Effectiveness of early pharmaceutical interventions in symptomatic COVID-19 patients: A randomized clinical trial.

Objective: We assessed the effectiveness of oral Hydroxychloroquine (HC), Azithromycin (AZ) and Oseltamivir (OS), alone or combined, among patients hospitalized with mildly symptomatic coronavirus infectious disease (COVID-19). Methods: Following the approval of the National Bioethics Committee and prospective registration (clinicaltrials.gov NCT04338698), a multicenter randomized clinical trial of adaptive design was conducted at 10 multispecialty hospitals in Pakistan. Patients were randomized into seven treatment groups. Starting April 15, 2020, consenting, eligible, otherwise healthy adult patients or those with co-morbidities under control, were recruited if they presented with mildly symptomatic COVID-19 (scored 3 on a 7-point ordinal scale anchored between 1 = not hospitalized, able to undertake normal activities, to 7 = death) confirmed by quantitative Real-Time Polymerase Chain Reaction (qRT-PCR). Two primary outcomes were assessed by day seven: Turning qRT-PCR negative; and clinical improvement of two points from the baseline. Outcome rates were compared using a chi-square test. Multiple imputations were applied to handle missing data. An interim data analysis was carried out on July 19, 2020, following which the study continued without treatment group changes. Data Safety and Monitoring Board advised to stop recruitment due to its futility on January 18, 2021. Results: Of 471 patients randomized, a total of 426 (90.4%) completed the follow-up for primary outcomes. Based on imputed data analyses at day seven: Total qRT-PCR negative cases were 137/471 (29%, 95% CI 25.0 - 33.4). By day seven, a total of 111/471 (23.5%, 95% CI 19.8 - 27.6) showed clinical improvement. No serious or non-serious adverse event was reported. Conclusions: Among patients with mild COVID-19, there was no statistically significant difference in the effectiveness of oral antimalarial, antiviral, or antibiotic treatments.Clinicaltrials.gov ID: NCT04338698.

Protocol of Pakistan randomized and observational trial to evaluate coronavirus treatment among newly diagnosed patients with COVID-19: Azithromycin, Oseltamivir, and Hydroxychloquine.

Background & Objective: This study aimed to assess the clinical effectiveness of Hydroxychloroquine Sulfate (200 mg orally 8 hourlies thrice a day for 5 days), oseltamivir (75 mg orally twice a day for 5 days), and Azithromycin (500 mg orally daily on day 1, followed by 250 mg orally twice a day on days 2-5) alone and in combination (in seven groups). Methods & Analysis: An adaptive design is deployed, set within a comprehensive cohort study, to permit flexibility in fast-changing clinical and public health scenario. Primary outcomes include turning the test negative for coronavirus nucliec acid and in bringing about clinical improvement on day 7 of follow-up on a seven-point ordinal scale. The randomized study will recruit participants of either gender above 18 years of age who will test positive for SARS-CoV-2 on Quantitative Reverse Transcription Polymerase Chain Reaction (PCR). Pregnant or lactating females, and those with severe respiratory distress, or with serious comorbidities will be excluded. Randomization will be done maintaining concealment of allocation sequence using a computer-generated random number list. The sample size will be subjected to periodic reviews by National Data Safety and Monitoring Board. Ethics and Dissemination: The trial is approved by the National Bioethics Committee (No.4-87/NBC-471-COVID-19-05/20/) and institutional Ethical Review Committee. This clinical trial conducted under Good Clinical Practice is expected to inform patients clinical guidelines for the use of these drugs in newly diagnosed with SARS-CoV-2. Trial Registration: The trial was prospectively registered on April 08, 2020 at clinicaltrials.gov with ID: NCT04338698.

Angiographic patterns of coronary artery disease in young patients presenting at a tertiary cardiac center.

Objective: To compare the patterns of coronary artery disease (CAD) between young adults ≤35 years of age and patients >35 years of age. Methods: The observational retrospective study was carried out in angiography department of emergency at Punjab Institute of Cardiology, Lahore between January 2020 and October 2020. Patients ≤35 years old were in Group-I whereas patients >35 years who served as controls were in Group-II. Patients with unstable angina, non-ST and ST elevation MI all were included. The patients with previous history of CAD (CABG/PCI) and angiography done for other purposes i.e., before valvular surgery or PPM implantation were excluded. Results: Out of 1268 patients, 552 were in Group-I and 716 were in Group-II. The prevalence of normal coronaries/ mild CAD was higher in Group-I i.e., 224(40.6%) than in Group-II i.e., 64 (8.9%). Single vessel disease (SVD) was comparable in both the groups 185 (33.5%) vs. 216 (30.2%). Double vessel disease and triple vessel disease (TVD) was common in Group-II and left main stem (LMS) involvement was also significantly higher in Group-II i.e., 32 (4.5%) vs. 8 (1.4%). Clot in coronary arteries with or without underlying CAD was seen more frequently in Group-I, 61(11.1%) vs. 34 (4.7%). Presence of clot was seen mostly in those patients who had moderate coronary artery disease. Conclusion: Young patients have different coronary artery disease patterns, so the management strategy must be different in this population. Majority of the young patients have non severe disease. Clot formation is commonly seen in young adults with moderate CAD.

Levels of platelet-derived microparticles and soluble p-selectin in patients of acute myocardial infarction (case control study).

OBJECTIVE: TTo measure levels of platelet-derived microparticles and soluble P-selectin in patients of acute myocardial infarction and their comparison with healthy controls. METHODS: This case-control study was conducted in Department of Haematology, University of Health Sciences Lahore from April to September 2013, and comprised patients of acute myocardial infarction in group 1 and healthy controls in group 2. Platelet-derived microparticles and soluble P-selectin were measured by enzyme-linked immunosorbent assay. SPSS21 was used for data analysis. RESULTS: Of the 80 participants, 50(62.5%) were patients and 30(37.5%) were controls. The mean levels of platelet-derived microparticles and soluble P-selectin were significantly higher in group 1 compared to group 2 (45.70±10.30 vs 10.60±0.96, and 51.46±9.30 vs 9.16±1.04, respectively) (p<0.001). There was no significant difference in levels of platelet-derived microparticles and soluble P-selectin in three intervals after acute myocardial infarction (p>0.05). Although levels of platelet-derived microparticles and soluble P-selectin did not correlate to creatinekinase-myocardial band levels (p>0.05), but there was a trend of significant correlation with cardiac troponin T (p<0.05). CONCLUSIONS: Levels of platelet-derived microparticles and soluble P-selectin can be used as novel early diagnostic marker of acute myocardial infarction.

Analysis of CYP2C9 polymorphisms (*2 and *3) in warfarin therapy patients in Pakistan. Association of CYP2C9 polymorphisms (*2 and*3) with warfarin dose, age, PT and INR.

Warfarin is a widely used anticoagulant characterized by having a narrow therapeutic index and exhibiting a wide range of inter-individual and inter-ethnic variation. Single nucleotide polymorphisms in hepatic VKORC1 and CYP2C9 genes causes decreased and increased metabolism of warfarin respectively. The objective of this study was to evaluate the allele frequency of CYP2C9 polymorphic variants *2 and *3 and the association of these allelic variants with PT/INR and daily/weekly dose of warfarin. Seventy-four patients with heart valve replacement were selected. Patients taking low warfarin dose (4.90-17.50 mg weekly) for at least last 3 months and had a stable INR in the range of 2-3 were included in this study. CYP2C9 polymorphism was analyzed by polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) technique. Among 74 patients, 9 (12.1 %) showed to have *2 allele, whereas 11 (14.1 %) had *3 allele. Genotype frequencies of wild and variant alleles were, 54.1, 17.6, 21.6 and 6.8 % for *1/*1, *1/*2, *1/*3 and *2/*3 respectively. None of the patient was homozygous for *2 and *3. Statistical analysis showed that low warfarin dose (weekly) is significantly associated with *1/*2 and *1/*3 genotypes (p value ≥ 0.001), whereas PT/INR showed no significant association with the any genotypes of CYP2C9. Our study suggest that polymorphic variants of CYP2C9 (*2 and *3) might influence warfarin dose requirements and associated with the low dose of warfarin in patients.

PROTECTIVE EFFECT OF SACCHARUM OFFICINARUM L. (SUGAR CANE) JUICE ON ISONIAZID INDUCED HEPATOTOXICITY IN MALE ALBINO MICE.

BACKGROUND: Isoniazid (INH) is the drug of choice for treatment of tuberculosis (TB) and it is a well-known-cause of acute clinical liver injury which can be severe and sometimes fatal. The study was designed to investigate the effects of Saccharum officinarum L. juice on oxidative liver injury due to INH in mice. METHODS: This was a laboratory based experimental study. Thirty mice were divided into three groups, containing 10 mice each. Group A being the control, group B and C were experimental and were treated orally with INH 100 mg/kg per day and INH 100 mg/kg per day plus Saccharum officinarum L. juice 15 ml/ kg per day respectively for a period of 30 days. Blood samples were taken at 30th day by cardiac puncture under anaesthesia and liver in each was taken out for microscopic examination. RESULTS: INH treated mice showed; rise in serum ALT, AST, ALP and total bilirubin levels (Mean?SEM), while group C mice treated with Saccharum officinarum L. juice significantly decreased the levels of these biochemical parameters. The histopathological examination of groups A showed normal liver structure which was deranged in (INH) group B, whereas group C showed significant recovery in histological structure. Saccharum officinarum L. constituents, especially flavanoids and anthocyanins have strong antioxidant properties which provides hepatoprotection against oxidative liver injury produced by INH. CONCLUSION: INH-induced liver injury is associated with oxidative stress, and co-administration of Saccharum officinarum L. juice (15 ml/Kg bw) may reduce this damage effectively in mice.

THE EFFECT OF FICUS CARICA L. (ANJIR) LEAF EXTRACT ON GENTAMICIN INDUCED NEPHROTOXICITY IN ADULT MALE ALBINO MICE.

BACKGROUND: Gentamicin is an aminoglycoside isolated from Micromonospora purpurea known for its nephrotoxicity. Ficus carica L is known to treat many ailments. This study was designed to investigate the effects of Ficus carica L. (Anjir) leaf extract on renal oxidative stress induced by gentamicin in albino mice. METHODS: In this laboratory based experimental study 30 mice were divided into three groups, containing 10 mice each. Group A being the control; groups B and C were experimental and treated with gentamicin 200 mg/kg/day intraperitoneally and, Ficus carica L. leaf extract 400 mg/kg/day orally with gentamicin 200 mg/kg/day intraperitoneally respectively for a period of 8 days. Blood samples were taken 24 hours after completion of the experimental period by cardiac puncture under anesthesia and kidneys of each mouse were taken out for microscopic examination. RESULTS: Gentamicin treatment increased serum urea and creatinine levels (group B). Ficus carica L. leaf extract treated animals showed significant reduction in biochemical markers of kidney functions in group C. The histopathological examination of group A showed normal renal structure which was deranged in group B treated with only gentamicin, whereas, group C exhibited marked improvement in histological structure. CONCLUSION: Ficus carica L. leaf extract is effective in preventing gentamicin induced functional and structural changes in kidney of albino mice.

Correction to: Pakistan Randomized and Observational Trial to Evaluate Coronavirus Treatment (PROTECT) of Hydroxychloroquine, Oseltamivir and Azithromycin to treat newly diagnosed patients with COVID-19 infection: A structured summary of a study protocol for a randomized controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

Pakistan Randomized and Observational Trial to Evaluate Coronavirus Treatment (PROTECT) of Hydroxychloroquine, Oseltamivir and Azithromycin to treat newly diagnosed patients with COVID-19 infection who have no comorbidities like diabetes mellitus: A structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: To evaluate the effectiveness of Hydroxychloroquine Phosphate/Sulfate (200 mg orally 8 hourly thrice a day for 5 days), versus oseltamivir (75 mg orally twice a day for 5 days), and versus Azithromycin (500 mg orally daily on day 1, followed by 250 mg orally twice a day on days 2-5) alone and in combination (in all seven groups), in clearing the coronavirus (COVID-19) nucleic acid from throat and nasal swab and in bringing about clinical improvement on day 7 of follow-up (primary outcomes). TRIAL DESIGN: An adaptive design, set within a comprehensive cohort study, to permit flexibility in this fast-changing clinical and public health scenario. The randomized study will be a multicenter, multiarm, multistage, randomized controlled trial with a parallel design. An observation only cohort will emerge from those not consenting to randomization. PARTICIPANTS: Eligible will be newly diagnosed patients, either hospitalized or in self-isolation, without any comorbidities or with controlled chronic medical conditions like diabetes mellitus and hypertension. Participants of any gender or age group having tested positive for COVID-19 on Real-Time qRT-PCR (Quantitative Reverse Transcription PCR) will be invited to take part in study at twelve centers across eight cities in Pakistan. Those pregnant or lactating, severely dyspneic or with respiratory distress, already undergoing treatment, and with serious comorbidities like liver or kidney failure will be excluded. INTERVENTION AND COMPARATOR: There will be a total of seven comparator groups: Each drug (Hydroxychloroquine Phosphate/Sulfate, Oseltamivir and Azithromycin) given as monotherapy (three groups); combinations of each of two drugs (three groups); and a final group on triple drug regimen. MAIN OUTCOMES: The laboratory-based primary outcome will be turning the test negative for COVID-19 on qRT-PCR on day 7 of follow-up. The clinical primary outcome will be improvement from baseline of two points on a seven-category ordinal scale of clinical status on day 7 of follow-up. RANDOMIZATION: Participants will be randomized, maintaining concealment of allocation sequence, using a computer-generated random number list of variable block size into multiple intervention groups in the allocation ratio of 1:1 for all groups. BLINDING (MASKING): This is an open label study, neither physician nor participants will be blinded. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): This is an adaptive design and parameters for formal sample size calculation in a new disease of a previously unknown virus are not available. Thus, the final sample size will be subjected to periodic reviews at each stage of adaptive design and subsequent advice of National Data Safety & Management Board (NDSMB) notified by Drug Regulatory Authority of Pakistan. TRIAL STATUS: Protocol Version 1.7 dated July 5, 2020. By July 03, 2020, the trial had recruited a total of about 470 participants across 12 centers after approval from the National Bioethics Committee and Drug Regulatory Authority of Pakistan. Recruitment started on April 20, 2020. The recruitment is expected to continue for at least three months subject to review by the National Data Safety and Management Board (NDSMB) notified by Drug Regulatory Authority of Pakistan. TRIAL REGISTRATION: Prospectively registered on 8 April 2020 at clinicaltrials.gov ID: NCT04338698 The full protocol is attached as an additional file, accessible from the Trials website (Additional file1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file2).

Frequency of HLA DQß1*0201 and DQß1*0301 Alleles and Total Serum IgE in Patients with Bronchial Asthma: A Pilot Study from Pakistan.

In Pakistan about 3.7% of the population is suffering from asthma, a chronic inflammatory disorder of airways. Asthma has wide spectrum of predisposing factors including environment and genetics. Many studies have been performed to determine association of asthma with serum IgE and major histocompatibility complex (MHC) alleles but conflicting results were reported. Therefore, present study was designed to determine frequency of HLA-DQß1*0201 and DQß1*0301 alleles in patients with bronchial asthma. This case control study included 85 asthmatic patients and 85 healthy controls. HLA-DQß1*0201 and DQß1*0301 alleles were detected by allele specific PCR and serum IgE was determined by ELISA. Median and inter-quartile range (IQR) of total IgE level were more increased in asthma patients (585.7 IU/mL and 247.2-848.1 IU/mL) compared to healthy controls (65.1 IU/mL and 28.1-181.3 IU/mL) (p<0.001). Frequency of HLA-DQß1*0201 and -DQß1*0301 alleles was more in healthy controls (32% and 38%, p=0.616) as compared to bronchial asthma patients (28% and 26%, p= 0.09). There was a significant association of IgE levels and HLA-DQß1*0201 allele. Patients positive for HLA-DQß1*0201 allele had low level of serum IgE 357.2 IU/mL (153.9-634.3 IU/mL) compared to the patients negative for this HLA allele i.e. 642.9 IU/mL (289.8-1299.5IU/mL) (p=0.005), whereas, HLA-DQß1*0301 allele was not associated with total serum IgE level (p=0.865). Our findings show that HLA-DQß1*0201 and -DQß1*0301 alleles were not associated with asthma; however, HLA-DQß1*0201 allele was associated with low levels of total serum IgE in the study population.