 disease pandemic: a population-based study.

OBJECTIVE: As a result of the coronavirus-19 disease (COVID-19) pandemic, Australia adopted emergency measures on 22 March 2020. This study reports the effect of the COVID-19 lockdown on appetite and overeating in Australian adults during the first month of emergency measures. DESIGN: This study reports analysis of data from the population-based, self-completed survey. The main outcome measure was an item from the Patient Health Questionnaire 9 asking: 'Over the past 2 weeks, how often have you been bothered by poor appetite or overeating?'. Data on sociodemographic factors, symptoms of anxiety and depression, and the impact of COVID-19 and lockdown were also collected. Multivariable logistic regression was used to examine associations with poor appetite or overeating. SETTING: An anonymous online survey available from 3 April to 2 May 2020. PARTICIPANTS: A total of 13 829 Australian residents aged 18 years or over. RESULTS: The weighted prevalence of being bothered by poor appetite or overeating in the past 2 weeks was 53·6 %, with 11·6 % (95 % CI 10·6, 12·6) of the cohort reporting poor appetite or overeating nearly every day. High levels of anxiety, concern about contracting COVID-19, being in lockdown with children and reporting a severe impact of the lockdown were associated with increased odds of poor appetite or overeating. CONCLUSIONS: Given the widespread prevalence of being bothered by poor appetite or overeating, universal public health interventions to address emotion-focused or situational eating during periods of lockdown may be appropriate.

Review of safety and minimum pricing of nitazoxanide for potential treatment of COVID-19

Background: Many treatments are being assessed for repurposing to treat coronavirus disease 2019 (COVI D-19). One drug that has shown promising results in vitro is nitazoxanide. Unlike other postulated drugs, nitazoxanide shows a high ratio of maximum plasma concentration (Cmax), after 1 day of 500 mg twice daily (BD), to the concentration required to inhibit 50% replication (EC50) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Cmax: E C50 roughly equal to 14:1). As such, it is important to investigate the safety of nitazoxanide for further trials. Furthermore, treatments for COVI D-19 should be cheap to promote global access, but prices of many drugs are far higher than the costs of production. We aimed to conduct a review of the safety of nitazoxanide for any prior indication and calculate its minimum costs of production. Methods: A review of nitazoxanide clinical research was conducted using EMBASE and MEDLINE databases, supplemented by ClinicalTrials.gov. We searched for phase 2 or 3 randomised controlled trials (RCTs) comparing nitazoxanide with placebo or active control for 5-14 days in participants experiencing acute infections of any kind. Data extracted were grade 1-4 and serious adverse events (AEs). Data were also extracted on gastrointestinal (GI) AEs, as well as hepatorenal and cardiovascular effects. Active pharmaceutical ingredient cost data from 2016 to 2019 were extracted from the Panjiva database and adjusted for 5% loss during production, costs of excipients, formulation, a 10% profit margin and tax. Two dosages, at 500 mg BD and a higher dose of 1100 mg three times daily (TDS), were considered. Our estimated costs were compared with publicly available list prices from a selection of countries. Results: Nine RCTs of nitazoxanide were identified for inclusion. These RCTs accounted for 1514 participants and an estimated 95.3 person-years-of-follow-up. No significant differences were found in any of the AE endpoints assessed, across all trials or on subgroup analyses of active- or placebo-controlled trials. Mild GI AEs increased with dose. No hepatorenal or cardiovascular concerns were raised, but few appropriate metrics were reported. There were no teratogenic concerns, but the evidence base was very limited. Based on a weighted-mean cost of US $61/kg, a 14-day course of treatment with nitazoxanide 500 mg BD would cost $1.41. The daily cost would therefore be $0.10. The same 14-day course could cost $3944 in US commercial pharmacies, and $3 per course in Pakistan, India and Bangladesh. At a higher dose of 1100 mg TDS, our estimated cost was $4.08 per 14-day course, equivalent to $0.29 per day. Conclusion: Nitazoxanide demonstrates a good safety profile at approved doses. However, further evidence is required regarding hepatorenal and cardiovascular effects, as well as teratogenicity. We estimate that it would be possible to manufacture nitazoxanide as generic for $1.41 for a 14-day treatment course at 500 mg BD, up to $4.08 at 1100 mg TDS. Further trials in COVI D-19 patients should be initiated. If efficacy against SARS-CoV-2 is demonstrated in clinical studies, nitazoxanide may represent a safe and affordable treatment in the ongoing pandemic.