Background and Objectives: Conduction disturbances such as left bundle branch block (LBBB) and complete atrio-ventricular block (cAVB) are relatively frequent complications following trans-catheter aortic valve implantation (TAVI). We investigated the dynamics of these conduction blocks to further understand luxating factors and predictors for their persistency. Materials and Methods: We prospectively included 157 consecutive patients who underwent a TAVI procedure. Electrocardiograms (ECGs) were obtained at specific time points during the TAVI procedure and at follow-up until at least six months post-procedure. Results: Of the 106 patients with a narrow QRS complex (nQRS) before TAVI, ~70% developed LBBB; 28 (26.4%) being classified as super-transient (ST-LBBB), 20 (18.9%) as transient (T-LBBB) and 24 (22.6%) as persistent (P-LBBB). Risk of LBBB was higher for self-expandable (SE) than for balloon-expandable (BE) prostheses and increased with larger implant depth. During the TAVI procedure conduction disturbances showed a dynamic behavior, as illustrated by alternating kinds of blocks in 18 cases. Most LBBBs developed during balloon aortic valvuloplasty (BAV) and at positioning and deployment of the TAVI prosthesis. The incidence of LBBB was not significantly different between patients who did and did not undergo BAV prior to TAVI implantation ). Progression to cAVB was most frequent for patients with preexisting conduction abnormalities (5/34) patients) and in patients showing ST-LBBB (6/28). Conclusions: During the TAVI procedure, conduction disturbances showed a dynamic behavior with alternating types of block in 18 cases. After a dynamic period of often alternating types of block, most BBBs are reversible while one third persist. Patients with ST-LBBB are most prone to progressing into cAVB. The observation that the incidence of developing LBBB after TAVI is similar with and without BAV suggests that a subgroup of patients has a substrate to develop LBBB regardless of the procedure. Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with severe aortic valve stenosis who do not qualify for surgical aortic valve replacement (AVR) ,2. DespiWe sought to investigate the incidence, timing and dynamics of conduction disturbances in patients undergoing TAVI with emphasis on the development of LBBB to better understand the role of luxating factors.All consecutive patients who underwent a TAVI between April 2014 and June 2016 in the Maastricht University Medical Center were included in this study. Exclusion criteria were a pre-existing permanent pacemaker implantation (PPI) and implantation of a prior aortic valve prosthesis.Our objective was to study at least 50 patients with a narrow QRS complex (nQRS) at baseline in order to analyze trends of conduction disturbances during TAVI. Taking into account patients with a wide QRS at baseline and to compensate for missing data and lost to follow-up, a total number of 150 patients was considered between April 2014 and June 2016. Patients were included from April 2014 to June 2016. Electrocardiographic data were prospectively collected in a central registry.Electrocardiograms (ECGs) were obtained preoperatively, postoperatively, before discharge and at follow-up after 6–12 months following TAVI.at baseline, within one minute prior to start of the procedure,after advancing the soft guidewire through the aortic valve,after placing the stiff wire through the aortic valve,after positioning the valvuloplasty balloon through the aortic valve,after performing the balloon aortic valvuloplasty (BAV),after positioning the TAVI prosthesis in the native valve,after deployment of the TAVI prosthesis andat the end of the procedure after removal of all catheters.Continuous 12-lead ECG (cECG) was recorded during key stages of the TAVI procedure as follows:All additional BAVs, both positioning and dilatation, following TAVI deployment, were also registered.All ECGs were reviewed for ventricular conduction disturbances such as LBBB, right bundle branch block (RBBB), intraventricular conduction disturbance (IVCD) and complete atrioventricular block (cAVB). According to the established Strauss criteria, LBBB was defined as a QRS duration of >140 ms (men) or >130 ms (women), QS or rS in leads V1 and V2 and mid-QRS notching or slurring in 2 of leads V1, V2, V5, V6, I, and aVL [Any new bundle branch block (BBB) on the cECG which had disappeared on the first postoperative ECG was defined as super-transient (ST). If a new BBB or cAVB was present postoperatively but disappeared at discharge or 6–12 months follow-up it was defined as transient (T). If the BBB or cAVB was still present on the follow-up ECG, it was considered persistent (P).In order to study procedural related factors contributing to conduction disturbances, TAVI prostheses were divided into “balloon-expandable” (BE) and “self-expandable” (SE) prostheses, with BE prostheses being Edwards Sapien XT and -3 prostheses and SE prostheses comprising of Medtronic CoreValve, Medtronic Engager, Medtronic Evolut-R, St. Jude Medical Portico and Symetis Acurate.2 test for categorical data with more than two categories.Categorical variables are presented as numbers, and proportions and binary logistic regression analysis were used to compare categorical variables with two categories and the χp-value < 0.05 was considered significant.For continuous variables, normality of distribution was assessed with the Kolmogorov–Smirnov test. Normal and skewed continuous variables are presented as means with standard deviation and medians with interquartile range, respectively. Differences between the groups were compared using the Kruskal–Wallis test, in case of a significant difference followed by a t-test while applying a Bonferroni correction for multiple comparisons. A two-side All statistical analyses were performed using Statistical Package for Social Sciences, version 23 .A total of 157 patients were reviewed, of whom 17 were excluded because they did not fulfil the eligibility criteria. Therefore, 140 patients qualified for analysis, of whom 106 had a narrow QRS (nQRS) complex before the TAVI procedure . The basFive out of the fourteen patients with a RBBB at baseline developed a cAVB, which was persistent in two patients and required a PPI. In the nine patients with a LBBB at baseline, two patients developed a ST-RBBB, one patient changed into nQRS and one patient developed a cAVB. In the 11 patients with an IVCD before TAVI, 8 developed a LBBB, being persistent in 2 patients. These alternating types of block show severe disturbance of the distal conduction pathways during the TAVI procedure.p < 0.05). Implantation depth was approximately 2 mm more in P-LBBB patients than in the other three sub-groups, p = 0.12  (p = 0.47)), T-LBBB (12.9% vs. 21.3% (p = 0.42)) and P-LBBB (29.0% vs. 20.0% (p = 0.32)), respectively ( = 0.49) ). This w = 0.49) A,B). Furectively . Also, tectively A,B.Patients with a SE prosthesis have almost twice the risk of developing a new LBBB during TAVI deployment and at late occurrence compared to BE prostheses, with most being persistent C,D.Approximately 15% of all new LBBBs occurred ‘late’, defined as after deployment of the TAVI prosthesis but before the end of the procedure. The patients with a SE prosthesis seemed to have almost double the risk of developing such a late conduction disturbance (4/19) compared to BE prostheses (11/87) C,D.All cAVBs occurred at positioning or deployment of the BAV or TAVI prosthesis. Four PPI occurred before discharge and nine at follow-up.The present study shows the high frequency and dynamic nature of conduction disturbances developing during TAVI. In the entire cohort only 32% of patients did not develop any conduction block during the TAVI procedure, while 23% developed a persistent left bundle branch block and 3% a persistent right bundle branch block. The remaining 45% developed various forms of transient blocks. The study shows the dynamicity of development of conduction disturbances by the frequent switching between LBBB, RBBB, cAVB and nQRS during the procedure. Importantly, particular P-LBBB and ST-LBBB patients progressed into AVB, requiring PPI. Furthermore, the percentage of LBBB is similar in patients with and without BAV, suggesting that the development of BBB is  inevitable in a subpopulation of patients following TAVI procedure. This may be explained by the fact that we described that the effective distance between the aortic valve and conduction system (EDACS) predicts LBBB, which is a patient-specific anatomy .The continuous ECG monitoring in the present study has elucidated the dynamics of conduction disturbances during the TAVI procedure, as evidenced by any conduction abnormality in ~70% of patients and even alternating blocks within the same patient. Besides the previously reported T-LBBB and P-LBBB , we now Striking was also the occurrence of new RBBB, with or without alternation to LBBB or cAVB. The occurrence of RBBB has been previously reported but with very low incidence . The higAlmost a quarter of all patients developed a P-LBBB with SE prostheses being particularly prone to persistency. Follow-up of one year showed that 16.7% (4/24) of patients with P-LBBB required a PPI at follow-up. Interestingly, an even larger percentage of patients with a ST-LBBB (21.4% (6/28)) required a PPI, showing that this subgroup should receive more intensive follow-up.There is little evidence concerning the exact mechanism for the development of conduction blocks following TAVI. Apparently, no animal studies are available to formulate suitable hypotheses. Our observations may help shed some lights on potential causes for these events.Most conduction blocks developed during the actual TAVI with resolution in the majority of cases by the end of the procedure. Only a minority of blocks developed after the procedure or even days later.The rapid development of the blocks may be caused by direct physical damage or compression-induced ischemic damage to the cells of the conduction system or interstitial edema. Permanent mechanical or ischemic damage cannot recover within hours, because myocytes, which are responsible for impulse propagation, do not divide. On the other hand, temporary ischemia may be caused by initial myocardial compression and subsequent settling of the prosthesis in the aortic root. Alternatively, damage may have caused swelling of the extracellular space, which results in disruption of the gap junctions ,21,22 anThe observation that the total number of TAVI-induced LBBBs in BAV and noBAV patients was similar, suggests that there are patients who are susceptible to any manipulation at the aortic annulus, regardless of whether this is from BAV or TAVI positioning. This suggests an anatomical substrate for TAVI-induced conduction blocks. Such substrate may be related to specific anatomy of the membranous septum , pre-exiBesides the presence of a patient-specific substrate, The observation that most LBBBs and cAVBs were luxated at BAV and at positioning and deployment of the TAVI prosthesis corresponds with the findings of Nuis et al. . In addiBecause of the observational design, our study could be hampered by information and selection bias. Still, all data were prospectively collected from a consecutive series of patients and entered in a central database with established definitions.As patients undergoing TAVI are increasingly younger and fitter, not only the procedure itself with associated conduction disturbances are important to assess but also preventive  cardiovascular risk factors such as smoking on TAVI outcomes will become more important and thus advisable for future research ,32.Continuous measurement of the ECG during TAVI is useful because important conduction abnormalities such as ST-LBBB can be detected. ST-LBBB may be a warning sign for progression to cAVB at follow-up, thus warranting adequate rhythm monitoring postoperative and in the outpatient care setting. An implantable loop-recorder could be a good interim solution until further data are available for selecting the correct patients who require a pacemaker to prevent them from cAVB-caused bradycardia.This study shows the high frequency of conduction blocks developing during TAVI and their dynamic nature, with most blocks disappearing within hours. The alternating pattern between LBBB, RBBB and progression to cAVB suggests involvement of the His bundle in the pathophysiology.Important novel observations in this study were that the use of BAV does not influence the occurrence of LBBB, but that the use of SE prostheses does. Moreover, ST-LBBB is not innocent, because it has a high risk of developing cAVB, therefore, perhaps indicating the need for PPI.


Coronavirus disease COVID-19 is a viral illness, currently affecting millions of people worldwide. Pneumonia is the most common extreme presentation of COVID-19 infection, manifesting by fever, dry cough, difficulty of breathing or shortness of breath and mainly ground-glass infiltrates in radiological images. Chest computed tomography (CT) has a potential role in the diagnosis, detection of complications and prognostication of coronavirus disease COVID-19. In addition to severe respiratory manifestations, there are a wide range of neurological manifestations ranging from nonspecific symptoms to necrotizing encephalopathies and stroke. Our study aimed to review lung and neurological manifestations in recent and post-COVID-19 Egyptian patients and to be familiar with magnetic resonance imaging (MRI) findings of Neuro-COVID patients.The present study included eighty COVID-19 patients with age ranged from 28 to 78 years (mean age 57.84 + 12.58 years) who were 54 males (mean age 56.64 + 12.50) and 26 females (mean age 48.65 + 14.24). All our patients were with recent or previous history of COVID-19 infection and subjected to careful history taking, thorough clinical examination, routine laboratory investigations and CT examination. The reported lung manifestations included normal lung shadows, ground-glass opacifications (GGOs), consolidations, reticulation, reticulation and GGOs (crazy paving) and fibrotic-like changes. Out of eighty COVID-19 patients, twenty showed neurological manifestations ranging from nonspecific symptoms to necrotizing encephalopathies and stroke. Patients with neurological manifestation were in addition to CT submitted to magnetic resonance imaging (MRI) as appropriate. MRI done to neuro-COVID patients showed that 8/20 (40%) had no abnormalities and 12/20 (60%) had abnormalities. The most common abnormalities are infarction, major or lacunar infarction, followed by acute disseminated encephalomyelitis (ADEM), posterior reversible encephalopathy syndrome (PRES) and meningoencephalitis.Old age patients, especially males, were more affected than females. Lung manifestations are common in COVID-19 patients than neurological manifestations. The presence of fibrotic changes in the lung could predict severe COVID-19 affection and bad prognosis. There might be an association between appearance of neurological manifestations and poor outcome in COVID-19 patients. Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease that may cause, in addition to lung disease, a wide range of non-respiratory complications due to involvement of organs by the virus or due to direct or indirect complications of this infection .Pneumonia is the most common extreme presentation of COVID-19 infection, manifesting by fever, dry cough, difficulty of breathing and various radiological CT findings . Chest CThe most common findings in chest CT of COVID-19 patients are GGOs, appearance of crazy-paving pattern, consolidations, thickening of interlobular septa, reticular pattern, mixed pattern, air bronchogram sign and bronchiolectasis, among others .There are several mechanisms involved in COVID-19-associated CNS dysfunction, particularly activation of inflammatory and thrombotic pathways and, in a few patients, a direct viral effect on the endothelium and the parenchyma. Thrombi are a major cause of multisystem organ dysfunction, including respiratory failure as had been previously reported .Types of neurologic complications in COVID-19 patients depend on state of patients. Those with mild cases present with headache or dizziness, whereas those with severe disease can also develop an encephalopathy with agitation, confusion, impaired consciousness, seizures and signs of corticospinal tract dysfunction . IschemiThe aim of the present study is to review lung and neurological manifestations and complications associated with COVID-19 infection and analyze potential mechanisms of their damage and to be familiar with MRI findings of neuro-COVID patients.This prospective interventional study was carried out following the approval of the Research Ethical Committee, from December 2020 to April 2021, on eighty patients; age range 28–78 years with past or present history of COVID-19 infection; collected from hospitals; ICU and out-patients clinic. The inclusion criteria included confirmed COVID-19 cases with positive PCR, and patients had history of recent contact with confirmed COVID-19-infected patients. The exclusion criteria were patients with chronic thromboembolic events in chest or brain not confirmed to be COVID-19 positive and patients with previous neurocognitive disorders. All patients were subjected to careful history taking, clinical examination, routine laboratory findings, CT examination and MRI examination as well done for patients complaining of neurological manifestations (20 patients). Informed written consent was obtained from all participants that their clinical, laboratory and radiological data had to be used in the study.Demographic data , medical history of comorbid diseases  and clinical data  were collected from patients compiled and analyzed.Chest CT was performed at time of admission for patient in acute phase. Chest CT was performed on GE 128 slice machine. The scans were obtained while the patient in supine position at end of inspiration with hands raised above head and hold his breath. Chest CT was carefully examined for each patient by three expert radiologists which interpreted the images in conjunction.MRI was done using a 1.5 Tesla MR scanner . MR sequence parameters were as follows: T1-weighted images parameters; T2-weighted images parameters; and diffusion weighted images.The CT severity score index was calculated for each one of the five lung lobes, by calculation of the dissemination of the chest manifestations (opacity), ground-glass opacity (GGO), consolidation, crazy-paving pattern, septal thickening and pulmonary fibrosis. The degree of consolidation and crazy-paving pattern were highly indicators for the disease severity and the disease progression/peak as formerly reported .Ground-glass opacity (GGO) is an increase in the lung density, with still visible bronchial vascular bundles. On the other hand, consolidation is opacification with obscured underlying vasculature. Fibrosis was defined as parenchymal bands, irregular interfaces , coarse reticular pattern and traction bronchiectasis .Representing less than 5% lobar involvement.5–25% lobar involvement.26–50% lobar involvement.51–75% lobar involvement.75% lobar involvement.To quantify the extent of pulmonary abnormalities , a semi-quantitative CT score  was assiThen, the final score will be the summation of individual lobar scores and will be out of 25 ; the total lung involvement is mild ≤ 10, moderate 11–20 and severe ≥ 20.Patients especially those having severe neurological manifestations had done MRI of the brain in addition to CT of chest (20 cases).Data of the present study were described as mean ± standard deviation (SD) or number and frequency percent. All statistical operations done using SPSS 26 .The present study included 80 patients having recent or previous history of COVID-19 infection presented with respiratory and neurological symptoms. Demographic and associated comorbidities in the studied patients are recorded in Table COVID-19 is optimized to disseminate rapidly and widely , primariChest CT is an important and fast imaging tool for the diagnostic workup of infected patients. Chest CT scan can predict the severity of the disease by showing the percentage of lung involvement and thus give an idea about the prognosis of the disease. Therefore, an appropriate and optimal management would be overtaken earlier, thus decreasing patient hospitalization and mortality rate. The prevalence of chest CT abnormalities in COVID-19 is dependent on the stage and severity of the disease .The current study showed that COVID-19 infection affects old age males more than females, and this could be to the biological differences between men and women . The oldNormal chest CT findings in the present study were detected in 12 (15%) in symptomatic patients and this could be attributed to early time of examination as previously reported by Adams et al. . HoweverThe ground-glass opacities (GGOs) whether alone 30 (37.5%) or with consolidation were the most common pattern of pulmonary changes in COVID-19 patients and were seen in 48 out of 80 (60%) patients. This coincided with previous other studies, Parry et al. , Omar etConsolidation alone was found in 12 (15%) in this study; this is in comparison to the findings reported by Omer et al.  and AdnaCT in the present study showed singular or multiple irregular areas of GGO or consolidation or both in 60 of the 80 (65%) patients. This was similar to previous studies of Li and Xia , who detIn the remaining patients, reticular pattern appears in 6 (7.5%) as a complex network of linear opacities on CT images, which is caused by interlobular and intralobular septal thickening as a result of lymphocytes infiltration as previously reported . PreviouSome CT images of COVID-19 patients 10 (12.5%) showed the feature of fibrosis; in the shape of reticulations, bronchiectatic changes or even honeycomb patterns. However, appearance of fibrosis may indicate either that the pulmonary lesions have been absorbed or signify fibrous hyperplasia.Fibrotic changes are progressive and may result in irreversible interstitial lung disease, which may lead to the decline of pulmonary function, worsening of symptoms, poor quality of life and early mortality as previously reported by researchers .The COVID-19 outbreak primarily targets the respiratory epithelium but also has neuro-invasive potential. Indeed, neuropsychiatric manifestations, such as fatigue headache, dizziness and delirium, are consistently observed in COVID-19 .In the present study, headache was the most common central CNS manifestation, while smell and taste impairment were the commonest manifestations affecting the peripheral nervous system (PNS). These findings are in agreement with the study of Agarwal et al. .Brain MRI is a feasible and important imaging modality in selected patients with COVID-19 pneumonia. MRI findings of the present study showed that eight cases out of 20 patients with neurological manifestation having mild or moderate coronavirus infection were normal. Our results coincided with Paterson et al. , who shoIn the current, study 12 patients with coronavirus infection showed infarction in 7 cases (major or lacunar). The rest of cases (five) with moderate or severe acute infection had the picture of ADEM in 3 cases, one case had PRES and one case had meningoencephalitis. Such findings were similar to previous studies that showed the correlation between severity of COVID-19 infection and MRI findings of brain. Mao et al.  showed tMultiple recent reports suggest that COVID-19 is associated with acute cerebrovascular disease, including intracranial hemorrhage, large-vessel occlusion, acute ischemic stroke and dural venous sinus thrombosis .Thus, the presence of neurological complications could be a bad prognostic element in COVID-19 patients. In the present study, ADEM, PRES and meningoencephalitis were detected only in moderate or severe COVID-19 cases. Our results coincided with Khatoon et al. , who fouFurther studies needed on a large number of patients to clarify the value of chest CT for prognostication in COVID-19 and the pathogenesis and long-term prognosis of CNS involvement in patients with COVID-19, including correlation with patient outcome.Lung manifestations are common in COVID-19 patients than neurological manifestations. The presence of fibrotic changes in the lung could predict severe COVID-19 affection and bad prognosis. There might be an association between neurological manifestations and poor outcome in COVID-19 patients.


Does hydroxychloroquine or lopinavir-ritonavir, administered as a 9-day course, prevent COVID-19–associated hospitalization in patients with COVID-19?In this trial that included 685 patients, rates of COVID-19–associated hospitalization in patients treated with hydroxychloroquine or lopinavir-ritonavir were not significantly different compared with those who received placebo.These findings may inform COVID-19 treatment guidelines for outpatients with COVID-19 and demonstrate that large-scale outpatient clinical trials of repurposed drugs can be successfully completed in low-income settings during the pandemic. This randomized clinical trial examines whether hydroxychloroquine or lopinavir-ritonavir is effective for reducing hospitalization among high-risk outpatients with early symptomatic COVID-19. Data on the efficacy of hydroxychloroquine or lopinavir-ritonavir for the treatment of high-risk outpatients with COVID-19 in developing countries are needed.To determine whether hydroxychloroquine or lopinavir-ritonavir reduces hospitalization among high-risk patients with early symptomatic COVID-19 in an outpatient setting.This randomized clinical trial was conducted in Brazil. Recently symptomatic adults diagnosed with respiratory symptoms from SARS-CoV-2 infection were enrolled between June 2 and September 30, 2020. The planned sample size was 1476 patients, with interim analyses planned after 500 patients were enrolled. The trial was stopped after the interim analysis for futility with a sample size of 685 patients. Statistical analysis was performed in December 2020.Patients were randomly assigned to hydroxychloroquine , lopinavir-ritonavir , or placebo.The primary outcomes were COVID-19–associated hospitalization and death assessed at 90 days after randomization. COVID-19–associated hospitalization was analyzed with a Cox proportional hazards model. The trial included the following secondary outcomes: all-cause hospitalization, viral clearance, symptom resolution, and adverse events.Of 685 participants, 632 (92.3%) self-identified as mixed-race, 377 (55.0%) were women, and the median (range) age was 53 (18-94) years. A total of 214 participants were randomized to hydroxychloroquine; 244, lopinavir-ritonavir; and 227, placebo. At first interim analysis, the data safety monitoring board recommended stopping enrollment of both hydroxychloroquine and lopinavir-ritonavir groups because of futility. The proportion of patients hospitalized for COVID-19 was 3.7% (8 participants) in the hydroxychloroquine group, 5.7% (14 participants) in the lopinavir-ritonavir group, and 4.8% (11 participants) in the placebo group. We found no significant differences between interventions for COVID-19–associated hospitalization . At the end of the trial, there were 3 fatalities recorded, 1 in the placebo group and 2 in the lopinavir-ritonavir intervention group.In this randomized clinical trial, neither hydroxychloroquine nor lopinavir-ritonavir showed any significant benefit for decreasing COVID-19–associated hospitalization or other secondary clinical outcomes. This trial suggests that expedient clinical trials can be implemented in low-income settings even during the COVID-19 pandemic.NCT04403100ClinicalTrials.gov Identifier:  Brazil has been one of the most affected countries in the world, with more than 9.9 million infections that have caused more than 242 000 deaths.2 shown to reduce the duration of hospitalization, and dexamethasone,3 shown to reduce mortality among severely sick patients. Although these treatments have reduced morbidity and mortality among hospitalized patients with COVID-19, developing treatments to prevent disease progression and hospitalization in an outpatient setting remain key priorities during the COVID-19 pandemic.6 In comparison with patients hospitalized with COVID-19, patients with COVID-19 in an outpatient setting will likely encompass different biological responses, so pharmaceutical interventions that show no clinical benefits in hospitalized settings may show different effects.6 Discovery of effective and affordable treatments for preventing disease progression and subsequent hospitalization in outpatient settings are critical to minimizing limited hospital resources, particularly for resource-limited settings.5 Repurposing existing treatments is an appealing approach, if effective, as they may already be available with known safety profiles.Unprecedented global research efforts to find effective treatments have identified remdesivir,8 through several mechanisms, including impairment of the terminal glycosylation of the angiotensin-converting enzyme receptor 2 (ACE2), the link between the envelope spike glycoprotein and also inhibiting the function of the endolysosome.7 Lopinavir-ritonavir, an HIV aspartate protease inhibitor type 1, has been reported to have in vitro inhibitory activity against SARS-CoV,9 and also improved clinical, radiological, and pathological outcomes in a marmoset model of Middle East respiratory syndrome coronavirus infection.10 Both drugs have been widely used in the pandemic, and evidence has now accumulated that they do not play a therapeutic role in advanced disease.12Some repurposed drugs have demonstrated activity against coronaviruses in preclinical studies. Hydroxychloroquine has been reported to have in vitro activity against SARS-CoV-213 To evaluate the efficacy of hydroxychloroquine and lopinavir-ritonavir to prevent progression of COVID-19 and hospitalization among outpatients with laboratory-documented SARS-CoV-2, we conducted a randomized clinical trial in Brazil. This trial started with clinical evaluation of hydroxychloroquine and lopinavir-ritonavir using a common placebo control group. The flexible platform trial design was intended to allow for additional agents to be added and tested with standardized operating procedures outlined in a single overarching protocol called a master protocol.17Treating COVID-19 early in outpatient settings may be key to preventing progression of the disease.CONSORT Extension) (ACE) statement for reporting this trial.19The TOGETHER Trial is a randomized clinical trial to investigate the efficacy of repurposed treatments for SARS-CoV-2 infection among high-risk adult outpatients. The trial was designed and conducted in partnership with local public health authorities from 10 participating cities in Brazil. We enrolled participants starting on June 2, 2020, and concluded the trial on September 30, 2020. Informed participant consent was obtained orally by a trained member of the study staff team. The protocol was approved in compliance with the International Conference of Harmonization – Good Clinical Practices, as well as local regulatory requirements. The trial was approved for research ethics by local ethics board. The full protocol, statistical analysis plan, and additional details are listed in 3, confirmed malignant neoplasm); immunocompromised status due to medication ; and patients with cancer.This trial included participants if they were 18 years or older; reported less than 8 days since onset of flulike symptoms or chest computerized tomography scan consistent with COVID-19. Eligibility for participation also required at least one additional criterion for high risk: aged 50 years or older; presence of pulmonary disease, specifically moderate or severe persistent asthma, chronic obstructive pulmonary disease, pulmonary hypertension, or emphysema; diabetes requiring oral medication or insulin; hypertension requiring treatment; known cardiovascular diseases ; symptomatic lung disease on chronic treatment; history of transplantation; obesity ; immunocompromised status due to disease  use of any of study drugs in 30 days prior to screening; (2) clinical evidence of progression of COVID-19 ; (3) history of known life-threatening cardiac arrhythmias; (4) long QT syndrome; or (5) known allergy to study drugs.We involved the local public health authorities from participating cities in the research. This included facilitation of active partnerships with several levels of local public health structure in Brazil.We randomized patients to the hydroxychloroquine, lopinavir-ritonavir, and placebo groups at 1:1:1. Randomization was stratified by site, age (aged 50 years or older vs less than 50 years), and time of onset of flulike symptoms (at least 5 days vs less than 5 days). Patients, investigators, health care practitioners, and sponsors were masked to the study drug assignment. The randomization schedule was prepared by a masked statistician and provided to site-level pharmacists.am for 9 days. Patients assigned to lopinavir-ritonavir group received a loading dose of 800 mg of lopinavir and 200 mg of ritonavir at the first 2 intakes, followed by 400 mg of lopinavir and 100 mg of ritonavir every 12 hours for the next 9 days. Patients assigned to the placebo group received corresponding tablets of inert material . Placebo bottles were matched for the same number of tablets as active hydroxychloroquine (placebo of hydroxychloroquine) and active lopinavir-ritonavir (placebo of lopinavir-ritonavir).Patients assigned to the hydroxychloroquine group received a loading dose of 800 mg at the time of randomization and then 400 mg in daily doses at 8:00 o2) and pulse , and temperature using a standard digital oral thermometer. Mid-turbinate nasal swab kits and sterile recipient storage were provided for nasal and oral samples as previously reported.20 On day 3, 7, 10, and 14, participants were instructed to self-record and transmit ECG for immediate analysis and also to collect nasal and oral samples for RT-PCR testing. Patients were contacted on a daily basis during the study drug period for medical adherence, adverse events, vital signs, and symptoms (Wisconsin Upper Respiratory Symptom Survey [WURSS-11]),22 and on days 14, 28, 56 and 90.We presented the protocol to potential participants during phone calls at participating cities  and during medical consultation due to acute flulike symptoms. If participants agreed, we scheduled a home visit by physicians. After obtaining informed consent, the procedures for screening were performed and a swab sample was collected for SARS-CoV-2 reverse transcriptase–polymerase chain reaction (RT-PCR) testing in suspected cases and/or cases confirmed by other diagnostic methods. A randomization visit was done for patients with SARS-CoV-2–positive RT-PCR results. At the participant’s home, we performed all procedures at the same visit for patients who had already received a positive SARS-CoV-2 RT-PCR result within the last 72 hours. We assessed cardiac safety using a 6-lead electrocardiogram (ECG) (Kardiamobile), and patients with a corrected QT interval (QTc) of less than 480 milliseconds were randomized. We assessed oxygen status using a pulse oximeter for noninvasive arterial oxygen saturation . An internal control amplification, RNase P, a human gene marker, was performed to monitor RNA extraction and RT-PCR quality. Specimens were considered positive if either or both N1 and N2 targets were detected. The cycle threshold, a semiquantitative measure of viral load, was less than or equal to 38.We performed RT-PCR testing that targeted the SARS-CoV-2 nucleocapsid genes N1 and N2.Our primary outcomes were COVID-associated hospitalization and death. We assessed the primary outcomes at 90 days after randomization. Secondary end points were hospital admissions for any cause; proportion of persons with clearance of SARS-CoV-2 (defined as 1 negative swab since baseline) at day 3, 7, and 14; and treatment-emergent adverse events.All serious and nonserious adverse events were reported as per local regulatory requirements. Reportable adverse events (AEs) included serious AEs, AEs resulting in study medication discontinuation, and AEs assessed related to study medication. QTc was monitored via 6-lead ECG at prespecified days after randomization. The digital recordings were deidentified and transferred to a central facility (Cardresearch) for reading. The QT intervals were measured by a certified cardiologist using the Bazett formula with a combination of automated detection of fiducial points with manual adjustment using a novel interface that allowed review of all 6 leads separately as well as calculated median beats to minimize erroneous measurements. If QTc was greater than 500 milliseconds or greater than 60 milliseconds above the baseline reading, study medication was withheld, and the ECG was repeated. Study drugs were discontinued if a second ECG confirmed a QTc change.A sample size of 492 patients per group was chosen for each experimental group to achieve 80% power with α = .05, 2-sided type 1 error for a pairwise comparison against the control  to detect minimum treatment efficacy defined by 37.5% relative risk reduction of preventing hospitalization assuming a control event rate of 20%. According to these assumptions, 160 events per pairwise comparison would be needed: 98 controls. Although the sample size calculation was done based on a binary outcome, the protocol dictated that COVID-19 hospitalization and COVID-19–associated mortality (primary outcomes) be analyzed using time-to-event analysis  if the proportional hazards assumption was met. Otherwise, it was prespecified that these primary outcomes would be analyzed as binary.Baseline characteristics are reported as proportions or median and interquartile range (IQR) for continuous variables. The Cox proportional hazards model was used for the analysis of time-to-event outcomes of COVID-19–associated and all-cause hospitalizations for both intention-to-treat (ITT) and per-protocol (PP) analyses.For viral clearance we fitted a longitudinal, mixed-effect logistic regression model with a treatment and time interaction term for binary patient outcomes (COVID-19 positive or negative) reported on day 3, 7, and 14 from randomization, with participant random effect. PP analyses were considered sensitivity analyses to assess the robustness of the results. The criterion for statistical significance was set at α = .05. All analyses were performed using R version 3.6.3  in December 2020.A data safety monitoring board (DSMB) was instituted to provide independent oversight for the trial. An interim analysis for early stopping based on either superiority or futility was planned to be conducted with data cut from September 18, 2020. At that time, a total of 500 patients were expected to have been enrolled into the trial, with 400 patients (approximately 133 per group) having undergone adequate follow-up to observe the outcome of hospitalization.Between June 2 and October 9, 2020, 685 participants were recruited and randomized. Among these participants, 632 (92.3%) self-identified as mixed-race, 377 (55.0%) were women, and the median (range) age was 53 (18-94) years . In totaAt the end of the trial, 8 participants from the hydroxychloroquine group (3.7%) had a COVID-19–associated hospitalization, and the median (IQR) time from randomization to hospitalization was 4.8 (1.4-6.1) days; 14 participants from the lopinavir-ritonavir group (5.7%) had a COVID-19–associated hospitalization, and the median (IQR) time from randomization to hospitalization was 3.6 (2.5-4.8) days; and 11 participants from the control group (4.8%) had a COVID-19–associated hospitalization, and the median (IQR) time from randomization to hospitalization was 2.4 (0.8-3.2) days . In the In the mixed-effect logistic model, the clearance for the hydroxychloroquine  and lopinavir-ritonavir  groups did not differ in comparison with the control group . SimilarWe found no difference in the resolution of combined symptoms using the WURSS scale between either hydroxychloroquine and placebo or lopinavir-ritonavir and placebo, or for individual symptoms. For time to chest tightness symptom resolution, hydroxychloroquine had an HR of 1.39  and lopinavir-ritonavir had an HR of 0.99  based on the ITT analysis. For time to dry cough resolution, ITT analysis showed an HR of 0.86  for hydroxychloroquine and an HR of 0.76  for lopinavir-ritonavir. For time to sore throat symptom resolution, hydroxychloroquine had an HR of 1.11  and lopinavir-ritonavir had an HR of 0.88  based on ITT analysis. The PP analyses on time to symptom resolution were similar to the ITT analysis.There were 46 (22.2%) treatment-emergent adverse events in the hydroxychloroquine group, of which 11 (5.3%) were serious and 1 (0.5%) leading to discontinuation. In the lopinavir-ritonavir group, there were 92 (39.7%) treatment-emergent adverse events, of which 20 (8.6%) were serious and 0 leading to discontinuation. In the placebo group, we recorded 46 (20.9%) treatment-emergent adverse events, of which 12 were serious (5.5%) and 0 leading to discontinuation .24 The DSMB recommended discontinuing the trial as this would be clinically irrelevant for recommending either treatment.Our study discontinued the treatment groups because of a low number of events occurring among participants in each group. We conducted a sample size reestimation using bayesian predictive power based on the actual event rate occurring in our trial and detected that greater than 10 000 participants would be required to detect a statistically significant difference between groups, assuming the event rate remained constant.Our study found no significant differences among hydroxychloroquine, lopinavir-ritonavir, or placebo in COVID-19–associated hospitalizations, time to hospitalization, or time to viral clearance. For both ITT and PP analyses of these clinical outcomes for the entire trial cohort and the subgroups, no important clinical benefits of hydroxychloroquine or lopinavir-ritonavir were found. The independent DSMB, based on interim analysis results, made the decision to stop enrollment to the hydroxychloroquine and lopinavir-ritonavir groups because of a low number of emerging events. This study reports on the final results inclusive of patients who had been randomized to hydroxychloroquine or lopinavir-ritonavir between the time of data-cut for interim analysis to the time of the DSMB meeting.25 In addition, their low cost, widespread availability, and known safety profiles make these drugs ideal in the context of COVID-19. Unfortunately, no repurposed therapies have been effective in studies of moderate to severe forms of the disease, so all current efforts have been focused on evaluating these options in patients with mild, early disease, arguing that the control of viral load in this phase will minimize the development of more serious COVID-19.13 Nevertheless, this discussion went beyond the frontiers of science and acquired political and ideological contours, which brought additional difficulty in conducting these studies.26 Brazil was particularly influenced by this bias, which resulted in the dismissal of 2 ministers of health and a wide-ranging social media campaign in favor of using treatments in the early stages of COVID-19 without proper proof of its effectiveness. In this context, this trial was initiated. We decided to use an adaptive clinical trial design to provide a faster response, through a centralized randomization system, using quadruple masking, and independent data analysis, and following CONSORT recommendations for clinical trials.During this pandemic, some drugs received great interest because of preclinical studies showing a potential benefit both in controlling viral replication and in eradicating both SARS-CoV and SARS-CoV-2, including experimental models of infection. In this context, repurposed therapies appear as an important option in the context of an emerging disease with no treatment option to date and high morbidity and mortality.26 During the conduct of our trial, data emerged on the role of both hydroxychloroquine or lopinavir-ritonavir among hospitalized patients via the RECOVERY trial. For both drugs, it became clear that they did not play a role in patients with advanced disease who were hospitalized.27 Similarly, there has been no demonstrated efficacy shown for hydroxychloroquine in outpatient populations.29 There had been, however, equipoise as to whether these drugs would play a role in prophylaxis and early treatment of COVID-19 infection.30 Our study, among the largest trial of these drugs in early treatment, suggests that hydroxychloroquine and lopinavir-ritonavir do not have a role in early treatment of COVID-19.We chose to evaluate hydroxychloroquine and lopinavir-ritonavir because of the early and widescale interest in their treatment effects and their off-label use early on in the pandemic. Much has been written about the roles of these drugs in the treatment of COVID-19 and the scientific debate and political support that hydroxychloroquine, in particular, received.Our study has both strengths and limitations. Strengths include the identification and rapid recruitment of high-risk patients for developing severe COVID-19. We used a network of local primary care centers in Brazil and sought the political support of local leaders to endorse the trial and encourage the population to participate. We successfully recruited patients in the primary care settings and made home visits using appropriate personal protective equipment by physicians and medical students. We experienced low loss-to-follow up of participants in the trial. From the first patient recruited to the completion of the enrollment for active interventions of hydroxychloroquine and lopinavir-ritonavir took just 90 days. To our knowledge, in addition to ANTICOV recently launched by the Drugs for Neglected Diseases Initiatives (DNDI) for several sub-Saharan African countries to study treatments in mild-to-moderate patients with COVID-19, this trial in Brazil is one of the first large randomized clinical trials for repurposed drugs that is being conducted solely in the setting of low- and middle-income countries. Although this publication reports the clinical findings of hydroxychloroquine and lopinavir-ritonavir group in Brazil only, we had extended this trial to South Africa and a related trial in the United States. Given the DSMB decision, based on the Brazilian data confirming a lack of clinical benefits for hydroxychloroquine and lopinavir-ritonavir for outpatient treatment of patients with COVID-19, the enrollment in the United States and South Africa for these interventions has been discontinued. Other agents are rapidly being screened and developed for SARS-CoV-2 infection and can be incorporated into this master protocol for an outpatient platform trial as additional groups. The flexible platform trial design allows additional agents to be added and tested with standardized eligibility criteria, outcomes, and measurements. If an intervention is shown to be effective, this design allows the replacement of the placebo group with the effective intervention as the comparator.Limitations of our trial were predominantly related to the challenges associated with conducting a trial during a pandemic wherein the disease was not well understood. We still do not understand the best clinical outcome to evaluate in trials for early treatment and prophylaxis trials. It is possible that neither viral clearance or hospitalization are the most important outcome, and outcomes such as inflammatory response may be more important. We found a low rate of hospitalizations, even though our population had risk factors for developing serious COVID-19 and median (range) age of 53 (18-94) years. It seems likely that we do not yet understand what demographic characteristics are associated with the highest risk of developing severe COVID-19.31 As of the writing of this study, as many as 388 clinical trials have been registered evaluating hydroxychloroquine or lopinavir-ritonavir. Several early treatment and postexposure trials have been completed evaluating hydroxychloroquine and none have demonstrated important treatment effects.32 Although consensus is emerging that hydroxychloroquine and lopinavir-ritonavir do not confer any benefit for treating COVID-19, evaluating other repurposed drugs is still warranted. The ANTICOV33 and TREATNOW are 2 trials registered currently evaluating hydroxychloroquine and lopinavir-ritonavir, respectively, in outpatient populations.34 Our findings from this large trial in an outpatient population to examine the efficacy of hydroxychloroquine or lopinavir-ritonavir suggest that the trial infrastructure from those trials may be more appropriately designed to evaluate other repurposed drugs for which there is little experimental evidence to evaluate their efficacy. Our study group is now evaluating the effect of ivermectin, fluvoxamine, and metformin on COVID-19–associated hospitalizations.Repurposing existing drugs is an appealing strategy to respond to the pandemic.This randomized clinical trial found no clinical benefit to support the use of either hydroxychloroquine or lopinavir-ritonavir in an outpatient population. This adds to the growing evidence that these drugs should not be used for the treatment of COVID-19. While evidence emerges to evaluate these drugs as prophylaxis, as treatment for both outpatients and inpatients, hydroxychloroquine and lopinavir-ritonavir do not appear to confer any clinical benefit. These results might affect several countries deciding whether to continue to offer both drug regimens for ambulatory patients presenting with mild COVID-19. The successful completion of this trial also demonstrates that expedient trials of repurposed drugs can be completed in low-income settings even during a global health crisis such as the COVID-19 pandemic.


Recent clinical trials evaluating the combination of chemotherapy with immune checkpoint inhibition for the primary treatment of lung cancer showed increased progression-free and overall survival compared with chemotherapy alone. However, the combination of these two modalities is less than additive and the mechanisms of resistance to this therapeutic intervention are discussed here. So far, the conventional biomarkers for immunotherapy, namely programmed death-ligand 1 expression or tumor mutational burden are poor predictors of the efficacy of immunochemotherapy, and the optimal sequence of chemotherapy and immunotherapy has yet to be defined. The 5-year overall survival (OS) rate for non-small-cell lung cancer (NSCLC) remains poor, from 70% in patients with stage IB disease to 0-10% in patients with stage IV disease. Advances in targeted therapy and immunotherapy have resulted in a significant improvement which is, however, experienced only by a minor fraction of all lung cancer patients. The most common targets of precision cancer medicine for this tumor type are epidermal growth factor receptor mutations, which are present in 15% of patients, rearrangements in the anaplastic lymphoma kinase gene as driver for approximately 5% of patients, and ROS1 rearrangements identified in 1%-2% of patients, besides other rare mutated driver kinases amenable to treatment with specific inhibitors. Additionally, immunotherapy is now applied frequently for lung cancer patients in a primary or secondary setting, but again, marked benefits are limited to approximately 15% of patients, mostly characterized by high immune checkpoint molecule expression or elevated tumor mutational burden. Studies have demonstrated a median OS of 20.0 and 30.0 months with pembrolizumab for locally advanced/metastatic patients exhibiting programmed death-ligand 1 (PD-L1) expression equal to or exceeding 50% of tumor cells. Although targeted therapies have offered new treatment options for NSCLC patients with specific driver mutations, these therapies are not helpful in the care of patients lacking such alterations, who account for the majority of patients. Therefore, the greater fraction of the lung cancer patients has still to be treated with cytotoxic chemotherapy. Response rates and durations of chemotherapeutic regimens are rather low, and combinations with immunostimulating modalities have been implemented to improve outcomes.Lung cancer shows the highest incidence of tumor-related mortality and accounts for approximately 2 million new cases per year worldwide. The standard pemetrexed combination is better tolerated compared to the other doublets.For the majority of patients diagnosed with advanced NSCLC, cytotoxic chemotherapy still remains the standard of care. Adjuvant therapy for NSCLC consists of platinum-based drug regimens and is applied for patients with stage II and IIIA disease after surgical resection. Carboplatin or cisplatin are combined with gemcitabine, vinorelbine, or taxanes (paclitaxel or docetaxel) and these regimens result in a median OS of 10-12 months for patients with non-squamous histology. Drug resistance to platinum-based doublets can be explained by low drug influx or increased efflux through the cell membrane, lack of intracellular activation, and increased drug inactivation or detoxification. For example, platinum agents are detoxified by coupling to glutathione and excretion of the conjugates. Furthermore, the cytotoxicity of these drugs depends on the cellular ability to repair DNA damage and alteration of the apoptosis signaling cascades. In summary, the efficacy of chemotherapy in advanced NSCLC is rather low and the situation is characterized by high chemoresistance and poor OS. No predictive biomarker is currently available for classical cytotoxic chemotherapy contrary to targeted and immune therapies.Platinum-based chemotherapy accomplishes a modest extension of survival and addition of a third chemotherapeutic shows minor improvements. However, the significance of the detection of PD-L1 in cancer cells by immunohistochemical analysis as biomarker is difficult to assess due to a significant intratumor heterogeneity and the lack of consensus as to the level of PD-L1 expression that discriminates positive vs. negative immunotherapy results (ranging 1%-50% expression).The reactivation of anticancer immunity by antibodies targeting checkpoint inhibitor molecules such as PD-1/PD-L1 and CTLA4 in cancer patients has led to new therapeutic options completely replacing chemotherapy in suitable patients. Single-agent immune checkpoint inhibitors are now administered for advanced NSCLC in both first-line therapy and second-line after failure of the initial chemotherapy. Factors qualifying NSCLC patients for immunotherapy are extended disease, absence of driver mutations and higher expression levels of PD-L1. In first-line therapy, PD-L1 expression of ≥ 50% makes patients candidates for monotherapy with the anti-PD-1 antibody pembrolizumab and others. Whereas an objective response rate (ORR) of 45% is observed in PD-L1 of 50% or more, this ORR drops to 27% in patients with PD-L1 of 1% or more,9. This superiority was confirmed by a phase II and III study, demonstrating that treatment with pembrolizumab prolonged OS by 2-4 months in PD-L1-positive (TPS R 1%) NSCLC patients who progressed after platinum-based chemotherapy vs. standard-of-care treatment. Several phase II/III studies compared second-line treatment with PD-1 antibody nivolumab vs. docetaxel and reported a doubling of OS (17.0 superior to 8.0 months) in response to this immunotherapy, and similarly, atezolizumab was found to be superior to docetaxel (13.8 vs. 9.6 months) in second-line treatment. However, the population of patients achieving a marked response that might result in long-term survival was found to be limited to a minority of approximately 20%-13. Neither analysis of PD-L1 nor of tumor mutational burden constitutes perfect biomarkers for the response to immunotherapy, and positive results of immune checkpoint inhibitors may be seen in some marker-negative patients. Thus, most NSCLC cases do not benefit from immunotherapy, and for many responding patients, the effect is transitory. The mechanisms of resistance to checkpoint inhibition are multifaceted and an area of ongoing investigation.A phase I study of pembrolizumab in patients with advanced NSCLC has shown high efficacy, revealing a median OS of 22.3 months in primary patients and a median OS of 34.9 months in patients whose PD-L1 tumor proportion score (TPS) is R 50%. This combination therapy has proved to be more effective than chemotherapy alone for patients with metastatic NSCLC independently of their PD-L1 expression. The addition of pembrolizumab to the platinum doublet was not associated with increased grade 3 or 4 adverse events (AEs) compared with chemotherapy alone. Regarding immune checkpoint-directed antibodies, similar results were obtained for chemotherapy combinations employing atezolizumab or nivolumab and are to be expected for other antibodies with the same specificity.Patients with PD-L1 expression ≥ 50% are typically treated with single-agent anti-PD-1 antibody pembrolizumab but some of these patients with rapidly progressing or extensive tumors may profit from a combination of a platinum-doublet chemotherapy and pembrolizumab,15,16. The pembrolizumab antibody was administered as 200 mg intravenous infusion every three weeks. Immunochemotherapy improved 12-month OS relative to chemotherapy alone . These improvements were detectable in all PD-L1 categories, with greatest effects in PD-L1-positive tumors. PFS was also prolonged with the supplementation of pembrolizumab  corresponding with an improvement of ORR (48% vs. 19%). The rate of severe AEs (≥ grade 3) was not significantly different for the pembrolizumab-combination and placebo groups (67% vs. 66%). These results corroborated findings of the earlier phase II KEYNOTE-021 trial, which had randomized 123 stage III B or IV non-squamous NSCLC patients in a 1:1 ratio to chemotherapy with or without pembrolizumab and reported improved ORR (55% vs. 29%) and median PFS (13.0 vs. 8.9 months). Atezolizumab with carboplatin and taxane-based regimens are also appropriate and have regulatory approval in this setting as well-19.The approval of this type of chemotherapy - immunotherapy combination is based on the phase III KEYNOTE-189 trial which randomized 616 patients with advanced, PD-L1-unselected, non-squamous NSCLC in a 2:1 ratio to chemotherapy (cisplatin/carboplatin with pemetrexed) with or without pembrolizumabvs. pembrolizumab alone are lacking. Cross-trial comparisons of KEYNOTE-024 and the PD-L1-high subgroup of KEYNOTE-189 indicate comparable outcomes between pembrolizumab combination therapy and pembrolizumab alone for PD-L1-high tumors . The KEYNOTE-042 trial compared pembrolizumab monotherapy vs. platinum-based chemotherapy as first-line therapy for advanced NSCLC and a PD-L1 ≥ 1%. KEYNOTE-407 evaluated chemotherapy (carboplatin-paclitaxel-nab-paclitaxel) with or without pembrolizumab for squamous NSCLC and demonstrated significant overall and PFS improvement with immunochemotherapy. The clinical efficacy of the rechallenge with immune-checkpoint agents either as monotherapy or in combination with chemotherapy for patients having received first-line immunochemotherapy is unknown. Immunotherapy is costly and a comparison of the KEYNOTE-189 trial data between cost and quality-adjusted life years proved that immunochemotherapy is not cost-effective for the treatment of NSCLC compared with chemotherapy alone.In conclusion, the goal of combing immune-checkpoint inhibitors and chemotherapy to achieve additive or synergistic efficacy has been verified but questions remain. It is still not clear whether patients with high PD-L1 expression may benefit from immunochemotherapy since trials evaluating chemotherapy plus pembrolizumab ,24. In contrast to these opinions and expectations preclinical studies demonstrated that chemotherapeutic agents can stimulate the immune system and increase antitumor immunity as part of the potency of these drugs,26. Accordingly, early clinical investigations revealed superior antitumor activity for a combination of chemotherapy and PD-1/PD-L1-directed antibodies in first-line treatment for advanced NSCLC-30. Chemotherapy enhances antitumor immunity mainly by induction of immunogenic cell death and remodeling of the immunosuppressive tumor microenvironment. Chemotherapeutic agents that increase antitumor immune responses by various mechanisms include drugs such as cisplatin, carboplatin, taxanes and pemetrexed used in NSCLC. Chemotherapy seems to stimulate CD8+ T-cells, increase the mutational load, and the diversity of neoantigens as well as the maturation of antigen-presenting cells (APCs). Furthermore, PD-L1 expression on tumor cells becomes upregulated, and tumor antigen presentation via MHC class I is facilitated. Concurrently, immunosuppressive cells including regulatory T-cells (Tregs) and myeloid-derived suppressor cells are eliminated-36.Effects of chemotherapeutic drugs have been studied incompletely and have been regarded as mainly immunosuppressive-42. Additionally, the infiltration of T-cells into the tumor is increased by disruption of tumor stroma and normalization of the tumor vessel supply in combination with an upregulation of adhesion molecules of the tumor vasculature. T-cell cytotoxicity against tumor cells is further enhanced by increased tumor Fas expression, Th1 cytokine production and increased CTL avidity, which eventually leads to the promotion of long-term memory T cells. By these mechanisms, platinum-based chemotherapy promotes tumor-specific immunity, and the combination with immune checkpoint inhibitors may mount efficient effector T cell attacks.This removal of immunosuppressive Tregs, MDSCs and a reduction of PD-1 ligand expression results in tumor vaccination which is potentiated by the delivery of tumor antigens, upregulation of MHC I and activation of APCs. The most important reason for refractoriness to immune checkpoint therapy is the absence of tumor neoantigens that can be recognized by T cells. At a second step of anticancer immunity, suitable tumor antigens are expressed but their presentation in combination with MHC on the tumor cell surface fails due to alterations in the antigen presenting mechanism such as in proteasome subunits, transporters associated with antigen processing, beta-2-microglobulin or MHC itself. Furthermore, immune cell infiltration or function within the tumor microenvironment is prevented by increased PI3K signaling, expression of the WNT/β-catenin signaling pathway and the loss of interferon-γ signaling.Despite the unique long-lasting response with checkpoint inhibitors, the majority of patients do not benefit due to primary resistance or relapse after an initial response, showing acquired resistance. Low expression of neoantigens, impaired antigen presentation, deficient interferon-γ signaling, and T cell exclusion as well are designated as tumor cell-intrinsic resistance factors. Tumor cell-extrinsic factors comprise inhibitory checkpoint molecules different from PD-1/PD-L1, immunosuppression by MDSCs and Tregs as well as deficient specific antitumor T cell responses,44. Still, the actual mechanisms of resistance to immunochemotherapy need to be studied in vivo in patients to identify the most important underlying cellular events. Such an investigation has to involve the assessment of longitudinal tumor samples throughout the course of treatment. Key findings in a recent report assessing immune markers in longitudinal biopsies demonstrated the importance of markers in early on-treatment samples and the non-predictive results of pre-treatment specimens. Assessment of the markers of immune system activation should be supplemented by analysis of tumor cell death, activation of DNA damage response and tumor cell signaling pathways, employing successive biopsies.For immunochemotherapy, the prerequisite for mounting an efficient anticancer immune attack may be a certain degree of tumor cell damage and the expression or release of neoantigens into the circulation. At present, it is not clear whether direct chemotherapy-triggered effects on tumor cells and an increase of neoantigens or indirect effects on the immune system such as elimination of immunosuppressive cell populations are the decisive mechanisms of immunochemotherapyP = 0.0007) and 0.62 (P = 0.00001) in favor of the combination treatment. Similarly, a meta-analysis based on 12 phase III studies with 9236 metastatic NSCLC patients reported a consistently higher efficacy of the combination of chemotherapy with either pembrolizumab or atezolizumab compared to chemotherapy alone. Although checkpoint inhibitors plus chemotherapy were found to be correlated with prolonged OS, compared with chemotherapy alone  in an analysis comprising 2978 NSCLC patients, significant heterogeneity was revealed between trials and according to the specific checkpoint inhibitor applied and the degree of PD-1/PD-L1 expression.Nevertheless, the significant clinical activity of immunochemotherapy has been documented by several meta-analyses. For example, a study covering a total of 4322 patients with advanced metastatic NSCLC who were treated with immune checkpoint inhibitors in combination with chemotherapy for first-line treatment or chemotherapy alone showed pooled HRs for OS and PFS of 0.74  have recently revolutionized cancer treatment, providing unprecedented clinical benefits, but therapy resistance can affect up to two-thirds of patients receiving ICIs. Conventional cancer treatments, including cytotoxic chemotherapy, radiation therapy, and targeted therapy, have immunomodulatory effects in addition to direct cancer cell-killing activities.Conventional cytotoxic cancer chemotherapy is often immunosuppressive and associated with drug resistance and tumor regrowth after a short period of tumor shrinkage. The frontline ICI phase II/III trials in advanced NSCLC were checked for ORRs and AEs of combinations and of individual drugs. The calculations suggest an enhanced efficacy that is less than additive for the immunochemotherapy combinations since the actual ORR and AE were less than the expected additive effect. The interplay between chemotherapy and immunotherapy is unclear which impedes the design of an optimal combination strategy. Each chemotherapy agent has unique effects on tumor cells and immune responses at different time schedules and the antitumor efficacy depends on the appropriate combination as well as the sequence and scheduling of the immunochemotherapeutic regimen. To date, chemotherapy and immunotherapy are administered concurrently in most clinical trials disregarding the impact of sequencing on antitumor immunity. Since chemotherapy can cause immunogenic cell death that induces T cell priming, the maximal efficacy of immunotherapy should be expected after prior chemotherapy.The interaction of chemotherapy and immune checkpoint inhibitors has been tested for formal criteria of synergism,58. In this phased regimen, paclitaxel/carboplatin alone was administered followed by ipilimumab/paclitaxel/carboplatin, which causes the release of neoantigens to precede ipilimumab exposure. In contrast, concurrent treatment with ipilimumab and chemotherapy was superior to sequential therapy in a mesothelioma model. However, in cases of lung cancer and melanoma, chemotherapy administered after immunotherapy achieved successful clinical responses,60. The ORR for chemotherapy administered after immunotherapy in NSCLC was significantly higher than that for chemotherapy before immunotherapy (53.4% vs. 34.9%). These findings point to the sensitization of tumors by anti-PD-1/PD-L1 inhibitors to a subsequent chemotherapy. For two cases of nivolumab-refractory lung cancer, subsequent chemotherapy achieved rapid regression. Concerning immunochemotherapy, inhibition of PD-1 on CD8+-tumor-infiltrating lymphocytes restored cytokine secretion and T cell proliferation and rendered tumor cells more sensitive to chemotherapy.Preclinical and clinical studies showed controversial results with respect to the sequence of chemoimmunotherapy. In a phase II study investigating carboplatin/paclitaxel in combination with concurrent or sequenced ipilimumab in small-cell lung cancer (SCLC), sequenced treatment was associated with improved PFS. Responding patients exhibited a novel subset of CD8+ T cells (CX3CR1+) that survive chemotherapy with intact CTL functions. This subset of effector T cells shows low proliferation and the ability to efflux chemotherapy drugs via the ABCB1 transporter and may be used as a biomarker in monitoring and predicting clinical response to chemoimmunotherapy. The scheduling and timing of chemotherapy in CIT are also critical for achieving clinical success. Some chemotherapy drugs work in a cell cycle-specific manner, suggesting that their direct tumor-killing activities and immunomodulatory effects can be influenced by the schedule of drug administration,65. However, these results are based on retrospective findings on small and highly selected patient populations. More investigations are needed to define the optimal sequencing of standard chemotherapy and PD-1/PD-L1 inhibitors,67.In metastatic melanoma patients who progressed after anti-PD1 monotherapy, immunochemotherapy induced a marked clinical response, with an ORR of 65% and a CR of 25%. Those with higher PD-L1 TPS will experience higher toxicity due to chemotherapy, which is about twice as profound as under immunotherapy alone, and patients with lower PD-L1 expression having combination treatment may receive costly and unnecessary immunotherapy. Single-agent pembrolizumab treatment is the standard first-line therapy for patients with PD-L1 ≥ 50, but immunochemotherapy for unselected patients should be replaced by precision medicine decision provided predictive biomarkers are identified.The approach of providing immunochemotherapy to every patient may not necessarily be an ideal solution


Patients with COVID-19 have similar thrombin potential on admission compared to those with non-COVID-19 pneumonia. In younger COVID-19 patients, lower ETP levels were associated with a higher risk of both MACE and bleeding.Patients with Coronavirus Disease-2019 (COVID‐19) have haemostatic dysfunction and are at higher risk of thrombotic complications. Although age is a major risk factor for outcome impairment in COVID-19, its impact on coagulative patterns here is still unclear. We investigated the association of Endogenous Thrombin Potential (ETP) with thrombotic and haemorrhagic events according to different ages in patients admitted for COVID-19. A total of 27 patients with COVID‐19-related pneumonia, without need for intensive care unit admission or mechanical ventilation at hospital presentation, and 24 controls with non-COVID-19 pneumonia were prospectively included. ETP levels were measured on admission. Patients were evaluated for major adverse cardiovascular events  and bleeding complications [according to Bleeding Academic Research Consortium (BARC) definition] during in-hospital stay. COVID-19 patients had similar ETP levels compared to controls . In the COVID-19 cohort, patients with in-hospital MACE showed lower ETP levels on admission vs those without , whereas ETP values were comparable in patients with or without bleeding . An interaction between age and ETP levels for both MACE and bleeding complications was observed, where a younger age was associated with an inverse relationship between ETP values and adverse event risk (pThe online version contains supplementary material available at 10.1007/s11239-021-02497-1. Coronavirus Disease-2019 (COVID-19) has haemostatic dysfunction and age is a major risk factor for adverse outcomeEndogenous thrombin potential levels and thrombotic/haemorrhagic events were evaluated according to different ages in patients admitted for COVID-19Patients with Coronavirus Disease-2019 have similar thrombin potential on admission compared to those with non-COVID-19 pneumonia.In younger COVID-19 patients, lower endogenous thrombin potential levels were associated with a higher risk of both thrombosis and bleeding.In patients with COVID-19 the risk of both thrombotic and haemorrhagic events needs to be differentially evaluated according with age and endogenous thrombin potential levels.Coronavirus Disease-2019 (COVID-19), caused by Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) infection, was first reported in December 2019 in China . In partAim of this study was to investigate the association of haemostatic capacity  on admission with early thrombotic and haemorrhagic complications according to different ages in patients hospitalized for COVID-19.This is a single-centre, observational, prospective study. Consecutive patients aged > 18 years with pneumonia due to SARS-CoV-2 infection requiring hospital admission in our Institution  from February 20th to May 29th, 2020 were included. All patients had a nasopharyngeal swab tested positive for molecular detection of SARS-CoV-2 RNA by reverse-transcriptase–polymerase-chain-reaction assay. To avoid any inclusion bias, after evaluation in the Emergency Room, all consecutive patients admitted to low-intensity or medium-intensity COVID-19 wards were enrolled. Patients were included regardless of clinical features at presentation and in-hospital therapies for COVID-19. Patients requiring mechanical ventilation or intensive care unit at hospital presentation were excluded. A consecutive cohort of patients hospitalized during the same time-frame because of infective pneumonia unrelated to SARS-CoV-2 aetiology and no need for intensive care unit at hospital presentation represented the control group. The Institutional Review Board approved the study protocol (IRB code CE 97/20), which was conducted according to the Declaration of Helsinki principles.2) over inspiratory oxygen fraction (FIO2) ≤ 100 mmHg [We identified eligible patients from hospital administrative data. An electronic case report form was generated, where individual data obtained after daily revision of the clinical records were entered. The data entry was prospectively performed by investigators involved in the patient’s management. A unique pseudonymized code was assigned to each patient. Data including demographic variables, clinical characteristics, medical history, vital signs on admission, laboratory data, medical treatments and clinical events during the hospitalization were collected in all patients. For the purpose of this study, the following in-hospital events were specifically considered: major adverse cardiovascular events (MACE), including cardiovascular death, acute myocardial infarction  , stroke,All patients underwent arterial and venous blood sampling upon admission (before starting any anticoagulant treatment). PaO2 was measured in the arterial samples and the following parameters were measured in the venous samples: (a) blood cell count by Sysmex XN-2000™ Hematology System ; (b) prothrombin time (PT) and activated partial thromboplastin time (aPTT) by BCS XP ; (c) fibrinogen levels, by Clauss method on BCS XP ; (d) D-dimer levels, by an immuno-turbidimetric assay for the quantitative determination of cross-linked fibrin degradation products in human plasma, performed on BCS XP ; (e) global haemostasis function, by INNOVANCE® ETP test, assessing the ETP of a plasma sample performed on BCS XP  (see below).Global haemostasis function was assessed by ETP, which was measured in platelet-poor plasma using a commercially available assay . Coagulation activation was initiated by incubation of plasma with phospholipids, human recombinant tissue factor  and calcium ions in the absence of thrombomodulin. Thrombin generation and subsequent inactivation was recorded by monitoring conversion of a specific slow reacting chromogenic substrate at a wavelength of 405 nm over time. Fibrin aggregation inhibitor prevents the interference of fibrin with the optical detection of the chromophore. A mathematical algorithm was applied to correct the substrate conversion curve. Therefore, the activity of α2-macroglobulin bound thrombin, which has no known biological activity, but is still capable of cleaving small chromogenic substrates, was subtracted from the substrate conversion curve. The corrected reaction curve corresponds to the activity of free thrombin.Formation of the first derivative of the corrected substrate conversion curve corresponds to the thrombin generation curve. The ETP value was calculated as area under the thrombin generation curve (AUC TG) Fig. . Lag timStudy endpoints were the following: (a) to compare ETP levels on admission in COVID-19 patients vs controls; (b) to assess the association between ETP levels on admission and occurrence of in-hospital thrombotic events (MACE) and bleeding complications in the overall population and according to different ages; (c) to evaluate the incidence of adverse events in COVID-19 patients vs controls.t test or Mann–Whitney U test, as appropriate, and proportions by chi-squared test. An interaction test was performed to evaluate the effect of ETP values on adverse outcome (MACE and any bleeding) across different ages by graphing a logit model of age and ETP, as independent variables, and MACE (or bleeding) as dependent variable. Age and ETP values were modelled as continuous variables. Models for the relationship between ETP and outcomes (MACE or bleeding) were plotted at different point values of age . The analysis was performed by Stata using the command “mfpigen and fplot”.The sample size was not hypothesis-driven, due to the observational nature of the study and the lack of previous specific investigations on the topic. We arbitrarily chose a sample size of at least 50 patients as the minimum number required to provide informative results. Continuous data are reported as mean ± standard deviation, if normally distributed, or median (interquartile range), if not normally distributed, whereas categorical variables are indicated as number (percentage). For the analysis on study parameters in COVID-19 patients vs controls, as well as in patients with vs without adverse events, continuous variables were compared by Student Pseudomonas aeruginosa, 3 Staphylococcus aureus, 1 Staphylococcus epidermidis, 1 Klebsiella pneumoniae, and 1 Staphylococcus hominis). Demographic characteristics, comorbidities and medical treatments were similar in COVID-19 patients and controls; regarding laboratory data, lymphocytes count was significantly lower, whereas aPTT and D-dimer levels tended to be higher in the former  during the hospitalization showed higher D-dimer levels on admission , lower ETP levels  and lower C max  vs those without . Conversely, no relationship between MACE logit function and ETP values was estimated in patients with age 85 years   Fig.  and no iIn this prospective study on a consecutive cohort of patients hospitalized for COVID-19, we found an interaction between age and ETP levels on admission for both in-hospital MACE and bleeding complications. In particular, in younger patients there was an inverse relationship between ETP values and adverse outcome . Notably, if ETP levels were reduced, the estimated risks of MACE and bleeding in patients aged 65 years were 10-fold and 6-fold higher, respectively, than in those aged 85 years. Moreover, in patients aged 65 years having the lowest ETP values, there was an estimated 100-fold increase in both MACE and bleeding vs those with similar age, but highest ETP levels. Importantly, such age-dependent pattern was not observed in patients with pneumonia unrelated to SARS-CoV-2 infection.Several reports have described an increased occurrence of arterial and venous thrombotic complications in COVID-19, either macrovascular and microvascular –14. SuchVarious investigations have evaluated age-related variations of coagulative parameters in healthy individuals. In particular, previous studies demonstrated a direct relationship between ETP values and aging, with such evidence pleading age-adjusted range values . SimilarBesides thrombotic events, bleeding is also a relevant cause of morbidity in patients hospitalized for COVID-19 . NotablyLastly, the results of the present study support an unbalanced coagulation equilibrium towards both thrombosis and bleeding with increased thrombin consumption in COVID-19. This is confirmed by the fact that 2/3 of patients with in-hospital MACE had also a bleeding event. Indeed, a similar haemostatic unbalance (with reduced ETP levels) has been described in patients with disseminated intravascular coagulation, where the consumption of coagulation factors exceeds the liver synthesis and is associated with both thrombotic and haemorrhagic complications .Our investigation has to be considered in light of its limitations. Data collection on medical history and comorbidities was mainly based on patients' reports and therefore is potentially biased. A gap between in vitro and in vivo ETP measurement may exist , as in vIn conclusion, the present study indicates that the risk of both early thrombotic and haemorrhagic events is increased in younger patients with low ETP levels on admission for COVID-19. This pattern was not present in patients with non-SARS-CoV-2 pneumonia. These findings may have implications for the management of COVID-19 patients. According to our data, younger patients with low ETP values should receive during hospitalization a strict surveillance and a close monitoring for changes in clinical features and for abnormalities of coagulative parameters  to prevent and early diagnosing serious adverse events . HoweverSupplementary file1 (DOCX 28 kb)Below is the link to the electronic supplementary material.


Many issues need to be studied regarding pregnant women during the SARS-CoV-2 (COVID-19) infection pandemic. The aim of this study was to assess fetal growth, fetal well-being, and any observed gross anomalies that may follow SARS-CoV-2 infection in Egyptian pregnant women. During fetal anomaly scan at 22 weeks, we compared 30 pregnant women with a history of SARS-CoV-2 infection at 6‑12 weeks of gestation (group A) with 60 pregnant women (group B) who had no history of SARS-CoV-2. Then, we followed them on 28 and 34 weeks of gestation with fetal biometry and Doppler study.Our results revealed no significant difference between both groups regarding fetal biometry, estimated fetal weight, amniotic fluid index, Doppler scan, and gross anomaly scan throughout all visits.According to the results of our pilot study, SARS-CoV-2 infection in pregnancy was not found to increase the risk of fetal growth restriction or possible fetal gross anomalies. Nevertheless, larger-scale studies are needed to confirm those findings. Perhaps, post-SARS-CoV-2 infection pregnancies may run an uncomplicated course regarding fetal parameters. By the end of 2019, four cases of pneumonia of unknown etiology were reported to World Health Organization (WHO). Wuhan, China, was the first affected place worldwide by the SARS-CoV-2 infection [SARS-CoV-2 is a capsulated single-stranded RNA virus . The knoFever, cough, lymphopenia, and elevated C-reactive protein levels are the main diagnostic signs of SARS-CoV-2 infection in pregnancy . There aA higher rate of thromboembolic complications was observed in SARS-CoV-2 infection cases in the general population. Therefore, the activation of coagulation pathways followed by the possibility of developing vascular coagulopathy (DIC) as well as thrombocytopenia could be the most compelling explanation till now .Pregnancy being known as a hypercoagulable state that is characterized by an increase in thrombin production and an increase in intravascular inflammation. The higher levels of coagulation and fibrinolytic factors, as plasmin, that are circulating in the blood of pregnant women may play a role in the pathogenesis of SARS-CoV-2 infection among pregnant women . MortaliPathological examination of the placentae from SARS-CoV-2 women had shown frequently increased fibrinoid deposition, enhanced inflammation, or maternal vascular malperfusion (MVM), including thrombi. All these findings are indicators for placental injury, which in turn lead to fetal distress with possible newborn long-term effects. Pathologic maternal blood flow due to MVM can lead to abnormal oxygenation with the possibility of adverse fetal outcomes like fetal demise . Althougn = 30), and were compared to other 60 pregnant women with no history of SARS-CoV-2 infection during their first-trimester group B (n = 60). All participants were recruited from the antenatal outpatient clinics in the Medical Research Centre of Excellence , Faculty of Medicine (Al-Azhar University), over a period of 8 months from August 2020 till March 2021. Ethical approval was taken from the ethical committee, Faculty of Medicine, Al-Azhar University (no. 00000430), before starting the study. Written consent was taken from all participated women in the study after a proper explanation of the aim and design of the study.This pilot case-control study was carried out on 30 pregnant women between 22 and 34 weeks of pregnancy who had positive PCR nasopharyngeal swab for SARS-CoV-2 infection between 6 and 12 weeks of pregnancy, followed by a negative swab to confirm recovery. They were assigned to group A, the study group  and followed up at 28 and 34 weeks by ultrasound and Doppler study to monitor fetal growth, amniotic fluid, and fetal blood supply through measuring umbilical blood flow  and evaluation of diastolic flow, measuring middle cerebral artery (MCA) flow and ductus venosus, if there was any growth restriction noted during flow up.Also, a routine obstetric antenatal assessment was done in each visit for all women: measuring blood pressure, pulse, respiratory rate, weight, general examination, and abdominal examination. Obstetric examination was done to assess fundal level in correlation to the last menstrual period. Routine antenatal laboratory investigations were done as scheduled.Biparietal diameter (BPD): Caliper placement using outer edge to inner edge, at the widest part of the skull, using an angle perpendicular to the midline falx.Head circumference (HC): Caliper placed around the outside of the fetal skull bone echoes by using an ellipse.Abdominal circumference (AC): Caliper placed at the outer surface of the skin line and two linear perpendicular measurements, usually the anteroposterior abdominal diameter (APAD) and transverse abdominal diameter (TAD) taken.Femur diaphysis length (FDL): Caliper placed at the ends of the ossified diaphysis without including the distal femoral epiphysis if visible.Uterine artery Doppler technique: Transabdominally, the probe was placed longitudinally in the lower lateral quadrant of the abdomen, angled medially. Color flow mapping was helpful to identify the uterine artery as it was seen crossing the external iliac artery. The sample volume is placed 1 cm downstream from this crossover point.Umbilical artery Doppler: A free-floating cord was determined, and the sample gate volume was placed over it, measuring 1 cm (two-third over the artery and one-third over the vein). The angle between the ultrasound beam and the direction of blood flow was kept as close as possible to 0°. Measuring 3‑6 waves in the image with avoiding any fetal movements or breathing movements during measurements.The fetal anomaly scan and Doppler studies at 22 weeks were done for all patients by a professional fetal medicine consultant using ultrasound machine GE Voluson P8 with RAB 2-6 RS Real-time convex transducer 2–5 MHZ . According to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) Guidelines in 2010, the following sonographic parameters were used to estimate fetal weight and size: biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL), where we used the Astraia software  for data entry and reporting.t test), while categorical data differences were compared by the Chi-square test. For all statistical tests, p values were considered statistically significant if less than 0.05.Statistical analyses were performed using the SPSS software . The distribution of the measured variables was determined using the Shapiro test. Normally distributed variables were presented as means ± standard deviation , who had a history of confirmed SARS-CoV-2 infection during their first trimester, were compared with those in group B (n = 60) who had no history of SARS-CoV-2 infection. When comparing the demographic characteristics for both groups, including age (p = 0.825), BMI (p = 0.659), parity (p = 0.865), no significant differences were detected , estimated fetal weight (EFW), no significant difference was found. In addition, the same insignificant values were found between both groups regarding uterine artery Doppler scan (mean uterine artery PI), amniotic fluid had done at 22 weeks  in group B. When ultrasound was done to all cases at 34 weeks, a case in group A had a fetus showed an estimated fetal weight on the 3rd centile, BPD on the 15th centile, and AFI of 5 with preserved normal Doppler parameters, picture suggestive of asymmetrical fetal growth retardation. The woman in group B, who had been diagnosed with polyhydramnios at 28 weeks, continued to have the same picture at 34 weeks ultrasound. Her investigations were all normal (idiopathic polyhydramnios). Another two cases in the same group showed an ultrasound picture of oligohydramnios, AFI < 5th percentile for age, with preserved normal fetal growth pattern. One of them was diagnosed with a confirmed rupture of membranes, temperature monitoring, and investigations  and then was managed accordingly. In the other case, we did not find an explanation for the decreased amniotic fluid (idiopathic oligohydramnios).Accordingly, there was no statistically significant difference between both groups regarding the fetal biometry , estimated fetal weight, uterine Doppler (mean uterine artery PI), amniotic fluid index, gross anomalies, and the umbilical artery PI Tables , 4.Tabl. As SARS-CoV-2 is still a new disease with limited experience worldwide, it is still early to draw evidence about an increased risk of severe consequences of SARS-CoV-2 infection on pregnant women.Since there is no clear evidence to confirm or rule out an association between ethnicity and outcome in SARS-CoV-2 , every cThis pilot study was done to address possible consequences of post-COVID infection on fetuses of 30 Egyptian women who had been infected with SARS-CoV-2 infection between 6 to 12 weeks of pregnancy. After confirmation of their recovery by negative PCR test, anomaly scan was done at 22 weeks, and antenatal follow-up with repeated growth scans and Doppler were done sequentially at 28 and 34 weeks. After analyzing our results, we found that both groups were comparable in all parameters studied with no significant findings.At the 22 weeks ultrasound, only one case in group A was found to have an echogenic focus in the left ventricle, which could be considered a normal variant. An isolated echogenic focus in the fetal heart at mid-trimester ultrasound scan in women aged 18–34 years is not associated with increased risk for trisomy 21 . Cosma’sWhen we monitored all the women in both groups regarding growth parameters and Doppler studies at 22, 28, and 34 weeks, we observed that pregnancies complicated by SARS-CoV-2 infection had no significant change in fetal growth parameter, velocity, and fetal Doppler compared to pregnancies not complicated SARS-CoV-2 infection. American research that addressed this issue very close to our goal was published early this year. They concentrated on fetal growth and hemodynamics. After studying 49 cases complicated by mild SARS-CoV-2 infection and a 98 case not complicated with the viral infection, in agreement with our study, they did not find any significant difference between post viral infection group and the control group [p < 0.05). Although the pathophysiology of SARS-CoV-2 infection in pregnancy has not been absolutely clear, they considered that third-trimester uterine artery measurement with biometric measures is enough to predict the risk of late-onset fetal growth restriction and stillbirth. However, they only found one case of intrauterine growth restriction in the study group [. These controversial results could be due to the difference in the degree of infection included as they include severe cases in their study. In our opinion, severe cases have different factors that may affect the study results as the severe form of the disease is associated with secondary infections and different organ function affection, which in turn can mislead the results.On the contrary, Anuk and his team found that the PI and RI of uterine and umbilical artery increased significantly in pregnant women in the SARS-CoV-2 infection group compared to the control group  and oligohydramnios (AFI = 5) with normal Doppler parameters. However, this might have been related to a history of previous preterm delivery with fetal growth restriction in her first pregnancy.Most of the researchers that found intrauterine growth restriction was between case reports and studies that recommend larger sample size studies , 25, whi.Although some papers talked about maternal-fetal placenta perfusion affection, they could not confirm fetal growth restriction . A higheWe searched in the literature, and we found that, in Egypt, a very limited number of studies had been done on the possible detrimental effects of SARS-CoV-2 on fetuses when infection acquired during early pregnancy. Thus, we hope that this pilot study will be a cornerstone for further larger multi-centric studies.Despite that, we have some limitations in our study; the short follow-up period and failure to complete the antenatal care after 34 weeks until the delivery date was one of our limitations in the study, which could lead to underestimation of risk fetal growth restriction. The socioeconomic characteristics and psychological stress during pregnancy can affect our results. We found great difficulty in collecting cases included in the study group due to the poor registry system for cases of SARS-CoV-2 infection, especially mild and moderate cases, as they usually received their medical care at home. We included only patients with the laboratory-confirmed positive qRT-PCR assay. However, the viral nucleic acid test has a false-negative rate of up to 30% .It is difficult to draw conclusions from a small-scale pilot study. However, our results found out that SARS-CoV-2 infection during early pregnancy did not have an impact on gross anomalies or fetal growth. In turn, SARS-CoV-2 infection during early pregnancy may not pose a risk on fetal intrauterine well-being. The impact of SARS-CoV-2 in pregnancy remains to be determined, and a concerted, global effort is required to determine the effects on implantation, fetal growth and development, labor, and neonatal health.