Effect of Combination Therapy of Hydroxychloroquine and Azithromycin on Mortality in Patients With COVID‐19

Conflicting evidence regarding the use of hydroxychloroquine (HCQ) and azithromycin for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection do exist. We performed a retrospective single‐center cohort study including 377 consecutive patients admitted for pneumonia related to coronavirus disease 2019 (COVID‐19). Of these, 297 were in combination treatment, 17 were on HCQ alone, and 63 did not receive either of these 2 drugs because of contraindications. The primary end point was in‐hospital death. Mean age was 71.8 ± 13.4 years and 34.2% were women. We recorded 146 deaths: 35 in no treatment, 7 in HCQ treatment group, and 102 in HCQ + azithromycin treatment group (log rank test for Kaplan–Meier curve P < 0.001). At multivariable Cox proportional hazard regression analysis, age (hazard ratio (HR) 1.057, 95% confidence interval (CI) 1.035–1.079, P < 0.001), mechanical ventilation/continuous positive airway pressure (HR 2.726, 95% CI 1.823–4.074, P < 0.001), and C reactive protein above the median (HR 2.191, 95% CI 1.479–3.246, P < 0.001) were directly associated with death, whereas use of HCQ + azithromycin (vs. no treatment; HR 0.265, 95% CI 0.171–0.412, P < 0.001) was inversely associated. In this study, we found a reduced in‐hospital mortality in patients treated with a combination of HCQ and azithromycin after adjustment for comorbidities. A large randomized trial is necessary to confirm these findings.

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is spreading worldwide since December 2019 and still no proven effective therapy has been found. First therapy proposed to treat coronavirus disease 2019 (COVID‐19) has been the association of lopinavir‐ritonavir, a protease inhibitor approved for HIV infection. However, Cao et al. observed no benefit comparing lopinavir‐ritonavir treatment of hospitalized patients with severe COVID‐19, ¹ and this treatment is currently not recommended. Currently, only remdesivir has been approved for COVID‐19 treatment, as it reduced recovery time by 4 days in 1,063 patients randomized to either remdesivir 200 mg loading dose followed by 100 mg daily or placebo for up to 10 days ² with a similar rate of adverse events between the 2 groups. ³ However, no effect on in‐hospital mortality was found.Chloroquine and its derivative hydroxychloroquine (HCQ), based on few preclinical studies, have also been proposed as therapies for COVID‐19. A Chinese randomized trial in patients with mild disease showed a significantly shorter recovery time in the group treated with HCQ vs. the standard of care along with a radiological improvement. ⁴ Differently, a retrospective study performed in the United States Veterans Health Administration medical centers found an increased mortality associated with the treatment with HCQ. ⁵ Moreover, an observational study has shown no significant association between HCQ use and risk of intubation or death. ⁶ Furthermore, a recent randomized controlled trial has found no differences between patients treated with HCQ plus the standard of care vs. the standard of care alone in terms of virus elimination. ⁷ On the basis of a very small nonrandomized study, azithromycin has been proposed as possible treatment in association with HCQ. ⁸ Azithromycin, is an antibiotic belonging to the class of macrolides, with some proven efficacy in acute respiratory distress syndrome. ⁹ , ¹⁰ It is known to have immunomodulatory properties through the polarization of macrophages toward the reparative state ¹¹ and the reduction in the production of pro‐inflammatory cytokines, such as IL‐8, IL‐6, TNF alpha, ¹² and iNOS expression. ¹³ Recently, two large retrospective studies evaluating in‐hospital mortality associated with the use of the combination of HCQ and azithromycin (or another macrolide, such as clarithromycin), have shown no benefits. ¹⁴ Despite the lack of a proven clinical efficacy and some concerns regarding the possible QT prolongations caused by the association of HCQ and azithromycin, ¹⁵ given the low price and the wide availability, the association of these two drugs has become the most used treatment in patients with moderate‐severe COVID‐19.Because of the urgent need to find answers to the many questions posed by the fight to SARS‐CoV2 infection and some negative evidences regarding the use of HCQ, we here propose a retrospective observational study to assess the efficacy of the combination of HCQ plus azithromycin for hospitalized patients with medium‐severe COVID‐19.     

Evaluation of <i>MGMT</i> Gene Methylation in Neuroendocrine Neoplasms

Unresectable neuroendocrine neoplasms (NENs) often poorly respond to standard therapeutic approaches. Alkylating agents, in particular temozolomide, commonly used to treat high-grade brain tumors including glioblastomas, have recently been tested in advanced or metastatic NENs, where they showed promising response rates. In glioblastomas, prediction of response to temozolomide is based on the assessment of the methylation status of the MGMT gene, as its product, O6 -methylguanine-DNA methyltransferase, may counteract the damaging effects of the alkylating agent. However, in NENs, such a biomarker has not been validated yet. Thus, we have investigated MGMT methylation in 42 NENs of different grades and from various sites of origin by two different approaches: in contrast to methylation-specific PCR (MSP), which is commonly used in glioblastoma management, amplicon bisulfite sequencing (ABS) is based on high-resolution, next-generation sequencing and interrogates several additional CpG sites compared to those covered by MSP. Overall, we found MGMT methylation in 74% (31/42) of the NENs investigated. A higher methylation degree was observed in welldifferentiated tumors and in tumors originating in the gastrointestinal tract. Comparing MSP and ABS results, we demonstrate that the region analyzed by the MSP test is sufficiently informative of the MGMT methylation status in NENs, suggesting that this predictive parameter could routinely be interrogated also in NENs.     

Results From a Large,Multicenter, Retrospective Analysis On Radium223 Use in Metastatic Castration-resistant Prostate Cancer (mCRPC) in the Triveneto Italian Region

Background

Radium 223 was introduced for metastatic castration-resistant prostate cancer based on the results of a randomized controlled trial showing risk reduction for death and skeletal events. Our aim was to evaluate the outcome of patients receiving radium 223 in a real-world setting.

Preclinical relevance of probiotics in type 2 diabetes: A systematic review

Type 2 diabetes (T2DM) is among the most prevalent metabolic diseases in the world and may result in several long‐term complications. The crosstalk between gut microbiota and host metabolism is closely related to T2DM. Currently, fragmented data hamper defining the relationship between probiotics and T2DM. This systematic review aimed at investigating the effects of probiotics on T2DM in animal models. We systematically reviewed preclinical evidences using PubMed/MEDLINE and Scopus databases, recovering 24 original articles published until September 27th, 2019. This systematic review was performed according to PRISMA guidelines. We included experimental studies with animal models reporting the effects of probiotics on T2DM. Studies were sorted by characteristics of publications, animal models, performed analyses, probiotic used and interventions. Bias analysis and methodological quality assessments were examined through the SYRCLE's Risk of Bias tool. Probiotics improved T2DM in 96% of the studies. Most studies (96%) used Lactobacillus strains, and all of them led to improved glycaemia. All studies used rodents as models, and male animals were preferred over females. Results suggest that probiotics have a beneficial effect in T2DM animals and could be used as a supporting alternative in the disease treatment. Considering a detailed evaluation of the reporting and methodological quality, the current preclinical evidence is at high risk of bias. We hope that our critical analysis will be useful in mitigating the sources of bias in further studies.     

Risk Factors for Dysphagia and the Impact on Outcome After Spontaneous Subarachnoid Hemorrhage

Neurocritical Care - Despite the tremendous impact of swallowing disorders on outcome following ischemic stroke, little is known about the incidence of dysphagia after subarachnoid hemorrhage (SAH)...     

Formalin-induced infidelity in PCR-amplified DNA fragments

A 643-nucleotide-long fragment of rDNA gene was amplified by PCR in the nematode worm Caenorhabditis. When the experiments were performed by using samples fixed in formalin, artefacts were detected. While the size of the amplified fragment resulted unaffected, very striking differences were seen in the nucleotide sequences of the amplified fragments. Furthermore, in many cases, the PCR reaction failed completely. The results obtained might warn of potential problems, especially when the amount of DNA to be amplified scarce.