The COVID-19 pandemic accelerated the development of decentralized clinical trials (DCT). DCT’s are an important and pragmatic method for assessing health outcomes yet comprise only a minority of clinical trials, and few published methodologies exist. In this report, we detail the operational components of COVID-OUT, a decentralized, multicenter, quadruple-blinded, randomized trial that rapidly delivered study drugs nation-wide. The trial examined three medications  as outpatient treatment of SARS-CoV-2 for their effectiveness in preventing severe or long COVID-19. Decentralized strategies included HIPAA-compliant electronic screening and consenting, prepacking investigational product to accelerate delivery after randomization, and remotely confirming participant-reported outcomes. Of the 1417 individuals with the intention-to-treat sample, the remote nature of the study caused an additional 94 participants to not take any doses of study drug. Therefore, 1323 participants were in the modified intention-to-treat sample, which was the a priori primary study sample. Only 1.4% of participants were lost to follow-up. Decentralized strategies facilitated the successful completion of the COVID-OUT trial without any in-person contact by expediting intervention delivery, expanding trial access geographically, limiting contagion exposure, and making it easy for participants to complete follow-up visits. Remotely completed consent and follow-up facilitated enrollment. The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic necessitated urgent identification of effective treatments. The need to keep participants and researchers safe made conducting clinical trials challenging. In April 2020, approximately 1,000 organizations reported delays or disruptions of existing clinical trials [The COVID-OUT trial is an example of a decentralized, quadruple-blinded, placebo-controlled, randomized controlled trial that allowed for rapid delivery of study materials to participants nationwide. The trial examined three medications  as outpatient treatment for preventing progression to severe COVID-19 or long COVID in non-hospitalized adults with documented early infection. In this trial, the loss to follow-up was minimal. Metformin demonstrated meaningful clinical outcomes, and ivermectin and fluvoxamine did not ,4. COVIDIn the COVID-OUT trial, decentralized strategies facilitated coordination among six institutions, expedited medication initiation, allowed collection of multiple data points without on-site interaction, and expanded the geographic radius from which participants could enroll. Made possible by multiple streams of coordination by the lead site, the COVID-OUT trial incorporated electronic screening and consenting platforms, overnight or same-day courier services for medication delivery, and virtual follow-up by research coordinators Table . We beliAs evidenced by multiple recent COVID-19 clinical trials –7, virtuThis trial was a phase 3, randomized, placebo-controlled trial that employed a 2-by-3 factorial design of parallel, distinct treatments. Because groups 1 and 2 had two active drugs, all participants received 2 types of pills to maintain the blind  was available to participants who elected to self-screen online by self-reported responses to eligibility questions. Most participants were screened over the phone while a research coordinator entered eligibility information into the REDCap database. Patients submitted documentation of a positive SARS-CoV-2 result through secure email or directly onto the secure REDCap screening form. Patients could be randomized before sending confirmation of a positive result, but they were encouraged to send it immediately, before randomization. Failure to provide documentation of a positive SARS-CoV-2 result meant they were ineligible. Preexisting medical conditions and home medications were recorded in the study database at baseline.Because metformin use is cautioned with a glomerular filtration rate (GFR) < 30ml/min, serum creatinine was assessed in persons at high risk for decreased GFR: age > = 75 or a history of chronic kidney, heart, or liver failure. If serum creatinine (sCR) was not available in the electronic health record (I) within 2 weeks, blood collection was required. Patients could choose in-person collection or self-collect blood samples that were returned to the lab via overnight FedEx. Study medications could be delivered and initiated while sCr results were pending; few days of metformin carries minimal risk in an individual with a GFR < 45. If the GFR returned as < 45 ml/min, participants were not eligible and instructed to discontinue and return study drugs via prepaid materials. By being proactive, study medication could be delivered as soon as possible to the maximum number of participants. In total, 14 (1%) participants who were randomized were then withdrawn based on the above operational criteria. The study team felt this was an acceptable amount of forgone cost to allow faster delivery of study medication to all potential participants.REDCap made it possible to complete eConsent that was compliant with FDA 21 CFR Part 11 for electronic signature capture. The eConsent document with the full consent text was sent to potential participants through REDCap and trained study staff assessed consent comprehension questions over the phone. Individuals could also self-consent online if they successfully read through short sections of the consent document followed by comprehension questions. Potential participants using the self-consent could also elect to have a consent conversation with a research coordinator over the phone at any time.After consent, a HIPAA-compliant email was immediately sent to onsite study personnel with participant weight, address, age, and pregnancy status. Weight and pregnancy/ lactational status were necessary because ivermectin was weight-based, and the ivermectin and fluvoxamine arms were not open for pregnant individuals. The research team assured that at least one research coordinator, and not more than two to limit COVID exposure, was on-site daily to then randomize participants to a treatment arm using a preprogramed randomization app.Because two study arms included two active medications, all participants received two types of pills to maintain blinding. All participants received metformin or metformin placebo, and then a subset received ivermectin or fluvoxamine or their exact matching placebos. Ivermectin was weight-based, so each dose required between 2 and 4 pills. To ensure that participants took the right number of pills, study medications were dispensed by the pharmacy team into 2-week pillboxes. Distinct blinded study packs were created for pregnant and lactating women containing only metformin or placebo.Due to operating hours, a new participant needed to be randomized before 3:30 pm for the investigational pharmacy to individually dispense the participant’s study drug the same day. However, most enrollments were after 3:30 pm. To ensure that the study medication was sent to the patient on the day of consent, the study pillboxes were pre-packed by the pharmacy with individual packet ID’s. The pillboxes were stored in the research team’s dedicated, locked office area. When a research coordinator randomized a new patient, the randomization app assigned one of the individual packet ID’s to the new participant ID (PID). The research coordinator then entered the individual packet ID with the PID, participant name, and DOB, into the paper drug accountability log.Research coordinators then put the study drug into study kits with the other materials  and applied a FedEx label addressed to the participant’s home. Every evening a study team member took the kits for participants enrolled that day to the FedEx at the airport. The airport FedEx was open until 8:15 pm each night, and everything that arrived there by 8:15pm was guaranteed to be delivered the next day via FedEx overnight shipping. To alleviate the burden on study team members so they could focus on follow-up with participants, a certified medical courier was contracted to arrive at the research building daily at 7:45 pm and make a direct route to the airport FedEx. The study team received an email alert from FedEx when each study kit was scanned at FedEx.Thus, prepacking and distribution by the study team meant that every participant enrolled before 7:45 pm, rather than 3:30 pm, would receive study drugs the next day, nationwide. Participants who enrolled within a 4-hour radius of the 6 participating institutions received study drugs the same day via same-day courier. The independent external study monitor conducted both remote and in-person monitoring to review the paper drug accountability log.The materials were packaged into cardboard boxes containing a daily symptom log, ClinCard  for compEach study kit contained a paper symptom log with prompts for participants to record their COVID-related symptoms on a 4-point scale . ParticiThe symptom log included pictorial instructions for nasal and blood specimen collection. Patients who collected SARS-CoV-2 PCR nasal swabs on Days 1, 5, and 10 or self-collected a finger prick GFR blood test could request help from research coordinators over the phone or by secure video. For optional stool samples, each microbiome self-collection kit included a paper copy of detailed collection procedures Table . Study cResearch coordinators contacted participants at various time points using the participant’s preferred contact method . On day 1, research coordinators confirmed that medications were received and started. They also ensured that any labs  were properly collected and return shipping arranged. On day 2, side effects of the drugs were assessed using the PROMIS Gastrointestinal Symptoms survey and recorded in REDCap . Other sOn day 14, research coordinators again assessed concomitant medication use and clinical progression, study drug discontinuation, and symptom log return. At day 28, symptoms, clinical progression, and any additional medications used during the study duration were recorded. Participants were paid throughout the study with each milestone: enrollment; follow-up assessments at Day 1, 5, 10, 14, 28, and then long-COVID assessments. The payments were made via the ClinCard system [Of 6,609 individuals screened, 5,178 were excluded and 1,431 were randomized; 14 individuals were ineligible after randomization: they provided inaccurate screening information, could not provide proof of SARS-CoV-2 infection, or withdrew immediately after completing randomization.Of the 1,417 in the intention-to-treat (ITT) sample, 94 participants informed study members that they took no study drug: 9 participants did not receive the study drug due to shipping failure; 8 were hospitalized before taking study drug; and 77 were no longer interested in taking study drug (consenting to study procedures) before they received the shipment. Therefore, 1,323 were in the modified intention-to-treat sample, which was the prespecified primary study sample. The difference between the ITT and mITT samples is due to the remote nature of the trial. Unlike in-person trials, when participants took the first dose on site, there was a lag time between consenting and receiving the trial intervention.Of the 1,323 in the primary sample, the COVID-OUT study enrolled fewer black (7.6%) participants compared to the general U.S. population (about 13%). The COVID-OUT trial population was similar to the US population for percent Native American (about 2%), and under-enrolled 12.1% Latinx, compared to about 18% Latinx for the US population.Eighteen participants 1.4%) were lost to follow-up for the primary outcome: severe Covid-19 within 14 days. Severe Covid-19 was defined using a binary 4-part composite outcome: (1) single oxygen reading < 94% (2) ED visit (3) Hospitalization (4) or Death. While little was known at the time about silent hypoxia due to COVID-19, one low oxygen reading does not equal severe COVID-19. Additionally, some participants reported improbable, non-physiologic variability of pulse oximetry readings . This may have been due to participant reporting of pulse rate instead of oxygen saturation, a falsely low reading due to the vasoconstriction of cold extremities, poor fit, skin tone, or inaccurate pulse oximetry readings. After the study began enrolling, the FDA issued a warning that home pulse oximeters can be inaccurate . Using a% were loWe chose to focus on the primary outcomes within 14 days of study drug initiation with 28-day outcomes as secondary endpoints. Pharmaceutical industry-sponsored trials focused on 28-day outcomes. In the COVID-OUT trial, there was a clinically meaningful reduction in hospitalizations by 14 days, but the confidence interval included 1.0. Through 28-day follow-up, the confidence interval did not include 1.0 , this exThe SARS-CoV-2 pandemic limited in-person clinical trial activities, prompting investigators to leverage virtual clinical trial methods. The surge in DCT development during the COVID-19 pandemic represents an inflection point that could transform the future of clinical research. Decentralized methods can enhance efficiency of intervention assessment and expand clinical trial access for patients who live far from medical centers, thereby improving generalizability of clinical trials despite infectious pandemics.Although our DCT strategies were not compared to in-person methods, our experience suggests that conducting the COVID-OUT trial remotely conferred several advantages. Most notably, the decentralized trial design adhered to current COVID-19 safety guidelines . PatientExpedited medication delivery was a critical component of this trial. Delivering study medications within 24 hours of enrollment improves statistical power for antiviral medications because earlier initiation is associated with larger effect sizes . AdditioWe now know that a one-time low reading on a home oximeter does not equal severe COVID-19. The FDA-identified inaccuracies of prescription home oxygen monitoring devices, combined with other potential issues likely influenced the accuracy of hypoxemia assessment. This had an overwhelming effect on the primary outcome because reported hypoxia was the most frequently occurring component of the binary, 4-part composite outcome. Real-time data entry into REDCap would have alerted the study team to spurious or low values, allowing real-time verification with the patient over the phone. As an alternative, when remotely collecting vital sign data, the addition of a related symptom may improve accuracy. For example, a low oxygen reading plus shortness of breath may better assess pulmonary involvement of COVID-19. Medication adherence was also monitored using self-reported symptom log data. Objective measures such as return of an empty pill pack or video drug intake observation may have informed researchers of true medication adherence.Initially, most participants were enrolled in participating health systems and thus their EHR could be reviewed. However, the EHR may not contain all follow-up events or new medications, so asking the participant is always preferred. While all participants consented to EHR access, home and new medications started during the trial were not confirmed in the EHR as obtaining records from clinics outside of participating systems would have been unreasonable.While paper symptom logs are part-11 compliant, paper symptom diaries created a significant data entry burden. The delay between receiving diaries and entering data prevented real-time quality control with participants who may have misread home oximeters, recording their pulse. Non-return of symptom diaries created missing symptom data. A subset of participants may have preferred paper symptom diaries but having an alternative direct electronic entry option would have been more appropriate.Early in the study, participants would forget to label their nasal swabs and stool samples with their participant-specific adhesive sticker. The burden of determining missing identification numbers fell upon lab personnel and study staff. In response to this challenge, research coordinators placed adhesive stickers labeled with day of collection and participant ID before shipping materials to participants. By minimizing what is required of the participant, more accurate data collection occurred.Initial data suggest that DCTs may improve sample diversity compared to clinic-based trials by reducing the geographic and time barriers that contribute to underrepresentation of people of color in clinical research . HoweverGeotargeting digital advertisements and partnering with clinical sites that serve diverse communities may also enhance recruitment. DCTs present a unique opportunity to meet participants within the communities they live, separate from traditional sites. Collaborating with community organizations for research strategy could strengthen the researcher-participant relationship.DCTs come with several challenges and advantages, both of which must be weighed in the context of the trial being designed. We hope that learning the details of the COVID-OUT trial will be helpful to other researchers and add to the emerging literature on decentralized clinical trials.Avula et al. supplementary material


Eradication of cccDNA is an ideal goal of chronic hepatitis B (CHB) therapy. Understanding the changes in the cccDNA pool during therapy provides a basis for developing CHB treatment strategies. On the other hand, the shift in the balance of the cccDNA pool following therapies allowed researchers to investigate the dynamics of cccDNA. Central to the description of cccDNA dynamics is a parameter called cccDNA half-life. CccDNA half-life is not an intrinsic property of cccDNA molecules, but a description of an observed phenomenon characterized by cccDNA pool decline. Since cccDNA has to be in the nuclei of host cells to function, the half-life of cccDNA is determined by the state and destiny of the host cells. The major factors that drive cccDNA decay include noncytopathic effects and hepatocyte turnover (death and division). In some cases, the determining factor is not the half-life of cccDNA itself, but rather the half-life of the hepatocyte. The main purpose of this review is to analyze the major factors affecting cccDNA half-life and determine the areas requiring further study. In addition, the discrepancy in cccDNA half-life between short-term and long-term nucleot(s)ide analog (NUC) therapy was reported. Hypotheses were proposed to explain the multi-phasic decline of cccDNA during NUC therapy, and a framework based on cccDNA dynamics was suggested for the consideration of various anti-HBV strategies. Covalently closed circular DNA (cccDNA) is the first viral product after hepatitis B virus (HBV) infection of hepatocytes. It serves as a stable repository of HBV genetic information in liver cells and represents the most impenetrable barrier to a functional cure for chronic hepatitis B (CHB) ,2,3. Ccc11 viruses decay and are produced daily  (L-FMAU), a reverse transcriptase inhibitor. They found that although L-FMAU caused a 200-fold suppression in viral DNA replication, no significant loss in cccDNA was observed in the infected hepatocytes during the 40-day treatment . In chroOutstanding examples exhibiting the influence of hepatocyte death on cccDNA is from the experimental therapy of HBV infection by T cells that were engineered to express HBV-specific chimeric antigen receptors (CARs) or T cell receptors (TCRs). Protzer’s lab reported that expression of CARs directed against the HBV surface proteins enables human T cells to kill HBV-infected human hepatocytes and to eliminate viral cccDNA in vitro and in vivo ,33. T ceIn nonproliferating primary cultures of woodchuck hepatocyte infected with woodchuck hepatitis virus (WHV), treatment of L-FMAU did not facilitate loss of cccDNA. No significant loss of cccDNA from the treated cultures was seen between days 8 and 40 post-infection, indicating a cccDNA half-life of at least 32 days . Ko et aDuring hepatocyte division, the HBV cccDNA minichromosome could be distributed unequally or even lost during mitosis since it is not a cellular chromosome equipped with centromere structures. Chong et al. examined the dynamic changes in HBV cccDNA in different cellular growth stages of a stably HBV-producing cell line, 1.3ES2 . They foIn contrast, some other studies did not observe significant cccDNA loss during cell division. Li et al. determined the distribution of HBV cccDNA in continuously passaged HepAD38 cells using a fluorescence imaging in situ hybridization (FISH)-based assay. The findings showed that nuclear HBV DNA symmetrically distribute to daughter cells. It is worth noting that the detected nuclear DNA was not necessarily cccDNA, since the probes used were not cccDNA-specific . The celTo determine the effect of cell proliferation on cccDNA in vivo, Lutgehetmann et al. transplanted primary tupaia hepatocytes (PTHs) chronically infected with woolly monkey HBV (WM-HBV) from chimeric mice into the urokinase-type plasminogen activator (uPA)/severe combined immunodeficiency (SCID)/beige (USB) mouse model. Transplantation of WM-HBV-infected hepatocytes led to an average of 3.8 PTH doublings within 80 days. Remarkably, a median 2-log decline of cccDNA per cell determined during PTH proliferation was due to both dilution of the cccDNA pool among daughter cells and a 0.5-log loss of intrahepatic cccDNA loads . The eff3-thymidine) incorporated into cell nuclei [3-thy-midine in normal adult rats, suggesting that a liver would renew in 450 days. Of note, it was estimated that in normal liver approximately 41% of labeled cells had died or divided by 60 days, and the remaining labeled cells had lifespans varying up to at least 6 additional months [3-thymidine to trace the life of hepatocytes in mice [Knowing the lifespan or turnover rate of hepatocytes is essential in exploring the dynamics of the cccDNA pool due to the close relationship between cell death and the change in the cccDNA pool. In 1961, Richard determined the lifespan of rat liver cells by tracing tritiated thymidine  can be detected. In contrast, non-S-phase nuclear PCNA, which is present in lower amounts and is not physically associated with DNA replication sites, is likely lost or undetectable by conventional immunocytochemical methods [The half-life of normal human hepatocytes does not permit experimental determination in vivo by lineage or H methods ,47,48. I methods ,50. This methods . Another methods ,45.In summary, normal hepatocytes of rat and mice exhibit a heterogeneity in half-life. The majority of hepatocytes have a half-life of 50–100 days, but a minority of hepatocytes can live longer than 300 days. The death rate of normal human hepatocytes is estimated to be approximately 0.5% per day, equivalent to a half-life of 100 days. However, details of half-life heterogeneity of human hepatocytes need further investigation.Hepatoma cell lines, such as HepG2, transfected stably or transiently with replication-capable HBV genome support cccDNA formation ,53,54. THowever, in cells supporting HBV infection, intracellular recycling of rcDNA seems not to play a primary role in establishing and sustaining the cccDNA pool. In HepG2-NTCP A3 cells infected with wild-type HBV or HBV that do not encode core protein (ΔHBc HBV) from its genome, cccDNA levels were comparable over 9 weeks of infection . ΔHBc HBA two-phase decline in serum HBV has repeatedly been observed during short-term NUC therapy. Tsiang et al. reported a biphasic clearance of serum HBV in a cohort of 10 chronic hepatitis B patients receiving adefovir (ADV) for 12 weeks . The ini11 and thus produced 1011 viruses per day before therapy , 109 viruses would be produced daily under a 99% inhibiting efficiency during therapy. Serum HBV levels enter the fast decline phase first, declining to 2 × 109 after approximately 7 days . Assuming a constant cccDNA pool, 109 viruses would also be produced at this time. This would be in accordance with the amount of serum HBV that was eliminated each day , predicting that the serum viral load would not decrease further. However, the experimental observations contradicted this hypothesis. Of note, a different inhibiting efficiency could only affect the first phase. For example, it would take 3.3 days for an agent with a 90% inhibiting efficiency  to reduce the total viral load from 2 × 1011 to 2 × 1010, after which it would plateau.The decay of the cccDNA pool is the most probable mechanism for the second-phase viral decline, since a model without cccDNA decay would predict a viral load plateau instead. Assuming that the cccDNA pool remained constant during therapy, this pool would produce an equal amount of new viruses at any time point, but at a slower rate (inhibiting efficiency) than in the natural steady state. For example, if a patient had a total serum virus load of 2 × 10Therefore, decreases in cccDNA or hepatocyte turnover should be involved in the second phase of decline in serum viral load during short-term therapy of NUC. The first, fast phase of viral load decline results from the short half-life of serum HBV (1 day). The subsequent decline in serum viral load must be primarily caused by the decline of cccDNA due to the daily production of new viruses approaching the daily decay of viruses. As depicted in Assuming that the decline of cccDNA is the primary cause of the second phase of decline in serum viral load, the cccDNA half-life would correspond to approximately 6–18 days ,59,60,61Direct analyses of cccDNA in the liver have also been performed in patients receiving long-term therapy. However, varying cccDNA decline rates have been observed throughout the course of the therapy. Data on cccDNA decline from 10 previous studies were collected . These sR mutations emerged and increased from undetectable to 40–90% within 16–28 weeks in serum HBV RNA from telbivudine-treated patients experiencing virological breakthrough. From these results, the cccDNA half-life for the majority of patients was inferred to be <12 weeks. However, these cccDNA half-lives might be overestimated , since the composition of LAMR would be influenced by the sizes of cccDNA pools, which most likely increased during the breakthrough.A recent study indirectly analyzed cccDNA turnover by monitoring the composition of HBV RNA from different viral quasi-species during NUC therapy . They foThree studies were performed with a long-term observation period of at least 60 months. One of the three studies used three sequential samples from each patient while they were receiving NUC treatment , which provided useful information for our analysis. This study reported a 1.03 log cccDNA reduction within the first year, equivalent to a half-life of 14.1 weeks, which is close to the half-life calculated above. Within the next 9 years, the same cohort experienced a further 1.94 log cccDNA reduction, which corresponds to a half-life of 76 weeks . This half-life was approximately 5 times longer than during the first year of treatment. Furthermore, HIV and HBV co-infected patients who received NUC treatment for an average of 65.8 months displayed half-lives of 36 weeks (HBe+) and 112 weeks (HBe−), both of which were significantly longer than the half-life during the first year of therapy. In addition, another study that tracked cccDNA changes during 60 months of NUC treatment reported a 1.56 log cccDNA reduction. Assuming that the cccDNA decreased by 0.8 log in the 1st year, the cccDNA reduction over the next 48 months would be 0.76 log, equivalent to a half-life of 82 weeks. Collectively, these findings demonstrated that during NUC treatment, cccDNA declines with varying half-lives, ranging from 1–2 weeks within the first 12 weeks, to 14 weeks within the first year, to 36–112 weeks within 2–10 years. Collectively, cccDNA declined in a multi-phasic model during long-term NUC therapy A.At the steady pretreatment state, the daily newly synthesized cccDNA must equal the daily decayed cccDNA in order to maintain the cccDNA pool size B. The raHowever, the fact that the cccDNA pool size declines in a multi-phasic manner and rarely disappears opposes one or both of the hypotheses. Rejection of Hypothesis 1 implies that the inhibition efficiency of NUC decreases (Hypothesis 3), or the conversion efficiency of newly produced viruses into cccDNA increases with therapy duration (Hypothesis 4). In both circumstances, the efficiency of cccDNA synthesis would be relatively higher in latter stage of therapy than in earlier stage. Hypothesis 3 may be plausible in the case of residual cccDNA producing HBV variants with lower sensitivity to the NUC being used. Comparing the sensitivity of residual variants with that of initial viruses would help to clarify this issue. Hypothesis 4 requires mechanisms such as enhanced intracellular recycling efficiency of HBV DNA-containing capsid particles into nuclei to form cccDNA. However, this possibility seems remote given that intracellular recycling of DNA-containing nucleocapsids is not essential for the maintenance of HBV cccDNA .If Hypothesis 2 is rejected, it would imply that cccDNA decays at different rates depending on the stage of therapy. For example, after a year of therapy, cccDNA would decay more slowly than it would have earlier. This suggests HBV-infected hepatocytes would have different half-lives, since cccDNA half-life is primarily determined by the half-life of hepatocytes (assuming NUC does not affect noncytopathic effects) (Hypothesis 5). In this scenario, cccDNA residing in hepatocytes with a short half-life would be eliminated at a faster rate, leading to a relatively larger slope in the declining curve. In contrast, cccDNA residing in hepatocytes with a long half-life would be eliminated slowly, resulting in a smaller slope. Previous studies indicate that hepatocyte half-life of rat and mouse are heterogenous and a small part of cells lived much longer than other cells ,43. ReceThe balance between cccDNA replenishment (synthesis) and decay during homeostasis provides an alternative framework for considering the effects of various therapies. An effective treatment could either slow down the cccDNA replenishment, speed up cccDNA decay, or exert both effects . NUCs inSiRNA, anti-sense oligonucleotide (ASO) and locked nucleic acid (LNA) suppress new virus production and cccDNA replenishment by destroying virus RNA directly or suppress cccDNA transcription by reducing HBx level ,86. On t10 copies of cccDNA in total (approximately 0.1 copy/cell) before treatment, and the patient receives an ideal therapy that can completely block the production of progeny viruses (so that any cccDNA replenishment can be ignored), the cccDNA half-life should be 10 days. This value is within the range of some estimates derived from studies of short-term NUC therapy  can be calculated. Assuming that a liver contains 10 therapy . HoweverAlthough it would be ideal for increasing cccDNA decay solely through noncytopathic effects, creating such methods might not be feasible. CRISIPR/cas9 strategies targeting cccDNA were successful in in vitro and animal models ,111,112.The genetic materials of HBV, such as HBV DNA, HBV RNA and cccDNA, are distributed in different compartments of the host and exhibit different half-lives. CccDNA in the nucleus decay much slower than viral particles in serum, resulting in a two-phase decline in serum viral load during short-term NUC therapy. Current evidence indicates that cccDNA also declined in a multi-phasic manner during long-term NUC therapy. Considering that cccDNA half-life is mainly determined by the hepatocyte turnover rate in the immune-inactive stage, cccDNA may be distributed across hepatocyte populations with different half-lives. If this hypothesis is true, strategies should be developed to accelerate cccDNA decay in order to reduce cccDNA levels within a set treatment period. Direct antiviral agents (DAA) such as NUC can be used to inhibit cccDNA replenishment, and new agents such as CpAM would support this position even more. However, there is still no efficient treatment promoting cccDNA decay on the market. Strategies are currently being developed to reestablish innate and HBV-specific immune responses.


N-Methyl-D-aspartate receptor (NMDAR) linked neurodegenerative diseases such as Alzheimer’s disease and dementia is constantly increasing. This is partly due to demographic change and presents new challenges to societies. To date, there are no effective treatment options. Current medications are nonselective and can lead to unwanted side effects in patients. A promising therapeutic approach is the targeted inhibition of NMDARs in the brain. NMDARs containing different subunits and splice variants display different physiological properties and play a crucial role in learning and memory, as well as in inflammatory or injury processes. They become overactivated during the course of the disease, leading to nerve cell death. Until now, there has been a lack of understanding of the general functions of the receptor and the mechanism of inhibition, which need to be understood in order to develop inhibitors. Ideal compounds should be highly targeted and even splice-variant-selective. However, a potent and splice-variant-selective NMDAR-targeting drug has yet to be developed. Recently developed 3-benzazepines are promising inhibitors for further drug development. The NMDAR splice variants GluN1-1b-4b carry a 21-amino-acid-long, flexible exon 5. Exon 5 lowers the NMDAR’s sensitivity to allosteric modulators by probably acting as an NMDAR modulator itself. The role of exon 5 in NMDAR modulation is still poorly understood. In this review, we summarize the structure and pharmacological relevance of tetrahydro-3-benzazepines.The number of  At least 50 million people worldwide suffer from Alzheimer’s disease or dementia. In 2019, 121,500 deaths were attributable to Alzheimer’s disease, making this disease the sixth leading cause of death in the United States . When Aβ3) and eukaryotic elongation factor 2 (eEF2), thus leading to the phosphorylation of synaptic tau. This Fyn activation is also linked to cyclic increases and decreases in NMDARs , neN-methyl-D-aspartate ..R)-OF-NBAllosteric interactions enable structural distance communication and represent a basic key biological concept. Allosteric interactions describe distinct structural regions in a protein whose conformational spaces are interlinked . In the According to published cryo-EM data on the GluN1/GluN2B receptor, the two LBD dimers undergo an extensive rotation as the receptor changes from an inactive to an active form . MutagenR)-OF-NB1, an optimized 3-benzazepine derived from ifenprodil, can be used as a positive example in drug development, leading to a powerful imaging tool in ALS and potentially other neurodegeneration diseases [Altogether, NMDARs are of high scientific and clinical interest and represent prime pharmacological targets. Ideal compounds display highly targeted and even splice variant specificity. The drug memantine is already approved as an NMDAR blocker for the treatment of moderate to severe Alzheimer’s dementia. However, memantine blocks all NMDARs, resulting in side effects. Selective modulation of NMDARs with particular subunits such as, e.g., the GluN2B subunit, could reduce the side effects. The latest advances in highly selective NMDAR drug research offer highly promising approaches as starting points for drug development. However, these compounds must still be further optimized. The understanding of the unique regulation of NMDARs by naturally embedded structures such as exon 5, as well as binding and the downstream allosteric network, starting from ATD to LBD and the eventual closing and opening of the pore in the TMD, is of importance for the development of appropriate drugs. Via this approach, positive therapeutic effects can be maximized, and negative side effects might be reduced, improving drug therapy for patients. Eventually, these optimized lead compounds need to be tested in further established and optimized disease models, such as hiPSC-derived neuron 3D neuronal networks and SK-N-SH cells . In termdiseases ,70,72,73


The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a new class of cholesterol-lowering medications that provide significant reductions in lipids but at a large cost relative to statins. With 2 such drugs now on the market, alirocumab and evolocumab, comparing the evidence base for these drugs is necessary for informed decision making.To compare the benefits and harms of the PCSK9 inhibitors alirocumab and evolocumab.ClinicalTrials.gov were used to search for randomized controlled trials of alirocumab or evolocumab with any relevant comparator reporting health outcomes, lipid outcomes, or harms through September 2015, and information was requested from manufacturers. Results were reviewed according to standard review methods.The databases Ovid MEDLINE, Cochrane Library, SCOPUS, and The database searches revealed 17 fair- and good-quality trials; however, none had primary health outcomes or directly compared PCSK9 inhibitors. Alirocumab (75 mg to 150 mg subcutaneously every 2 weeks) resulted in significantly greater reductions in low-density lipoprotein cholesterol  at 12-24 weeks in patients with (a) heterozygous familial hypercholesterolemia and (b) patients at high or varied cardiovascular (CV) risk who were not at LDL-C goals with statin therapy. The highest strength evidence was for patients with high CV risk not at LDL-C goals. Alirocumab also resulted in high-density lipoprotein cholesterol (HDL-C) increases of 6%-12%. Low- and moderate-strength evidence for adjudicated CV events at 52-78 weeks for a priori analyses indicated no benefit. Low- and moderate-strength evidence also found no differences in harms except possibly slightly more injection-site reactions. Evolocumab (120 mg subcutaneously every 2 weeks to 420 mg every 4 weeks) resulted in significantly greater reductions in LDL-C (-32% to -71%) at 12-52 weeks in patients with heterozygous or homozygous familial hypercholesterolemia, patients intolerant of statins, and patients with varied CV risk not at LDL-C goal with statin therapy. The highest strength evidence was for heterozygous familial hypercholesterolemia and patients not at LDL-C goals. Moderate-strength evidence showed HDL-C increases in the range of 4.5%-6.8%. Harms were not different between groups, except possibly slightly greater overall adverse event reporting. Evidence on adjudicated CV outcomes was insufficient to draw conclusions because of sparseness of events, study limitations, and inability to assess consistency of findings.Alirocumab and evolocumab have evidence of large improvements in lipid levels. The strength of the evidence is greater for alirocumab than evolocumab in patients with high CV risk who were not at LDL-C target goals, while evidence for evolocumab is stronger in patients with heterogeneous familial hypercholesterolemia and patients with varied CV risk who were not at LDL-C target goals. Evidence on adjudicated CV outcomes for a priori analyses is unable to show benefit for alirocumab and is insufficient to draw conclusions for evolocumab. Important questions remain about the comparative effects on long-term health outcomes. What is already known about this subjectThe proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab produce large reductions in low-density lipoprotein cholesterol (LDL-C) when given in addition to statins in a variety of populations with hypercholesterolemia or alone or in combination with ezetimibe in patients intolerant to statins.Cardiovascular benefits are as yet not clearly established, with some analyses of incidentally reported or secondary outcomes indicating benefit.Concerns raised about the evidence include the methodology behind cardiovascular endpoint analyses, long-term effects of large reductions in lipids, whether comparison groups were optimal, and cost of the drugs in light of these concerns.What this study addsThis study compared the strength of the evidence base for each of the PCSK9 inhibitors alirocumab and evolocumab.The evidence base for alirocumab is stronger than evolocumab for patients at high cardiovascular risk who have not reached LDL-C targets with statin therapy. Although there is strong evidence that alirocumab lowers lipids significantly, there is currently no evidence of a benefit in cardiovascular outcomes when limiting to adjudicated cardiovascular events and a priori analyses.Evidence for evolocumab is stronger than alirocumab for patients with heterogeneous familial hypercholesterolemia and patients with varied cardiovascular risk not at LDL-C target, but evidence on cardiovascular events is insufficient or absent. Evolocumab also has evidence in these other populations: homozygous familial hypercholesterolemia, populations of patients with varied cardiovascular risk, and follow-up studies of varied populations.2 However, there are patients for whom statins alone or in combination with other lipid-low-ering therapies are not always adequate to reduce cardiovascular risk, even at maximally tolerated doses. There are also patients who are intolerant of statin therapy, in whom treatment with drugs such as ezetimibe alone are also inadequate. Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) have been under development as novel therapies, potentially filling these gaps in current standard therapies for hypercholesterolemia. The first 2 drugs in this new class of antihyperlipidemic treatments received U.S. Food and Drug Administration (FDA) approval in mid-2015. In combination with other treatments—typically maximally tolerated statins— alirocumab was approved for use in heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease who required additional low-density lipoprotein cholesterol (LDL-C) lowering, and evolocumab was approved for patients with clinical atherosclerotic cardiovascular disease or heterozygous and homozygous familial hypercholesterolemia who required additional LDL-C lowering.HMG-CoA reductase inhibitors, or statins, have been the primary therapeutic intervention for hypercholesterolemia for decades. They have been successful in reducing the risk of major cardiovascular events and mortality in a wide range of at-risk individuals.5 In this cost-conscious era of health care, clinicians, payers, and the public are already questioning how to best manage this costly new drug class.6 While there have been reviews of the evidence published,8 there has been concerning criticism of the analysis of the evidence, as well as the evidence itself. These concerns center around long-term health outcomes 10 and comparison groups in trials .14Alirocumab  and evolocumab (Repatha) have shown striking LDL-C reductions over 10 to 78 weeks (26%-67%). But, as with many novel specialty drugs, the promise of better results with PCSK9 inhibitors comes with a high price tag—in this case, the cost is estimated at more than $14,000 per patient per year.18 In the meantime, Navarese et al. (2015) pooled data from the 24 available smaller studies with follow-up ranging from 2 months to 2 years and reported that PCSK9 inhibitors as a group reduce all-cause mortality  and rates of myocardial infarction .7 However, these findings have been questioned based on concerns that the statistical approach used by Navarese et al. is biased in how study arms with zero events were handled.10 Critics demonstrated that use of a few different less-biased conventional methods produced results of consistently smaller magnitude and in 1 case lost statistical significance. Because of the instability and imprecision of these findings, critics urge us to wait for the results of the adequately designed cardiovascular endpoint trials now underway before promoting use of these drugs. Given the increased demand by payers such as Medicare for definitive evidence that interventions improve health outcomes, and not merely intermediate endpoints,19 this debate has important implications for coverage policy determinations as well.To date, no clinical trial of a PCSK9 inhibitor designed a priori, with adequate size and duration, to assess cardiovascular outcomes as the primary outcomes has yet been completed. However, 4 such trials are underway and are expected to be completed in 2018.12 In the largest PCSK9 inhibitor trial to date, the ODYSSEY LONG-TERM trial of alirocumab,20 which alone accounts for 45% of mortality events in the Navarese 2015 meta-analysis,7 only 47% of patients were receiving high-dose statins, despite the trial's focus on high-risk patients. In their published response to this criticism, the ODYSSEY LONG-TERM authors agreed with this limitation and promised that the ongoing ODYSSEY Outcomes study (NCT01663402) will address this uncertainty.21Additionally, there has been criticism that even the LDL-C benefits of PCSK9 inhibitors may have been overestimated because of underutilization of high-intensity statin therapy.22 The purpose of this review was to evaluate the body of evidence for each drug based on the population and comparators studied to better stratify the evidence for decision making with regard for their place in therapy and for selecting a specific PCSK9 inhibitor.To support the work of the participating organizations of the Drug Effectiveness Review Project, the Pacific Northwest Evidence-based Practice Center conducted a systematic review of the comparative effectiveness of alirocumab and evolocumab versus each another, other lipid-lowering regimens, or placebo.For this systematic review, randomized controlled trials (RCTs) of alirocumab or evolocumab were included that reported 1 or more health outcomes , lipid outcomes , or harms . For cardiovascular events, only those that were adjudicated through a formal process were included; those events that were reported as incidental findings were excluded.ClinicalTrials.gov, and requested information from drug manufacturers. Two reviewers, using consensus to resolve disagreements, assessed studies for eligibility. Study characteristics, including baseline patient characteristics, and study results were abstracted by 1 reviewer and checked by a second reviewer for accuracy.To identify relevant studies, Ovid MEDLINE , the Cochrane Library databases (2009 through 2015), and Scopus (2010 through 2015) were searched, using drug names as search terms. Additional studies were located by hand searching reference lists of included studies, 23 Individual studies were assigned ratings of good, fair, or poor. Studies with major flaws were rated as poor; those with essentially no flaws were rated as good; and the remainder were rated as fair. Data in studies that were clinically and methodologically similar were pooled using random effects models, and statistical heterogeneity was explored using the I-squared statistic.24The internal validity  of individual studies were assessed based on predefined criteria developed for the Drug Effectiveness Review Project .25 This grading assessed the limitations, directness, consistency, and precision of the body of evidence for each outcome and resulted in evidence rating of high strength (★★★★), moderate strength (★★★), low strength (★★), or insufficient (★) to draw conclusions. In the tables presented in this review, these ratings are shown as stars. Individual study quality and the strength of evidence ratings were dually reviewed with disagreements resolved using consensus.For studies with multiple arms of differing doses, the doses within the FDA-approved dosing range were analyzed. Body of evidence strength was graded for a given key outcome based on the guidance established for the Evidence-based Practice Center Program of the Agency for Healthcare Research and Quality.43 There are no completed or ongoing studies that directly compared different PCSK9 inhibitors. Study details are summarized in For this review, 17 trials were included in 19 publications .20,26-4338 Evidence for alirocumab compared with placebo in patients with heterozygous familial hypercholesterolemia who took a low- to moderate-intensity statin was insufficient .39 There were no studies of alirocumab in patients with homozygous familial hypercholesterolemia.Compared with placebo, there was low-strength evidence that alirocumab achieved a higher LDL-C reduction in patients with heterozygous familial hypercholesterolemia who took a maximum statin dose plus ezetimibe, based on 1 fair-quality trial (N = 77). Similar effects were shown for high-density lipoprotein cholesterol (HDL-C), but there was insufficient evidence to draw conclusions about harms.34 In patients with homozygous familial hypercholesterolemia who took a maximum statin dose and ezetimibe  that evolocumab (140 mg every 2 weeks to 420 mg every 4 weeks) achieved a greater LDL-C reduction in patients with heterozygous familial hypercholesterolemia who were largely taking a high-intensity statin plus ezetimibe, with a greater improvement in HDL-C and no differences in harms (moderate-strength evidence).zetimibe , low-str41 There is also low-strength evidence from the GAUSS study (N = 62) that the combination of evolocumab (420 mg every 4 weeks) plus ezetimibe (10 mg) led to a greater percentage of LDL-C reduction than ezetimibe (10 mg) alone, but there was insufficient evidence to draw conclusions on other outcomes.41There was no evidence for alirocumab in patients who were intolerant to statins. In statin-intolerant patients, there was low-strength evidence based on 2 fair-quality, 12-week RCTs  that evolocumab (280 mg every 4 weeks or 140 mg every 2 weeks) led to a greater reduction in LDL-C than placebo, with similar effects in HDL-C and harms.27 Similarly, the difference in the percentage of change in LDL-C and HDL-C at 24 weeks was greater with alirocumab . Moderate-strength evidence found that there was no difference in overall adverse event reporting between alirocumab and ezetimibe and that the rate for reporting any adverse event was high (69%). Low-strength evidence found that withdrawal because of adverse events and serious adverse events were not different between the groups. Low-strength evidence suggested a higher rate of injection-site reactions with alirocumab than with placebo injection plus ezetimibe, but this estimate was imprecise . Neurocognitive events were rare.Several studies evaluated a PCSK9 inhibitor in patients with varying levels of cardiovascular risk, who had not achieved an LDL-C of < 100 mg/dL or < 70 or 75 mg/dL using mainly statin-based therapy before randomization. Very few patients had familial forms of hypercholesterolemia in these studies. In high-risk patients, moderate-strength evidence based on a good-quality trial  demonstrated that alirocumab (75 mg to 150 mg given every 2 weeks) resulted in a higher proportion of patients with high cardiovascular risk reaching the study goal of LDL-C < 70 mg/dL at 24 weeks  than ezetimibe (10 mg).30 The difference in the percentage of reduction in LDL-C and HDL-C was also greater. High-strength evidence found no statistical difference in overall adverse event reporting and that the rate for reporting any adverse event was high (75%). Moderate-strength evidence found that withdrawal because of adverse events and serious adverse events were also not different between groups. Low-strength evidence suggested that the risk of injection-site reactions  or neurocognitive events were not increased, although the estimates were imprecise because of few events.Based on 2 trials , there was high-strength evidence that alirocumab (75 mg to 150 mg given every 2 weeks) resulted in a higher proportion of patients with high cardiovascular risk reaching the study goal of LDL-C < 70 mg/dL at 24 weeks than placebo .35 This study provided insufficient evidence to draw conclusions about HDL-C, serious adverse events, or withdrawal because of adverse events because of the small magnitude of change or event rates. In patients with high cardiovascular risk, a small 12-week (N = 104 for placebo comparison) study provided low-strength evidence that evolocumab (420 mg monthly) resulted in higher rates of meeting LDL-C targets of < 100 mg/dL and < 70 mg/dL when added to statins in Japanese patients, compared with placebo.29 There was greater mean change in LDL-C but insufficient evidence to draw conclusions about other outcomes.In a comparison of evolocumab and ezetimibe (both with statin therapy) in patients with high cardiovascular risk, the LAPLACE-2 study (N = 329 for this comparison) provided low-strength evidence that when added to either atorvastatin (10 mg or 80 mg), compared with ezetimibe (10 mg), evolocumab (420 mg monthly) resulted in higher rates of meeting an LDL-C target of < 70 mg/dL at 12 weeks, with similar rates of patients with overall adverse events.30 For evolocumab, adjudicated cardiovascular events were reported as secondary or post hoc outcomes, but evidence was insufficient to draw conclusions because of too few events (imprecise estimates), study limitations, and lack of ability to verify findings across multiple studies  fair-quality RCTs indicated that in patients stabilized on statins who have not achieved an LDL-C of < 100 mg/dL, alirocumab (150 mg subcutaneously every 2 weeks for 8-10 weeks) resulted in significantly more patients achieving study goal (LDL-C < 100 mg/dL) and a greater percentage of reductions (49%-67% more) than statins alone.35 There is also moderate-strength evidence of modest HDL-C increases with evolocumab (420 mg monthly) and moderate- to high-strength evidence of no differences in adverse events. Based on 1 good-quality longer-term trial , there is moderate-strength evidence that evolocumab (420 mg given every 4 weeks) also results in significantly more patients achieving a goal of LDL-C < 70 mg/dL, compared with placebo; low-strength evidence of a modest increase in HDL-C; and evidence of no difference in harms (low- and moderate-strength evidence depending on outcome).In short-term comparisons of evolocumab and placebo, LAPLACE-TIMI 57 and LAPLACE-2 (N = 996 for placebo comparison) provided high-strength evidence that, at 12 weeks in patients with varying risk levels and not meeting LDL targets, significantly more patients taking evolocumab (420 mg monthly) than taking placebo (both with statin therapy) achieved an LDL-C of < 70 mg/dL and had a greater percentage of reduction in LDL-C.37 This reduction was largely sustained at 48 weeks . This analysis of the 2 studies also provided low-strength evidence of a greater proportion of patients meeting an LDL-C goal of < 100 mg/dL or < 70 mg/dL and a greater increase in HDL-C at 12 weeks than with standard therapy alone.There is moderate-strength evidence, based on a pooled analysis of 2 open-label extension studies (OSLER 1 and 2), of patients completing 1 of 12 previous trials , that evolocumab (420 mg monthly or 140 mg every 2 weeks plus standard care - primarily statins) reduced LDL-C by 61% more than standard care alone at 12 weeks.There is low-strength evidence that slightly more patients on evolocumab experienced any adverse event at 12 weeks, compared with statins alone, without differences in serious adverse events but insufficient evidence to draw conclusions about other adverse event outcomes.This systematic review of PCSK9 inhibitor drugs finds low- to high-strength evidence of moderate-to-large magnitude reduction in LDL-C when added to statin therapy in patients with familial forms of hypercholesterolemia and alone or added to ezetimibe in those who are intolerant of statins. Although there are no direct comparison studies, and the lipid outcomes are fairly similar across the trials, the strength of this evidence varies by population and by drug. In patients with heterozygous hypercholesterolemia, the trials of evolocumab were larger (499 vs. 98), and the strength of the evidence was consistently stronger than for alirocumab  was $681,000 for those with familial hypercholesterolemia (either type) and $557,000 for patients with established cardiovascular disease and LDL-C > 70 mg/dL.44 Although these are estimates for comparison with continuing statins alone, they clearly exceed the typical threshold for cost-effectiveness of $50,000 to $100,000 per QALY.44 The analyses using this model suggest that in order for the drugs to be cost-effective, the price range should be closer to $3,600 per year than the current price range of approximately $14,000 per year.In addition to the uncertainty around long-term outcomes, and with an estimated price of almost $14,000 per year,Another important issue raised about this evidence is the comparison groups, including the concomitant antihyperlip-idemic therapy given. Clearly, in a step-therapy approach, the choices in the face of inadequate treatment include continuing to maximize the current therapy, add a second treatment, or even switch treatments. Pharmacologically, the PCSK9 inhibitors are likely to work better when used alongside a statin, and most of the studies continue statin therapy in PCSK9 inhibitor-treated patients. A fair comparison, then, would be maximization of the statin therapy  in the control group in particular. Most of these studies do not adhere to this standard (Tables 2 and 3); consequently, future studies are required to determine the true incremental benefits of PCSK9 inhibitors.45 and without good-quality evidence on cardiovascular outcomes for the PCSK9 inhibitors, it is less clear how to interpret and apply the findings of these studies. Using the percentage of reduction in LDL-C from baseline is not a better marker, since we do not yet understand the implications of 30%-60% above and beyond any initial reductions with a statin. Adding to this lack of clarity, are the several studies in varied- or average-risk populations. In a recent editorial, Shrank et al. (2015) discussed the challenges and implications of determining the best use of PCSK9 inhibitors in light of the recent changes in recommendations for treating hyperlipidemia but recommends a step-approach that promotes maximizing the use of low-cost statin medications rather than PCSK9 inhibitors.14The bulk of the evidence, then, is from patients currently receiving varying doses of statins who have not achieved study-specified target LDL-C levels. While this less than optimal use of statins is not an ideal comparator as an alternative strategy to PCSK9 inhibitors, it may reflect real-world statin use. When limited to populations of patients who are at high cardiovascular risk and whose baseline LDL-C on statin therapy are above targets of 70 mg/dL to 75 mg/dL or < 100 mg/dL, we find large absolute reductions in LDL-C and higher proportions of patients achieving these study goals. However, with recent guidelines suggesting that therapy be directed by risk level and not specific LDL-C targets,With 2 PCSK9 inhibitors approved and others in the pipeline, there will not only be questions about the role of this new class of drugs in the treatment of hypercholesterolemia, but also comparative questions about whether there are important differences among the drugs. Because these drugs will be taken for many years and are expensive, and because there are still questions regarding long-term benefit and harm, studies in the highest risk populations that are designed to assess cardiovascular and potential harm outcomes with appropriate comparison groups  are needed in order to shed light on these important questions.The main limitations of this review are those related to the evidence itself, as previously described . Additional potential limitations of this review include the search strategy and the exclusion of studies published in languages other than English. It was attempted to locate all studies relevant to the scope of this review, but it is possible that evidence was missed. There was limited ability to assess potential publication and reporting bias because of the few opportunities to pool studies and the lack of availability of study protocols. Finally, the scope of this review limited the inclusion of some studies included in other reviews  and within those incidentally reported cardiovascular outcomes.Alirocumab and evolocumab have evidence of large improvements in lipids and limited evidence on cardiovascular outcomes, but the strength of evidence differs between the drugs. The strength of evidence is greater for alirocumab than evolocumab in patients with high cardiovascular risk not at LDL-C target, while evidence for evolocumab is stronger in patients with heterogeneous familial hypercholesterolemia and patients with varied cardiovascular risk not at LDL-C target. Important questions remain about the comparative effects of either drug on long-term health outcomes.


Severe acute respiratory syndrome-coronavirus 2 (COVID-19) vaccines may incur changes in thyroid functions followed by mood changes, and patients with Hashimoto thyroiditis (HT) were suggested to bear a higher risk.We primarily aim to find whether COVID-19 vaccination could induce potential subsequent thyroid function and mood changes. The secondary aim was to find inflammatory biomarkers associated with risk.The retrospective, multi-center study recruited patients with HT receiving COVID-19–inactivated vaccines. C-reactive proteins (CRPs), thyroid-stimulating hormones (TSHs), and mood changes were studied before and after vaccination during a follow-up of a 6-month period. Independent association was investigated between incidence of mood state, thyroid functions, and inflammatory markers. Propensity score–matched comparisons between the vaccine and control groups were carried out to investigate the difference.Final analysis included 2,765 patients with HT in the vaccine group and 1,288 patients in the control group. In the matched analysis, TSH increase and mood change incidence were both significantly higher in the vaccine group (11.9% versus 6.1% for TSH increase and 12.7% versus 8.4% for mood change incidence). An increase in CRP was associated with mood change (p< 0.01 by the Kaplan–Meier method) and severity (r = 0.75) after vaccination. Baseline CRP, TSH, and antibodies of thyroid peroxidase (anti-TPO) were found to predict incidence of mood changes.COVID-19 vaccination seemed to induce increased levels and incidence of TSH surge followed by mood changes in patients with HT. Higher levels of pre-vaccine serum TSH, CRP, and anti-TPO values were associated with higher incidence in the early post-vaccine phase. Hashimoto thyroiditis (HT) is an autoimmune condition featured by lymphocytic destruction and chronic inflammation of thyroid gland , 2, and In the era of COVID-19 posing the greatest threat to public health, the introduction of various types of vaccines successfully decreased the rate of COVID-19 infection for both healthy populations and those with underlying diseases , 7. ImmuNext, whether vaccine-associated inflammatory marker changes are inducible to thyroid dysfunction and symptom changes in patients with HT has not been studied. Thyroid functions are critically linked to mood states, and the rate of mood swings is significantly higher in the HT population, with reports in the large samples of three times of incidence in 1 year as compared to general population , 15. ConThe retrospective, multi-center study recruited patients with clinical or subclinical HT to receive standard two-dose inactivated CoronaVac (BBIBP-CorV) vaccines during May 2021 to January 2022. Because there have not been guidelines for vaccine safety in China for patients with HT during recruitment period, vaccination was primarily decided voluntarily by patients. Thus, patients not receiving vaccines during study period were included as the control group, and corresponding matching by propensity scores was done to reduce bias. Diagnosis of HT was the presence of clinical symptoms of hypothyroidism combined with the increased levels of anti-TPO and/or anti-TG antibodies. Ethical approval was obtained at the Second Affiliated Hospital of Shantou University Medical College as a waiver option for the retrospective study protocol. This study was performed according to the principles of Declaration of Helsinki, Good Clinical Practice, and all patients provided informed consent before participation.The primary outcome was to evaluate the mood and thyroid function changes after COVID-19 vaccination, and an exploratory analysis was carried out to identify potential associations between inflammation markers and primary outcome. To illustrate role of vaccines and to control for the potential psychiatric-related conditions during COVID-19 pandemic, a control cohort with HT was recruited in the same hospitals that did not receive vaccines as geographical match during study period. The smallest sample size was calculated by PASS (V 15.0) before recruitment to reach the effect size of the thyroid-stimulating hormone (TSH) levels of 5% difference with pre-specified alpha of 0.05 and beta of 0.20, and the upper limit was dependent upon the actual size of recruited during study period (consecutive recruitment). Key exclusion criteria of the study are as follows: 1) critically ill conditions with a survival prognosis of less than 1 year; 2) diagnosis of Grave’s disease; 3) history of anaphylaxis to contents of vaccine products; and 4) acutely ill patients or patients with active cancers, who may show increased inflammation markers.The demographic data were extracted from Case Record Forms of the five tertiary referral hospitals, and the electronic data capture systems were applied to save and monitor de-identified profiles, in which each patient was coded for follow-up track. Demographic information included gender and age. Patients were followed up online to test their mood state on a weekly basis, and serum tests were performed in clinical laboratories of enrollment centers. Follow-up started from the date of vaccination to the 24th week after vaccination (end of follow-up).The serum levels of markers were tested one to three times during a 3-month period prior to vaccination and at the end of follow-up. Mean values were applied in final calculation to represent baseline inflammation profiles. Markers included C-reactive protein , interleukin-6 (IL-6), TSHs, and anti-TPO and anti-TG antibodies. At the full length of follow-up, Beck Depression Inventory (BDI) was administered online at each weekend to assess the mood change levels of patients dating back 2 weeks. Definition of mood changes was a BDI score of more than or equal to 13 , 18. DiaClinic coordinators with supervision gather data in community clinics when patients were not reachable in the tertiary hospitals (either as inpatients or outpatients). All data were extracted from Case Record Form of the follow-up sites, and the electronic data capture systems were applied to save and monitor de-identified profiles.http://www.r-project.org/). First, nomogram was constructed to predict incidence of TSH increase and, second, was built to predict disease-free survival (DFS) time during follow-up . Each statistical test was based on a pre-determined statistical hypothesis with a type I error of 0.05. The paired Student’s t-test was applied to compare continuous variables of the same cohort in chronological settings for parametric tests, including changes in CRP, BDI scores, and TSH values. Statistics used in comparison study were carried out in SPSS V.24.0 software.The study enrolled 4,556 patients with HT, and 503 patients did not consent to follow-up and thus were excluded. Thus, final analysis included 2,765 patients in the vaccine group and 1,288 patients in the control group . Before vaccination, mean CRP levels of the vaccine group were 581.12 ± 789.94 μg/dl, and mean TSH values were 293.29 ± 111.70 μIU/dl. Anti-TG antibody levels were 92.17 ± 375.92 IU/ml, and BDI scores were 8.52 ± 5.17. Anti-TPO antibody levels were 38.36 ± 100.55 IU/ml. Among all participants, 499 patients had a prior history of psychiatric diseases, and 104 patients had other autoimmune diseases (AIDs). Baseline demographics and serum markers of both groups are shown in As there could be episodes of incident mood and thyroid function changes during course of HT that were potentially unrelated to vaccination, baseline and follow-up data of the control group were compared with those of the vaccine group after propensity score matching to find whether incident mood changes were associated with vaccination. Matching yielded a total of 1,039 pairs, with the imbalance test results shown in Using the McNemar test, the percentage rate of TSH increase was significantly different between the two groups . Further comparison of mean TSH values also showed significance (316 ± 195 μIU/dl versus 259 ± 90 μIU/dl, p< 0.01 by the Wilcoxon signed-rank test, To test the predicting values of serum markers before and after vaccination and to evaluate the relationship between demographics and rates of mood changes, univariate and multivariate survival analyses were carried out to find the independent markers associated with incidence of mood changes Table 2.Final analysis was done to see whether there was an association between mood change–predicting serum markers with change in thyroid function after vaccination. Baseline demographic and serum markers were subject to univariate and multivariate regression analyses of TSH increases in the vaccine group, and results are shown in As COVID-19 vaccines became widely covered in general population, thyroid function changes became evident in a small range of samples characterized by subclinical to clinical thyroiditis , 21. ThyMood changes, a mood disorder that affects 6% to 7% of the general population, is quite commonly seen in patients with hypothyroid states due to the deranged levels of thyroid hormones and persistent inflammation , 22. AutSafety of COVID-19 vaccines has been widely evidenced in recent studies of autoimmune conditions, and most effort has been intensified on immunogenicity and vaccine-related adverse events following vaccination . ReportsOur work bears several limitations. Follow-up time was relatively short such that long-term disease-related outcomes cannot be assessed. In addition, third-dose vaccines took place 6 months after the second dose, and we did not assess outcomes after booster vaccination, which may provide more data on serum marker changes and their associations with mood change outcomes. In addition, we did not report immune response to vaccines, although response has been widely evidenced to be robust. Trajectory of these values could be evaluated in long-term follow-up and may be a source of validation for current study. Although nomogram was developed over a multi-center research protocol, a validation by an independent cohort is required to find predicting values.Patients with HT seemed to have increased incidence of mood changes after COVID-19 vaccines. This outcome seems related to changes in the CRP and TSH levels. Baseline serum markers—CRP, TSH, and anti-TPO antibodies—could predict outcome of mood changes and TSH increase after vaccination.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Second Affiliated Hospital of Shantou University Medical College. The patients/participants provided their written informed consent to participate in this study.Prof XW and Dr AZ conceptualized and designed the study, and reviewed and revised the manuscript. Drs YM, NL designed the data collection instruments, carried out the initial analyses, and wrote the first draft of the manuscript. Drs JZ, YJ, YX, YOW, GZ, GJ, YAW, ZZ, GF, SH and CL coordinated and supervised data collection and critically reviewed the manuscript for important intellectual content. Drs YL, SC, XW, PZ, XL, YN, ML and SL collected data and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. The work reported in the paper has been performed by the authors, unless clearly specified in the text. All authors contributed to the article and approved the submitted version.


Primary care providers play a key role in screening for tobacco use and assessing desire to quit. Tobacco treatment specialists (TTS) are certified in helping patients who desire tobacco cessation. A primary care nurse practitioner within one Midwestern healthcare organization obtained TTS certification and integrated specialized tobacco cessation visits within a primary care clinic from February 2021 to February 2022.  To determine the efficiency and effectiveness of an integrated TTS-certified nurse practitioner (TTS-NP) in a primary care setting 1-year postimplementation.  This program evaluation utilized retrospective electronic health record review and included thirty-three patients. The logic model served as a framework to define efficiency and effectiveness. n = 14) and 63% (n = 17) reported cessation at the first and second follow-up. TTS-NP visit's cost, independent of any other coverage, was less than other specialty visits in primary care.  Patients were referred by a provider (57.6%), nurse (15.2%), or self (27.3). Patients opted for in-person initial visits (81.8%) more than virtual (18.2%). Of a total of 73 scheduled visits, 8 (11%) were no-showed. Patients who self-referred had the lowest no-show rate (5.6%) compared to those referred by a provider (12.8%) or nurse (12.5%). Of the patients included, 87.9% set a goal quit date. Average time until first and second follow-up was 34.6 and 130.4 days after goal quit date. Follow-up was defined as the date of the patient's first message reply to the TTS-NP, or first visit following the goal quit date. A total of 51.9% ( TTS-NP visits in primary care enabled patients to benefit from lower cost and longitudinal follow-up within a familiar setting. Over half of patients achieved cessation. Results of this program evaluation suggest support for TTS-certified providers in primary care. Smoking tobacco is a significant problem that harms nearly every organ of the human body . AccordiSupporting patients and providing advice to quit is of utmost importance, as those who can achieve 1 week without smoking are 9 times more likely to successfully quit . TherefoTo close this gap in tobacco cessation treatment, it is imperative to implement evidence-based interventions. One such way for healthcare providers to build competence is to receive tobacco treatment specialist (TTS) certification. Programs for TTS certification provide nationally standardized, evidence-based competencies, knowledge, and skills for providers supporting patients who are attempting tobacco cessation . These pAt one primary care clinic in a Midwestern health system, a primary care nurse practitioner (NP) sought to improve patients' tobacco cessation treatment and thus obtained TTS certification. Once certified, the NP initiated education within the multidisciplinary team regarding the ability to integrate tobacco cessation consults in the primary care clinic. Prior to integration of the TTS-certified NP (TTS-NP) into the primary care clinic, all patients were required to visit a separate facility for nicotine dependence within the organization to receive specialized tobacco treatment care with a TTS. Visits incorporating the TTS-NP in primary care began in February 2021 and continued through February 2022.Previous research of this program studied the perceptions of stakeholders at the participating clinic, including physicians, physician assistants, NPs, registered nurses, and licensed practical nurses . A crossThis program evaluation was implemented to assess the efficiency and effectiveness of the process for TTS-NP visits integrated in one primary care clinic. By utilizing retrospective electronic health record (EHR) review, this program evaluation's primary outcome included measures of efficiency and effectiveness, with smoking cessation rates being a secondary measure included within the evaluation of effectiveness. The logic model served as a framework for defining effectiveness and efficiency. The logic model is a planning tool which illustrates how a program is expected to produce results by presenting the resources available, activities carried out, expected outcomes or results of the project, and impact of the program . ProcessThe setting for the TTS-NP visits was one of five ambulatory primary care clinics within a large Midwestern tertiary healthcare center. The involved primary care clinic is located on the outer edge of a city with a population of over 100,000 people. This clinic utilizes a multidisciplinary team-based approach to care for patients by integrating providers and staff from pediatrics, internal medicine, family medicine, pharmacy, and subspecialties. It employs the patient-centered medical home model, which allows increased communication between behavioral health specialists and primary care team members by having the entire team colocated. The advantage of this clinic is that patients do not have to drive into the heart of the city to receive care at the main multicomplex healthcare center.Data from patients 18 years of age or older who completed an initial visit for smoking tobacco cessation with the TTS-NP after integration in primary care in February 2021 were included in the analysis. Patients were excluded from analysis if they visited with the TTS-NP for cessation of chewing tobacco. Patients were included in the analysis of smoking cessation rates if they met criteria and had EHR documentation of a set goal quit date and two documented follow-up timepoints. Follow-up timepoints included communication between the patient and any healthcare provider or nurse that discussed tobacco cessation status, either by means of an in-person visit, virtual (telephone or video) visit, or patient online service portal message. For patients who were enrolled in patient online services, the TTS-NP sent a portal message on the goal quit date with an open response to enable patients to send a message reply, and follow-up was defined as the date of the patient's first reply mentioning cessation status. For patients who did not utilize online services, follow-up was defined as the date of first in-person or virtual visit following the goal quit date. Cessation was defined as patients' self-reported abstinence from smoking any cigarettes between their goal quit date and the date of their follow-up portal message or visit. The Institutional Review Board at Viterbo University and Mayo Clinic approved this study.For the TTS-NP visits, the process began when a patient was referred by another care provider or registered nurse, or when a patient self-referred by contacting the clinic with an interest in tobacco cessation. The patient was then added to the TTS-NP calendar, and the appointment scheduling team coordinated with the patient to schedule the TTS-NP visit. The visits were integrated into the normal schedule template for the TTS-NP. Patient visits were typically limited to a 30-minute appointment slot. TTS-NP visit times were shorter compared to 60-minute visits at the specialized clinic for nicotine dependence within the organization and 40- and 60-minute visits for other integrated collaborative specialties (such as cardiology and endocrinology) within the primary care clinic. During the appointment, the TTS-NP assessed the patient's tobacco dependence and utilized motivational interviewing, behavioral counseling, and shared decision-making techniques to assist the patient in developing a personalized plan for smoking cessation, which could include initiation of prescription medication and/or the patient setting a goal quit date for smoking cessation.All data to evaluate efficiency and effectiveness of the TTS-NP visits in primary care was collected retrospectively via EHR review. Demographic data was confirmed by the TTS-NP at the time of the patient visit and included patient age, years smoked, packs per day, motivation and confidence self-ratings on a 0-10 scale, number of previous quit attempts, presence of cooccurring mental health or substance use disorders, and longest previous quit attempt.Within the logic model framework, efficiency is measured by process variables, including inputs, activities, and outputs. “Inputs” are resources necessary for implementation ; “activities” are the actions performed by the program personnel using those resources ; and “outputs” are products or deliverables that result from the activities  . TherefoWithin the logic model, effectiveness is defined by program “outcomes,” including the short- and intermediate-term changes that occur in people or conditions because of activities and outputs . Evaluatt-distribution confidence level, and 95% confidence interval for average amount of time elapsed between referral and initial visit and average amount of time that passed between initial appointment, first follow-up, and second follow-up.Evaluation of demographic, efficiency, and effectiveness data included descriptive statistics. All statistics were calculated utilizing Microsoft Excel data analysis and Analysis ToolPak. The Excel “count” feature was utilized to tally the total number of patients who visited with the TTS-NP and met study inclusion criteria, the total number of appointments scheduled with the TTS-NP, and the number of visits in each 18-week period. Percentages were calculated in Excel to analyze the proportion of patients who set goal quit dates, no-show rates, visit formats, longest previous quit attempt, referral sources, and smoking cessation rates at the first and second follow-up timepoints. Excel data analysis was utilized to calculate the mean, standard error, r-value was calculated. The same method was utilized to measure correlation between patients' confidence and motivation self-ratings with cessation at first and second follow-up. Cost estimates were calculated by utilizing the healthcare organization's cost estimator tool. The Current Procedural Terminology (CPT) billing codes for primary care-based TTS-NP visits, primary care-based visits in other specialties, and TTS visits in the nicotine dependence specialty clinic were utilized to estimate cost of professional charges without any insurance coverage or uninsured discounts.Data reflecting whether a patient did or did not achieve cessation was coded numerically to assess the degree of relationship between cessation at first and second follow-up. Cessation was coded into ordinal values, where a value of 1 indicated “yes” and 2 indicated “no,” and an n = 15) and 54.5% were female (n = 18). Other demographic characteristics analyzed included age, number of years smoked, packs per day smoked, number of previous quit attempts, and self-rated levels of motivation and confidence levels on a scale from 0 to 10  patients were referred to visit with the TTS-NP by another provider , while 15.2% (n = 8) were referred by a nurse, and 27.3% (n = 9) self-referred. No-show rates varied based upon referral source, as depicted in n = 27) compared to virtually . The mean time between referral and initial appointment with the TTS-NP was 13.8 days . While the TTS-NP sent a message to patients on their goal quit date, many patients waited to respond or to request their follow-up visit. The average time between goal quit date and first follow-up from the patient was 34.6 days , and average time between goal quit date and second follow-up was 130.4 days . Out of 73 visits scheduled, a total of 65 visits were completed, equating to an 11% no-show rate. Six patients (18.2%) were lost to follow-up, defined as no documentation in the EHR of smoking cessation completed after their initial TTS-NP visit.Evaluation of the TTS-NP visits revealed that a total of 57.6%  set a goal quit date, and 81.8% (n = 27) were included in the smoking cessation rate analysis as they had at least two follow-up timepoints documented by a healthcare provider in the EHR after the goal quit date. The TTS-NP was the responsible provider for 70.4% (n = 19) and 48.1% (n = 13) of the first and second follow-up timepoints, respectively; the remainder were completed and documented by another healthcare provider, such as the patient's primary care provider, another specialty provider, or a nurse.Of all the participating patients, 87.9% (n = 14) of patients achieved smoking cessation at the first follow-up, whereas 63% (n = 17) achieved smoking cessation at the second follow-up. An analysis of the correlation between variables evaluating effectiveness is shown in A total of 51.9%  was below the average clinic no-show rate of 18.8% . A lowerThere was also demonstrated efficiency among the multidisciplinary care team in utilizing the TTS-NP, given 75% (27/36) of the total referrals were from another physician, NP, PA, or nurse. Lastly, the TTS-NP visits demonstrated efficiency in patient follow-up, as 81.8% had at least two follow-up timepoints documented, showing that a majority of patients had longitudinal care within their primary care setting, where they reported feeling satisfied with the convenience of scheduling and comfort or familiarly with clinic staff and feeling confident with their primary care provider giving personal recommendations .The integration of TTS visits in primary care was effective with regard to maintaining a steady number of visits throughout the entirety of the 54 weeks during which it was active. The TTS-NP was effective in working with patients to set goal quit dates, as almost 90% of the patients succeeded in doing so. According to the United States Department of Health and Human Services (DHHS), an average of 47.1% of cigarette smokers had attempted to quit smoking between 2012 and 2014 . TherefoDuration of time elapsed between goal quit date and first and second quit date was impacted by the patients' promptness of message reply, as well as the limited number of TTS-NP visit slots. The smoking cessation rates among patients who visited with the TTS-NP in primary care were above the reported cessation rate of the specialty clinic, with 52% and 63% achieving smoking cessation at the first and second follow-up timepoints, respectively. The specialty clinic location advertises “the 6-month stop rate among outpatients who receive a tobacco treatment specialist consult … is over 25 percent” . Over haA limitation is that data from retrospective EHR review was manually studied and entered by one researcher, so there is possibility for human error. For example, as patient online service portal messages were not billed or tallied on the TTS-NP calendar, it is possible that some follow-up may have been inadvertently missed. Another limitation is that this study only evaluated one TTS at one specific primary care setting. Personalities and clinic environment impact the ability to generalize this to other primary care sites. Lastly, staffing challenges and the SARS-CoV-2 pandemic were moderators to the longevity of the TTS-NP visits. Staffing challenges amid the pandemic led to a reduction in the available weekly TTS-NP visit slots, and subsequently, the TTS-NP transitioned to a new professional role.This program evaluation revealed numerous benefits of integration of a TTS-NP in the primary care clinic and supported its efficiency and effectiveness. The cost of TTS-NP visits was lower than the cost of other specialty visits, which benefits both the patient and the healthcare system. Improved cessation rates revealed that patients were well-supported in their journeys toward smoking cessation when patients visited with the TTS-NP. Longitudinal follow-up with patients led to improvements in smoking cessation rates over time. Because primary care providers commonly follow their patients for a prolonged period, this enables improved follow-up for tobacco smoking cessation. While further research is needed to understand the patients' long-term cessation rates and perceptions of the TTS-NP visits, the results of this program evaluation provide support for a TTS-certified provider in the primary care clinic and may encourage more primary care providers to obtain specialty certification to improve access to care and patient outcomes.


Immune checkpoint inhibitors (ICIs) are widely used to treat a variety of cancers and common infectious diseases with high efficacy. During the coronavirus disease 2019 (COVID-19) pandemic, studies suggested that COVID-19 patients may benefit from ICI immunotherapy. However, clinical studies on the safety and efficacy of ICI in COVID-19 patients are still being conducted. Currently, it is not clear whether cancer patients undergoing ICI immunotherapy should adjust their treatment strategy after infection with SARS-CoV-2 and whether ICI can reduce the viral load of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this study, reports of patients with different types of tumors infected with SARS-CoV-2 under ICI immunotherapy were classified and sorted, including lung cancer, melanoma, squamous cell carcinoma of the head and neck, and hematologic malignances. The safety and efficacy of ICI in antitumor and anti-SARS-CoV-2 therapies were compared and further discussed to provide more reference materials for the application of ICI treatment. In a word, COVID-19 has changed the ICI treatment strategy for cancer patients indeed, and ICI treatment may be a “double-edged sword” for cancer patients complicated with COVID-19. Under physiological conditions, these molecules and co-stimulatory molecules are strictly regulated to achieve a balance to prevent overactivation of the autoimmune system, leading to tissue damage. In tumors and chronic infectious diseases, upregulated expression of multiple ICs and their ligands may lead to “T-cell exhaustion,” which mediates antigenic immune escape. Based on the immune escape mechanism, ICI immunotherapy has been widely used in several cancer patients and common infectious diseases and has achieved good efficacy .in vivo mediate immune escape mechanisms, for both virus and tumor antigens. Coronavirus disease 2019 (COVID-19) is an acute infectious disease mainly involving the respiratory system caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused a global pandemic and seriously affected normal human life. Studies have pointed out that there is also “T-cell exhaustion,” a serious phenomenon in patients with severe COVID-19, manifested by decreased cytokine secretion ability, low proliferation ability, and accelerated apoptosis of T lymphocytes, accompanied by upregulated expression of ICs and their ligands [ICI immunotherapy has also been widely studied and applied in infectious diseases. In a phase II clinical trial in patients with advanced liver cancer due to hepatitis C cirrhosis, Sangro et al.  found th ligands . Mild an ligands . In addiTherefore, this study classifies the reports of patients with different types of tumors infected with SARS-CoV-2 receiving ICI treatment, compares and discusses the safety and efficacy of ICI immunotherapy against tumors and SARS-CoV-2, and provides more references for the application of ICI treatment .2p = 0.177) [ICI immunotherapy has changed the treatment pattern of patients with lung cancer and significantly improved prognosis. Nevertheless, studies have shown that age and ICI treatment are related to the severity of COVID-19 ,9. In co= 0.177) . Luo et = 0.177)  followed= 0.177) .Clinicians are discussing the need to adjust the dose and timing of immunotherapy in COVID-19 patients. Sehgal et al.  reportedMellinghoff  reports Another 70-year-old lung adenocarcinoma patient diagnosed with COVID-19 was treated with a combination of two immunotherapeutic agents (nivolumab and ipilimumab) but eventually died from cytokine release syndrome, suggesting that a higher mortality risk may be associated with the combination immunotherapy . HoweverOn the other hand, higher levels of SARS-CoV-2-responsive IgG, neutralizing serum activity, and a stronger humoral immune response were found in a patient with NSCLC who received pembrolizumab in combination with chemotherapy than in a normal COVID-19 patient . Continu3CTLA-4 was first used in melanoma patients and improved prognosis; the subsequent approval of PD-1 inhibitors further extended survival. A Japanese study on cancer statistics indicated that the efficacy of ICIs varied by subtype of melanoma, with a poor response rate for acral and mucosal melanoma and a high response rate for primary hyperplasia of connective tissue melanoma . A retroAhmed  reportedSimilarly, Pala  reportedIn advanced melanoma, especially in patients with metastatic melanoma resistant to PD-1/PD-L1, ipilimumab combined with PD-1 inhibitors appears to be more effective than ipilimumab alone. Moritz et al.  pointed 4Immunotherapy has become a new standard treatment for recurrent and metastatic head and neck cancers . HoweverFor patients with platinum-refractory recurrent squamous head and neck carcinoma, ICI treatment based on nivolumab can bring longer survival benefits than standard monotherapy but with a higher incidence of grade 3 and above AEs . To date5The first case of COVID-19 in patient with hematologic malignancy was reported from Wuhan, China. Although hospitalized patients with HM had a similar case rate of COVID-19 compared with normal healthcare providers (10 and 7%), the case fatality rate was significantly higher, with 62% for patients with HM compared with 0%, respectively . Studies6The COVID-19 pandemic has created new challenges for oncology clinicians and cancer patients with COVID-19 receiving immunotherapy. Based on the current clinical problems, this review systematically summarizes the reports of ICI in patients with different cancers complicated by COVID-19, providing more references for ICI application in tumor patients undergoing immunotherapy and COVID-19 patients. According to existing reports, ICI does not appear to increase the risk of infection or exacerbation of COVID-19. Most reports indicate that ICI is safe for patients with tumors complicated with COVID-19. But combined ICI treatment does not benefit patients, but increases the risk of death and incidence of AE. In addition, prolonging the treatment time of ICI or prolonging the administration interval had no significant effect on OS and even could reduce the occurrence of AEs in solid tumor. However, it should be noted that there are significant differences between HMs and solid tumors, including the T-cell response after infection and the duration of RNA, which lead to a worse outcome. This may be related to the complex tumor microenvironment of hematologic tumors and the systemic immune dysfunction of lymphocytes, especially the low response of B cells to vaccines . COVID-1