Outcome definitions

The primary outcome was the clinical recovery rate at 7 days from the beginning of treatment. Clinical recovery was defined as continuous (>72 hours) recovery of body temperature, respiratory rate, oxygen saturation and cough relief after treatment, with following quantitative criteria: axillary temperature ≤36.6°C; respiratory frequency ≤24 times/min; Oxygen saturation ≥98% without oxygen inhalation; mild or no cough. Secondary outcomes included the latency to pyrexia relief (for patients with pyrexia at the time of enrollment), the latency to cough relief (for patients with moderate or severe cough at the time of enrollment), the rate of AOT or NMV, all-cause mortality, dyspnea, rate of respiratory failure (defined as SPO2 ≤90% without oxygen inhalation or PaO2/FiO2 <300mmHg, requires oxygen therapy or additional respiratory support), and the rate of patients needed to receive intensive care in ICU. Safety outcomes included adverse events occurred during treatment and premature discontinuation.

clinical recovery rate

all-cause mortality

dyspnea

rate of AOT or NMV

premature discontinuation

rate of respiratory failure


Outcomes
Outcomes were assessed at 28 days after randomisation, with further analyses specified at 6 months. The primary outcome was 28-day all-cause mortality. Secondary outcomes were time to discharge from hospital and, among patients not on invasive mechanical ventilation at randomisation, post-enrolment use of invasive mechanical ventilation (including extracorporeal membrane oxygenation) or death. Prespecified subsidiary clinical outcomes were cause-specific mortality, use of haemodialysis or haemofiltration, major cardiac arrhythmia (recorded in a subset), and receipt and duration of ventilation (for which full data are still being collected from relevant routine sources).
Information on suspected serious adverse reactions was collected in an expedited fashion to comply with regulatory requirements

all-cause mortality

time to discharge from hospital

cause-specific mortality

major cardiac arrhythmia

use of haemodialysis or haemofiltration

suspected serious adverse reactions

receipt and duration of ventilation


Outcomes

The primary clinical endpoint was the necessity for intubation and invasive mechanical ventilation. Secondary outcomes were time of invasive mechanical ventilation, admission to the ICU, length of ICU stay, and mortality.

time of invasive mechanical ventilation

admission to the ICU

length of ICU stay

mortality


 Outcomes

The primary outcome was a composite of mechanical ventilation, hospitalization >14 days or in-hospital death.

Secondary outcomes included: days of mechanical ventilation, days of high-flow nasal cannula (HFNC), days of oxygen requirement, time to respiratory failure development (PaO2/FiO2<200), the severity of multiple organ dysfunction (by SOFA score) at day 3 and 7; days in ICU or intermediate care unit, hospital length of stay, and mortality at 30 days. The kinetics of inflammatory biomarkers, including total lymphocyte count, C-reactive protein (CRP), procalcitonin, LDH, D-dimer, ferritin and IL-6 were determined on days 0, 3 and 7; and SARS-CoV-2 RT-PCR in nasopharyngeal swab on days 3 and 7.

Radiological outcomes included the comparison of infiltrates progression on chest CT scans on enrollment and day 5, based on COVID-19 pneumonia severity scores[20–23]. For the combined analysis with portable chest X-rays, a blinded thoracic radiologist expert categorized images as “progression” vs “stable or improved”.

Also, pre-planned analyses of baseline neutralizing antibodies (NAbs) titers, and anti-SARS-CoV-2 IgG titers were determined in participants from the early plasma group and in the subset of participants from the deferred plasma group who had not yet received plasma on days 0, 3 and 7.

Analysis of the primary outcome and clinical secondary outcomes was performed by intention-to-treat (ITT). Laboratory and radiology secondary outcomes were analyzed by modified-ITT, excluding a patient who withdrew consent before any intervention.

Safety outcomes were evaluated in all participants.

days of mechanical ventilation

days of high-flow nasal cannula (HFNC)

days of oxygen requirement

at day 3 and 7

days in ICU or intermediate care unit,

hospital length of stay

mortality

at 30 days

on enrollment and day 5

neutralizing antibodies (NAbs) titers

anti-SARS-CoV-2 IgG titers

days 0, 3 and 7

total lymphocyte count

C-reactive protein (CRP)

procalcitonin

LDH

D-dimer

ferritin

on days 0, 3 and 7

SARS-CoV-2 RT-PCR

on days 3 and 7


Outcomes

The primary outcome was the cumulative lung lesion remission rate (lung CT examination indicated absorption of lung inflammation). Secondary outcomes were the improvement of clinical symptoms (cough, diarrhea, dyspnea, fever, myalgia) before and after treatment; the changes of blood routine test and IL-6; changes of oxygen therapy. In addition, we also analyzed the peripheral blood T lymphocyte subsets (count and proportion) before and after treatment. Safety endpoints were the frequencies of adverse events in each group.

cumulative lung lesion remission rate

changes of oxygen therapy

before and after treatment

before and after treatment

frequencies of adverse events


 Outcomes

The primary outcome was the variation in gas exchange over time evaluated through the ratio of partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FiO2) at baseline, 7, and 14 days after randomization. This ratio was blindly calculated using the result of the arterial blood gas (ABG) analysis collected routinely around 6:00 am.

The secondary outcomes were the time until successful liberation from mechanical ventilation, the ventilator-free days (during the 28 days after inclusion in the study; numbers of days without mechanical ventilation), the variation in D-dimer levels collected at baseline during inclusion in the study and repeated 72–96 h later, all-cause 28-day mortality, in-hospital mortality, and the intensive care unit (ICU)-free days at 28 days.

To determine the successful liberation from mechanical ventilation, we considered the maintenance of spontaneous ventilation without the need for invasive mechanical ventilation support for a minimum of 72 h. All patients received the lung-protective ventilation strategy with low tidal volume. Each unit used its ventilator liberation protocol. The patients underwent prone positioning of at least 16 h if PaO2/FiO2 ratio < 150 mmHg. Other ventilator adjuncts to improve oxygenation in the setting of severe ARDS, such as inhaled nitric oxide and extracorporeal membrane oxygenation, were not available in our service.

The D-dimer measurement was performed through the automated assay VIDAS® D-dimer Exclusion II™ (bioMérieux SA, Lyon, France) with a cutoff of 500 μg/L.

The safety outcome analyzed was the occurrence of bleeding using the Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria, which classified the bleeding in major, minor and requiring medical attention [14]

variation in gas exchange over time

ventilator-free days

variation in D-dimer levels

all-cause 28-day mortality

in-hospital mortality

intensive care unit (ICU)-free days

at 28 days

occurrence of bleeding


 End points

The primary endpoints were the achievement of two successive negative SARS-CoV-2 PCR analysis tests 48 h apart by nasopharyngeal swab, normalization of body temperature for 48 h, improvement of radiological abnormalities at Day 14 and the hospital discharge rate. The secondary endpoints were the normalization of C-reactive protein (CRP) and serum ferritin levels.

normalization of body temperature

hospital discharge rate

48 h apart

for 48 h

at Day 14

serum ferritin levels


Outcomes
 2.8.1. Primary outcome

The primary endpoint was time to clinical improvement, defined as the days from randomization until normalization. Clinical improvement was assessed by five components including body temperature, respiratory rate, oxygen saturation, alleviation of cough, and absorption of pulmonary infection by chest CT. Normalization was defined as body temperature < 37.0 °C, respiratory rate < 24 times per minute indoors, and oxygen saturation > 94% (fingertip). Alleviation of cough was defined as a reduced severity of cough from a physician-reported scale of severe or moderate to mild condition or absence. Absorption of pulmonary infection was defined as an absorption area > 2/3 by Digital Imaging and Communications in Medicine (DICOM) images on chest CT. Alleviation of these five clinical symptoms were required to stay normal for at least 72 h on all components to fulfill the primary endpoint of clinical improvement.
 2.8.2. Secondary outcomes

Prespecified secondary outcomes included clinical improvement rate, median time and proportion of defervescence, mean time and proportion of significant inflammatory absorption of lung lesions, a negative conversion rate of the viral nucleic acid test, mortality at day 28, and the conversion from mild or ordinary to severe or critical severe status. The diagnosis and classification of mild, ordinary, severe, and critical severe conditions of this disease were set according to Chinese guidelines for COVID-19 [4], [12].

Defervescence time was defined as the days from randomization to a temperature less than 37.0 °C maintained for at least 24 or 72 h. A throat swab viral nucleic acid test was repeated after 48 h following a negative test result. The conversion rate in severe and critical severe subjects was assessed with a six-point scale. The patient being discharged from the hospital or the score decreasing by two points from the baseline was considered to be conversion.
 2.8.3. Exploratory outcomes

The exploratory outcomes were changes in laboratory indicators, including routine blood test, C-reactive protein (CRP), coagulation function, myocardial enzymes, and hepatic and renal functions. The recovery rates of the above indicators from abnormal to normal were also calculated.

time to clinical improvement

clinical improvement rate

mortality

at day 28


 Primary clinical outcome
There was a significant difference in the 28-day mortality, no patient died (0%) in the treatment group, while five patients died (12.8%) in the standard group; P= 0.027 (Fig. 3). Among patients in the treatment arm with bromhexine, two patients were admitted to ICU (5.1%) while in the standard arm, eleven patients (28.2%) were transferred to ICU. There was a significant difference in the ICU admission between the treatment and the standard group (P = 0.006). Moreover, among patients in bromhexine arm, one patient received mechanical ventilation (2.6%), while in the standard arm nine patients (23.1%) were intubated and underwent mechanical ventilation. There was also a highly significant difference in the intubation and mechanical ventilation between the two groups (P = 0.007) as shown in Table 2.
Secondary clinical outcomes
There was also a significant difference in the secondary outcome of this study (Fig. 4). Improvement of cardinal respiratory symptoms such as cough and dyspnea within two weeks among the two groups were assessed:
Dyspnea remained in 3.4% in the treatment group vs 48.3% in the standard group P ≤ 0.001 and cough remained in the treatment group 6.9% vs 40.0% in the standard group, P = 0.003). Similar results for lassitude between the two groups were observed (6.9% vs 34.5%, P = 0.010). At baseline, there was no significant difference in the frequency of fever, headache, and gastrointestinal symptoms between the two groups.
The patients in the bromhexine group showed improvement in the level of LDH (363.2±83.6 vs. 445.3±115.2; P = 0.056), NLR [1.7 (1.0) vs. 3.0 (6.3); P=0.052] and CRP [0% vs. 81.8%; P < 0.001)] within two weeks compared to the standard group (Table 2).
There was no significant difference in the length of stay in the hospital [from randomization to discharge] between the two groups (treatment 7.6±3.5 days and standard 8.1±5.5 days; P = 0.587).

within two weeks

lassitude

mortality

fever

headache

gastrointestinal symptoms

improvement in the level of LDH

CRP

NLR

within two weeks

length of stay in the hospital

[from randomization to discharge]

ICU admission

intubation and mechanical ventilation


 Outcomes

The primary endpoint was the timing to achieve viral RNA negative conversion for SARS-CoV-2 in all three specimens, including nasopharyngeal swabs, throat swabs and stool swabs. When a COVID-19 patient was discharged from hospital, the viral RNA negative conversion of all three specimens needed to be considered. The secondary clinical endpoint was the timing when CT imaging improvement was observed, which was mainly based on the size and density reduction of lesions. Safety data included adverse events during treatment, severe adverse events, and premature discontinuation of treatment. Adverse events were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 [23].

timing when CT imaging improvement

adverse events during treatment

severe adverse events

premature discontinuation of treatment


Main outcome measure Negative conversion of severe acute respiratory syndrome coronavirus 2 by 28 days, analysed according to the intention to treat principle. Adverse events were analysed in the safety population in which hydroxychloroquine recipients were participants who received at least one dose of hydroxychloroquine and hydroxychloroquine non-recipients were those managed with standard of care alone.

Outcome

The primary outcomes for this trial were whether patients had negative conversion of SARS-CoV-2 by 28 days and whether patients with severe covid-19 had clinical improvement by 28 days. However, as the trial was stopped early and only two patients with severe disease were enrolled, results on clinical improvement are not presented. We defined negative conversion of SARS-CoV-2 as two consecutive reports of a negative result for SARS-CoV-2 at least 24 hours apart without a subsequent report of a positive result by the end of the study. We considered the date of the first negative report as the date of negative conversion. In the original protocol, the primary endpoint was prespecified as the “Negative conversion rate by Day 10” (approved by the ethics committee on 6 February 2020). However, with the increasing knowledge of covid-19 from our clinical practice, we realised that the duration of SARS-CoV-2 in respiratory samples of many patients was longer than 10 days, recently highlighted by a detailed virological study.14 We therefore modified our primary outcome to test whether patients had a negative conversion of SARS-CoV-2 by 28 days (approved by the ethics committee on 17 February 2020). Probability of negative conversion at day 4, 7, 10, 14, or 21 was specified as a secondary outcome in the protocol, but this does not appear on the trial registration list. The listed secondary outcome in the trial registration was adverse events coded using the latest version of Medical Dictionary for Regulatory Activities coding dictionary, recorded in standard medical terminology and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events.

Other prespecified secondary outcomes not listed in the trial registration but included in the protocol were the probabilities of alleviation of clinical symptoms; improvement of C reactive protein, erythrocyte sedimentation rate, tumour necrosis factor α, interleukin 6, and absolute blood lymphocyte count; improvement of lung lesions on chest radiology; all cause death; and disease progression in patients with mild to moderate disease. The time frame for these secondary outcomes was from randomisation to 28 days. Prespecified secondary outcomes for patients with severe disease are not listed here but are included in the protocol. Owing to the early termination of our study, we could not justify the results from these analyses with an underpowered sample size and therefore decided not to emphasise them in this paper to avoid misinterpretation. The only one presented here is the alleviation of clinical symptoms within 28 days, which is an important outcome of interest prespecified in our protocol. The definition of the alleviation of clinical symptoms was resolving from fever to an axillary temperature of 36.6°C or below, normalisation of SpO2 (>94% on room air), and disappearance of respiratory symptoms including nasal congestion, cough, sore throat, sputum production, and shortness of breath.

negative conversion of SARS-CoV-2

clinical improvement

by 28 days

Negative conversion rate

Probability of negative conversion

at day 4, 7, 10, 14, or 21

adverse events

improvement of C reactive protein

erythrocyte sedimentation rate

tumour necrosis factor α

interleukin 6

absolute blood lymphocyte count

all cause death

from randomisation to 28 days

alleviation of clinical symptoms

within 28 days

by 28 days

by Day 10

negative conversion of SARS-CoV-2

by 28 days

by 28 days

Adverse events


Study arms and treatment plans

Patients were randomly divided into two treatment groups, a case group comprising 56 patients and a control group comprising 55 patients. On the first day of admission, laboratory studies including complete blood count and erythrocyte sedimentation rate (ESR) were performed. The case group received oral AZM 500 mg daily, oral LPV/r 400/100 mg twice daily and oral HCQ 400 mg daily. The control group received oral LPV/r 400/100 mg twice daily and oral HCQ 400 mg daily; for both treatment groups, all medications were administered for 5 days.

On the first day of admission, for patients assigned to the case treatment group, the risk for ventricular arrhythmia in concurrent treatment with HCQ and AZM was calculated based on the proposed guideline by the ACC [23], and patients with a score of ≥7 were excluded from the study.

Patients were assessed by daily measurements of core body temperature, respiratory rate, heart rate and peripheral capillary oxygen saturation (SpO2). Daily electrocardiogram (ECG) studies were also conducted to monitor possible evolution of heart rate-corrected QT (QTc) interval prolongation, in which case, treatment with AZM and HCQ would have been stopped. For correction of the QT interval, Bazett's formula (QTc = QT/√RR) was used [24]. In case of deterioration in general and/or pulmonary condition, methylprednisolone was prescribed [25]. Patients were discharged when they achieved a stable SpO2 > 92%, had no respiratory distress and were afebrile for 3 consecutive days. The primary endpoints in this trial were a decrease in mortality, duration of hospitalisation and need for intensive care unit (ICU) admission. Secondary endpoints were determined as improvements in SpO2 and vital signs as well as the general wellbeing of the patient.

Sample size calculation was performed for non-inferiority tests of difference between two group proportions. We assumed an effectiveness of 65% for the intervention group and effectiveness of 50% for the control group. We also assumed a margin of non-inferiority of at least 10% between the two groups. With these assumptions, a sample size of 48 cases in each group was calculated. After consideration of a dropout rate of 10%, the total sample size of 110 cases was calculated. The power of the study was determined as 90% (G*Power, Erdfelder, Faul, & Buchner, 1996).

complete blood count

erythrocyte sedimentation rate (ESR)

risk for ventricular arrhythmia

core body temperature

respiratory rate

heart rate

daily measurements

electrocardiogram (ECG)

Daily

decrease in mortality

duration of hospitalisation

improvements in SpO2 and vital signs

general wellbeing of the patient


 Outcome measures
The primary outcome of this study was the rate of hospitalization. Secondary outcomes were clinical improvements (e.g., resolution of fever, cough and dyspnea) and improvement of CT findings at days 14 after initiation of the treatment. Patients were assessed clinically (e.g., temperature, respiratory rate, cough, and dyspnea) and paraclinically (e.g., CBC-diff and C-Reactive Protein) at onset of admission and 5th day of treatment. In addition, the chest CT scans were done at first and 14 days after the onset of treatment. For each patient, the chest CT scan was evaluated for the presence of groundglass opacities and/or consolidation. Each five lobe of the lung was assessed and the overall lung involvement was reached by summing the five lobe scores (range of possible scores, 0 – 20 for each lobe and total lung involvement of possible score of 0-100 percent). The Chest CT was repeated in day 14 and compared with the initial finding. Reduced lung CT involvement; not adjusted" values were computed according to this equation:
Reduced Lung CT involvement, not adjusted =
Day 14 total long involvement – Initial total lung involvement
Reduced lung CT involvement; adjusted values was computed with the following equation that included the initial total lung involvement in the denominator:
Reduced lung CT involvement; adjusted value = (Initial total long involvement ― Day 14 total long involvement)
Initial total lung involvement

rate of hospitalization

improvement of CT findings

in day 14


Primary outcomes and Secondary outcomes

The primary outcome of this study was the SOFA Score, and the secondary outcome was the all-cause mortality up to 30 days. All outcomes were determined by an independent clinical endpoint determination committee.

SOFA Score

all-cause mortality

up to 30 days


Abstract. The COVID-19 pandemic is showing an exponential growth, mandating an urgent need to develop an effective treatment. Indeed, to date, a well-established therapy is still lacking. We aimed to evaluate the safety and efficacy of hydroxychloroquine (HCQ) added to standard care in patients with COVID-19. This was a multicenter, randomized controlled trial conducted at three major university hospitals in Egypt. One hundred ninety-four patients with confirmed diagnosis of COVID-19 were included in the study after signing informed consent. They were equally randomized into two arms: 97 patients administrated HCQ plus standard care (HCQ group) and 97 patients administered only standard care as a control arm (control group). The primary endpoints were recovery within 28 days, need for mechanical ventilation, or death. The two groups were matched for age and gender. There was no significant difference between them regarding any of the baseline characteristics or laboratory parameters. Four patients (4.1%) in the HCQ group and 5 (5.2%) patients in the control group needed mechanical ventilation (P = 0.75). The overall mortality did not differ between the two groups, as six patients (6.2%) died in the HCQ group and 5 (5.2%) died in the control group (P = 0.77). Univariate logistic regression analysis showed that HCQ treatment was not significantly associated with decreased mortality in COVID-19 patients. So, adding HCQ to standard care did not add significant benefit, did not decrease the need for ventilation, and did not reduce mortality rates in COVID-19 patients

recovery

need for mechanical ventilation

death

within 28 days


Clinical study
Patients
The study was initially designed as a multi-center study across hospitals in Changsha city and in other cities of Hunan Province,
China. However, per a government order, all patients from hospitals in Changsha city had to be relocated to the First Hospital of Changsha, a designated treatment center for all COVID-19 patients in Changsha city, and hospitals in other cities of Hunan
Province were not able to participate due to various reasons. The study was changed to a single-center study. This study was approved by the ethics committee of the First Hospital of Changsha (file number KX-2020002) and was conducted at the hospital. The study was also registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn/), number ChiCTR2000029496.
Hospitalized COVID-19 patients with confirmed SARS-CoV-2 detection, clinically classified as moderate or severe, at an age over 18 years, and without comorbidity of severe heart, lung, or brain diseases, were eligible for enrolling into this study. Moderate patients were defined as “patients with fever, symptoms of the respiratory system and pneumonia changes in CT images, and severe patients were defined as “patients with any of the following: (1) Respiratory distress, respiratory frequency  30/ min; (2) Under rest status, arterial oxygen saturation (SaO2 )  93%; (3) Arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2)  300 mmHg. In this study, we aimed to observe moderate and severe COVID-19 patients as these patients would likely benefit more from antiviral treatments.
Trial design and treatments
This was a randomized, open-label, parallel-group study.
Patients eligible for the study were assigned, in a 1:1:1 ratio, to
Novaferon, Novaferon plus Lopinavir/Ritonavir, or Lopinavir/
Ritonavir group. An SAS generated simple randomization schedule was prepared by a statistician not involved in the trial. Using the order in which they enrolled in the study, patients were assigned to a treatment group that was implemented by a research assistant.
Informed consent was obtained from all enrolled patients.
Antiviral effects were assessed on day three, day six, and day nine after starting drug administration.
The approved dosage of Novaferon for hepatitis B application is the daily injection of 10 mg of protein in 1.0 ml volume per vial.
Lopinavir/Ritonavir (Kaletra) was manufactured by AbbVie Inc.; each tablet contained 200 mg of Lopinavir and 50 mg of Ritonavir.
The total daily doses (40 mg) of Novaferon were administered to patients twice per day by oxygen-driven aerosolized inhalation for 15 min of 20 mg of Novaferon (2  1 ml vials) diluted with saline.
For patients receiving Lopinavir/Ritonavir (Kaletra), two tablets were orally taken twice per day. The aerosolized inhalation was administrated to hospitalized patients in the negative-pressure wards at the designated COVID-19 center to minimize the risk of disease transmission.
Assessments
Samples of nasopharyngeal swabs on day three, day six, and day nine during the seven to ten-day course of antiviral treatment were collected from the patients and tested for SARS-CoV-2 nucleic acids by RT-PCR. SARS-CoV-2 clearance in COVID-19 patients was defined as two consecutive negative-detection of SARS-CoV-2 RNA in nasopharyngeal swab samples with an interval of over 24 h.
Adverse events were monitored throughout the trial, reported and graded based on the WHO Toxicity Grading Scale for Determining the Severity.
The peak levels of the SARS virus were around ten days after onset, and then the viral level began to decrease without effective antiviral treatment in SARS patients (Peiris et al., 2003).
Considering the homology of gene sequences of SARS-CoV-2 and SARS was over 90% (Zhu et al., 2020), we assumed that the intervention of antiviral drugs in COVID-19 patients would likely enhance or shorten the time to viral clearance. In this regard, this study's primary endpoint was chosen based on the SARS-CoV-2  clearance rates in COVID-19 patients assessed on day six of antiviral treatment. The secondary endpoint was the median time to SARS-CoV-2 clearance

on day three, day six, and day nine

Adverse events

SARS-CoV-2  clearance rates

on day six of antiviral treatment

median time to SARS-CoV-2 clearance


Outcomes

The primary clinical endpoint was time to clinical improvement within 28 days after randomisation. Clinical improvement was defined as a two-point reduction in patients' admission status on a six-point ordinal scale, or live discharge from the hospital, whichever came first. The six-point scale was as follows: death=6; hospital admission for extracorporeal membrane oxygenation or mechanical ventilation=5; hospital admission for non-invasive ventilation or high-flow oxygen therapy=4; hospital admission for oxygen therapy (but not requiring high-flow or non-invasive ventilation)=3; hospital admission but not requiring oxygen therapy=2; and discharged or having reached discharge criteria (defined as clinical recovery—ie, normalisation of pyrexia, respiratory rate <24 breaths per minute, saturation of peripheral oxygen >94% on room air, and relief of cough, all maintained for at least 72 h)=1. The six-point scale was modified from the seven-point scale used in our previous COVID-19 lopinavir–ritonavir RCT11 by combining the two outpatient strata into one.

Secondary outcomes were the proportions of patients in each category of the six-point scale at day 7, 14, and 28 after randomisation; all-cause mortality at day 28; frequency of invasive mechanical ventilation; duration of oxygen therapy; duration of hospital admission; and proportion of patients with nosocomial infection. Virological measures included the proportions of patients with viral RNA detected and viral RNA load (measured by quantitative RT-PCR). Safety outcomes included treatment-emergent adverse events, serious adverse events, and premature discontinuations of study drug.

time to clinical improvement

within 28 days after randomisation

all-cause mortality

at day 28

duration of oxygen therapy

duration of hospital admission

treatment-emergent adverse events

serious adverse events


Outcomes
Primary and Secondary Outcomes

The primary efficacy end point was the percentage of subjects with viral negative by Day 14 and the time from randomization to clinical improvement, defined as the time from randomization to an improvement of two points (from the status at randomization) on a seven-category ordinal scale or live discharge from the hospital, whichever came first. The ordinal scale, which is refer to National Early Warning Score 2 (NEWS2), have been used as end points in clinical trials in patients hospitalized with COVID-19. Secondary clinical end points included the percentage of subjects with viral negative by Day 7, the incidence of mechanical ventilation by Day 14, ICU admission by Day 14, and all-cause mortality by Day14.

by Day 14

by Day 7

incidence of mechanical ventilation

by Day 14

ICU admission

by Day 14

all-cause mortality

by Day14


Outcomes
The primary endpoint was time to achieve a negative RT-PCR result for SARS-CoV-2 in a nasopharyngeal swab sample. Secondary clinical endpoints were time to resolution of symptoms defined as a NEWS2 of 0 maintained for 24 h; daily NEWS2 and sequential organ failure assessment (SOFA) score; length of hospital stay; and 30-day mortality. Other virological endpoints included the time to achieve negative SARS-CoV-2 RT-PCR in all clinical samples, including nasopharyngeal swab, posterior oropharyngeal saliva, throat swab, stool, and urine; daily viral load changes in the first 7 days; and emergence of amino acid mutations in the nsp5 gene encoding a 3C-like protease.
The serum cytokine response was also measured.
Safety endpoints were the frequencies and duration of adverse events

time to resolution of symptoms

a NEWS2 of 0 maintained for 24 h

length of hospital stay

mortality

daily viral load changes

in the first 7 days

serum cytokine response

daily


 Outcomes

The primary outcome was the time to recovery, defined as the first day, during the 28 days after enrollment, on which a patient met the criteria for category 1, 2, or 3 on the eight-category ordinal scale. The categories are as follows: 1, not hospitalized and no limitations of activities; 2, not hospitalized, with limitation of activities, home oxygen requirement, or both; 3, hospitalized, not requiring supplemental oxygen and no longer requiring ongoing medical care (used if hospitalization was extended for infection-control or other nonmedical reasons); 4, hospitalized, not requiring supplemental oxygen but requiring ongoing medical care (related to Covid-19 or to other medical conditions); 5, hospitalized, requiring any supplemental oxygen; 6, hospitalized, requiring noninvasive ventilation or use of high-flow oxygen devices; 7, hospitalized, receiving invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO); and 8, death.

The key secondary outcome was clinical status at day 15, as assessed on the ordinal scale. Other secondary outcomes included the time to improvement of one category and of two categories from the baseline ordinal score; clinical status as assessed on the ordinal scale at days 3, 5, 8, 11, 15, 22, and 29; mean change in status on the ordinal scale from day 1 to days 3, 5, 8, 11, 15, 22, and 29; time to discharge or National Early Warning Score of 2 or less (maintained for 24 hours), whichever occurred first; change in the National Early Warning Score from day 1 to days 3, 5, 8, 11, 15, 22, and 29; number of days with supplemental oxygen, with noninvasive ventilation or high-flow oxygen, and with invasive ventilation or ECMO up to day 29 (if these were being used at baseline); the incidence and duration of new oxygen use, of noninvasive ventilation or high-flow oxygen, and of invasive ventilation or ECMO; number of days of hospitalization up to day 29; and mortality at 14 and 28 days after enrollment. Secondary safety outcome measures included grade 3 and 4 adverse events and serious adverse events that occurred during the trial, discontinuation or temporary suspension of infusions, and changes in assessed laboratory values over time.

time to recovery

clinical status

at day 15

as assessed on the ordinal scale

at days 3, 5, 8, 11, 15, 22, and 29

during the trial

up to day 29

number of days of hospitalization

up to day 29

mortality

at 14 and 28 days after enrollment

grade 3 and 4 adverse events

serious adverse events


A 4.5 mm fibreoptic bronchoscope (UE Medical Company Ltd, Zhejiang, China) loaded with a lubricated reinforced Parker Flex-Tip® tracheal tube (Well Lead Medical Company Ltd., Guangzhou, China) was inserted until the carina was visualised, and the tube was advanced over the bronchoscope into the trachea. During attempts at tracheal intubation, HFNO was maintained for the HFNO group, whereas no oxygen was administered for the SMO group. After removal of the bronchoscope, successful intubation was confirmed by capnography. If Spo2 <90% occurred during intubation, bronchoscopy was terminated and face-mask ventilation was initiated to correct desaturation. The primary endpoint was the total time of intubation, defined as the sum of the time spent from the beginning of bronchoscopy until proper tracheal tube placement was confirmed. The secondary endpoints included the lowest Spo2 during intubation, incidence of mask ventilation for Spo2 <90%, Pao2/Fio2 before intubation, incidence of Spo2 <80% during intubation, incidence of minimum Spo2 >95% during intubation, and 7 day mortality.

total time of intubation

lowest Spo2 during intubation

Pao2/Fio2 before intubation

mortality

7 day


 End Points

The primary efficacy end point was clinical status assessed on day 14 on a 7-point ordinal scale consisting of the following categories: 1, death; 2, hospitalized, receiving invasive mechanical ventilation or ECMO; 3, hospitalized, receiving noninvasive ventilation or high-flow oxygen devices; 4, hospitalized, requiring low-flow supplemental oxygen; 5, hospitalized, not requiring supplemental oxygen but receiving ongoing medical care (related or not related to Covid-19); 6, hospitalized, requiring neither supplemental oxygen nor ongoing medical care (other than that specified in the protocol for remdesivir administration); and 7, not hospitalized (see Table S1 in the Supplementary Appendix, available at NEJM.org).

The secondary end point of the trial was the proportion of patients with adverse events that occurred on or after the first dose of remdesivir for up to 30 days after the last dose. Prespecified exploratory end points included the time to clinical improvement (defined as an improvement of at least 2 points from baseline on the 7-point ordinal scale), the time to recovery (defined by the National Institute of Allergy and Infectious Diseases [NIAID] as an improvement from a baseline score of 2 to 5 to a score of 6 or 7), the time to modified recovery (defined as an improvement from a baseline score of 2 to 4 to a score of 5 to 7 or from a score of 5 to a score of 6 or 7), and death from any cause.

clinical status

on day 14

time to clinical improvement

time to recovery

time to modified recovery

death from any cause


 Outcomes

The primary efficacy end point was the time to clinical improvement, defined as the time from randomization (D0) to an improvement of 2 points on a 7-category ordinal scale or live discharge from the hospital (Dend), and improvement rate of follow-up CT scans at D14. The 7-category ordinal scale has been used in other COVID-19 randomized controlled trials31 and also recommended by the World Health Organization R&D Blueprint expert group32 (see this article’s Methods section in the Online Repository). Other clinical outcomes included clinical improvement rate as assessed with the 7-category ordinal scale on D7, D14, D21, and D28, time from randomization to lymphocyte recovery and to invasive mechanical ventilation, the duration of hospitalization in survivors, and the time from treatment initiation to death and virus clearance time. The primary safety end point was the incidence of serious adverse events occurring up to 28 days. Safety outcomes included adverse events and serious adverse events that occurred during treatment. Particularly, the eventual negative impact of ruxolitinib on SARS-CoV-2 virus clearance and its specific IgM and/or IgG-antibody formation and/or lymphocyte recovery was also included in the safety profile. Lymphopenia was defined as peripheral absolute lymphocytes less than 1.0 × 109/L. Lymphocyte recovery time was defined as the first day at which lymphocytes returned to the normal levels within the observation period. The virus clearance time was defined as the time from randomization to the first day of at least 2 consecutive negative RT-PCR assays separated by 24 hours apart. The secondary end point is the overall mortality at D28. The investigational outcomes included the dynamic changes in the virus copies, cytokine profile, SARS-CoV-2–speicific antibody, and its correlation with clinical treatment response.

time to clinical improvement

at D14

clinical improvement rate

on D7, D14, D21, and D28

time from treatment initiation to death

incidence of serious adverse events

up to 28 days

serious adverse events

IgM and/or IgG-antibody formation

lymphocyte recovery

overall mortality

at D28

virus clearance time

dynamic changes in the virus copies

cytokine profile

SARS-CoV-2–speicific antibody


ABSTRACT
To the best of our knowledge, there is no published study on the use of interferon-1a (IFN-1a) in the treatment of severe COVID-19. In this randomized clinical trial, the efficacy and safety of IFN-1a were evaluated in patients with severe COVID-19. Forty-two patients in the interferon group received IFN-1a in addition to the national protocol medications (hydroxychloroquine plus lopinavirritonavir or atazanavir-ritonavir). Each 44g/ml (12 million IU/ml) dose of interferon-1a was subcutaneously injected three times weekly for two consecutive weeks.
The control group consisted of 39 patients who received only the national protocol medications. The primary outcome of the study was time to reach clinical response.
Secondary outcomes were duration of hospital stay, length of intensive care unit stay, 28-day mortality, effect of early or late administration of IFN on mortality, adverse effects, and complications during the hospitalization. Between 29 February and 3 April 2020, 92 patients were recruited, and a total of 42 patients in the IFN group and 39 patients in the control group completed the study. As the primary outcome, time to the clinical response was not significantly different between the IFN and the control groups (9.7  5.8 versus 8.3  4.9 days, respectively, P  0.95). On day 14, 66.7% versus 43.6% of patients in the IFN group and the control group, respectively, were discharged (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.05 to 6.37). The 28-day overall mortality was significantly lower in the IFN than the control group (19% versus 43.6%, respectively, P  0.015). Early administration significantly reduced mortality (OR, 13.5; 95% CI, 1.5 to 118). Although IFN did not change the time to reach the clinical response, adding it to the national protocol significantly increased discharge rate on day 14 and decreased 28-day mortality. (This study is in the Iranian Registry of Clinical Trials under identifier IRCT20100228003449N28.)

time to reach clinical response

duration of hospital stay

length of intensive care unit stay

mortality

adverse effects


 Main Outcomes and Measures  Primary outcome was time to clinical improvement within 28 days, defined as patient discharged alive or reduction of 2 points on a 6-point disease severity scale (ranging from 1 [discharge] to 6 [death]). Secondary outcomes included 28-day mortality, time to discharge, and the rate of viral polymerase chain reaction (PCR) results turned from positive at baseline to negative at up to 72 hours.

Outcome Measures

The primary end point was time to clinical improvement within a 28-day period. Clinical improvement was defined as patient discharge or a reduction of 2 points on a 6-point disease severity scale.13 The scale was defined as follows: 6 points, death; 5 points, hospitalization plus extracorporeal membrane oxygenation (ECMO) or invasive mechanical ventilation; 4 points, hospitalization plus noninvasive ventilation or high-flow supplemental oxygen; 3 points, hospitalization plus supplemental oxygen (not high-flow or noninvasive ventilation); 2 points, hospitalization with no supplemental oxygen; 1 point, hospital discharge.

Patient discharge criteria included body temperature returned to normal for longer than 3 days, respiratory symptoms significantly improved without the need for oxygen support, and 2 consecutive negative PCR test results from nasopharyngeal swabs at least 24 hours apart.

Secondary clinical outcomes were as follows: (1) 28-day mortality, including analysis of time from randomization to death; (2) duration of hospitalization, including analyses of time from randomization to discharge, time from admission to discharge, and 28-day discharge rates; and (3) conversion of nasopharyngeal swab viral PCR results from positive at baseline to negative at follow-up assessed at 24, 48, and 72 hours. Once nasopharyngeal swab viral PCR testing yielded negative results 2 times consecutively, no further testing was performed.  A post hoc analysis was added to compare rates of improvement at days 7, 14, and 28.

This clinical trial was an open-label, randomized clinical study. To avoid assessment bias, the evaluation of clinical outcomes was performed by an investigator who was blind to the study group allocation.

time to clinical improvement

within 28 days

mortality

time to discharge

at up to 72 hours

mortality

duration of hospitalization

at 24, 48, and 72 hours

rates of improvement

at days 7, 14, and 28


Outcomes
The primary outcome was the rate of positive-to-negative conversion of SARS-CoV-2 nucleic acid from the initiation of treatment to day 21, with the enrollment day as the first day of treatment. The secondary outcomes were: 1) the rate of positive-to-negative conversion of SARS-CoV-2 nucleic acid at day 14; 2) the rate of antipyresis (defined as axillary temperature ≤37.3°C for more than 72 hours) from the first day of treatment; 3) the rate of cough alleviation from initiation; 4) the improvement rate of chest CT at days 7 and 14; 5) the deterioration rate of clinical status from mild/moderate to severe/critical status during the study period. The severe status was defined as meeting any of the following criteria: experiencing respiratory distress, RR≥30 times/minute; oxygen saturation ≤93% in the resting state; arterial blood oxygen partial pressure (PaO2)/oxygen concentration (FiO2) ≤300 mmHg (1mmHg = 0.133kPa).5 The critical status was defined as meeting any of the following criteria: development of respiratory failure requiring mechanical ventilation; occurrence of shock; requirement for ICU monitoring and treatment because of complications with other organ failures.5
Specimens from pharyngeal swabs were tested every 2 to 3 days. Negative conversion of nucleic acid was defined as negative detection of SARS-CoV-2 nucleic acid for two consecutive instances separated by more than 24 hours.
Criteria of chest CT improvement included: 1) no new exudative lesions; 2) decreasing size of exudative lesions; 3) decreasing densities of lesions.
All participants were monitored for adverse events. Safety outcomes were assessed from serious adverse event reports. Any unexpected medical occurrence resulting in death, prolonged hospitalization, persistent or significant disability or incapacity, which was judged to be causally related to the study intervention, would be reported as a serious adverse event to the
Institutional Review Board. Potential adverse events for the study were defined as follows (1) anaphylaxis; (2) elevation of ALT or AST to more than 2.5-fold the upper normal limit or elevation of TBIL to more than 1.5-fold the upper normal limit; (3) acute pancreatitis; and (4) diarrhea.

at day 14

the rate of antipyresis

from the first day of treatment

improvement rate of chest CT

at days 7 and 14

during the study period

adverse events

serious adverse event


 Outcome Measures

The primary outcome was all-cause mortality within 28 days after randomization; further analyses were specified at 6 months. Secondary outcomes were the time until discharge from the hospital and, among patients not receiving invasive mechanical ventilation at the time of randomization, subsequent receipt of invasive mechanical ventilation (including extracorporeal membrane oxygenation) or death. Other prespecified clinical outcomes included cause-specific mortality, receipt of renal dialysis or hemofiltration, major cardiac arrhythmia (recorded in a subgroup), and receipt and duration of ventilation. Among those receiving invasive mechanical ventilation at the time of randomization, the outcome of successful cessation of invasive mechanical ventilation was defined as cessation within (and survival to) 28 days. All information presented in this report is based on a data cutoff of December 14, 2020. Information regarding the primary and secondary outcomes is complete for 99.9% of trial participants.

all-cause mortality

time until discharge from the hospital

cause-specific mortality

major cardiac arrhythmia

receipt and duration of ventilation


 Outcomes

The primary outcome measurement for this study was time to clinical recovery (TTCR), defined as the number of days from randomization to clinical recovery. Maximum TTCR was 28 days. Patients were considered to have achieved clinical recovery when they had met all of the following criteria for at least 48 hours: 1. axillary body temperature ≤36.9°C or oral body temperature ≤37.2°C; 2. complete relief of all symptoms other than cough; 3. cough graded as mild or absent on a patient-reported scale of severe, moderate, mild, absent.

Secondary outcome measurements included (up to 28 days): 1. time to SARS-CoV-2 RNA negativity, defined as the time from randomization to the day of the first test in two consecutive tests of nasopharyngeal or oropharyngeal swabs with negative SARS-CoV-2 RNA; 2. length of hospital stay, defined as the number of days from randomization to discharge; 3. Changes on chest CT scan; 4. duration (days) of supplemental oxygenation; 5. frequency of adverse events; 6. clinical status; 7. all-cause mortality; 8. duration (days) of supplemental oxygenation; 9. vital signs; 10. results of laboratory testing.

We used a semi-quantitative scoring system similar to the method reported by Pan et al. to estimate the pulmonary manifestations on CT scan [16]. The five lobes of the lungs were assigned a total score of 20 points, based on the volume of tissue affected. The score was given based on the overall affected areas of each side of the lung. Every 10% of affected areas from each lung can be recorded 1 point. Changes in cytokine levels and COVID-19-specific IgG/IgM levels were measured during the first week of hospitalization.

time to clinical recovery (TTCR)

up to 28 days

Maximum TTCR was 28 days

time to SARS-CoV-2 RNA negativity

length of hospital stay

Changes on chest CT scan

frequency of adverse events

clinical status

all-cause mortality

vital signs

results of laboratory testing

Changes in cytokine levels

COVID-19-specific IgG/IgM levels


Outcome Measures

The primary end point was the time to clinical improvement, defined as the time from randomization to an improvement of two points (from the status at randomization) on a seven-category ordinal scale or live discharge from the hospital, whichever came first. The end point of clinical improvement was used in our previous influenza study17 and was also recommended by the WHO R&D Blueprint expert group.18 Ordinal scales have been used as end points in clinical trials in patients hospitalized with severe influenza.16-19 The seven-category ordinal scale consisted of the following categories: 1, not hospitalized with resumption of normal activities; 2, not hospitalized, but unable to resume normal activities; 3, hospitalized, not requiring supplemental oxygen; 4, hospitalized, requiring supplemental oxygen; 5, hospitalized, requiring nasal high-flow oxygen therapy, noninvasive mechanical ventilation, or both; 6, hospitalized, requiring ECMO, invasive mechanical ventilation, or both; and 7, death.

Other clinical outcomes included clinical status as assessed with the seven-category ordinal scale on days 7 and 14, mortality at day 28, the duration of mechanical ventilation, the duration of hospitalization in survivors, and the time (in days) from treatment initiation to death. Virologic measures included the proportions with viral RNA detection over time and viral RNA titer area-under-the-curve (AUC) measurements.

Safety outcomes included adverse events that occurred during treatment, serious adverse events, and premature discontinuation of treatment. Adverse events were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0.

time to clinical improvement

clinical status

on days 7 and 14

mortality

at day 28

duration of mechanical ventilation

adverse events

serious adverse events

premature discontinuation of treatment


 Main Outcomes and Measures  Primary end points were (1) maximum high-sensitivity cardiac troponin level; (2) time for C-reactive protein to reach more than 3 times the upper reference limit; and (3) time to deterioration by 2 points on a 7-grade clinical status scale, ranging from able to resume normal activities to death. Secondary end points were (1) the percentage of participants requiring mechanical ventilation, (2) all-cause mortality, and (3) number, type, severity, and seriousness of adverse events. The primary efficacy analysis was performed on an intention-to-treat basis.

End Points

Study end point analysis was planned to be performed in 2 phases, an early biochemical phase and a later clinical phase. The coprimary end points of the biochemical phase were the difference in maximal high-sensitivity cardiac troponin (hs cTn) levels between the 2 groups and the time for C-reactive protein to reach levels greater than 3 times the upper reference limit. The primary end point of the clinical phase was the time from baseline to clinical deterioration, defined as a 2-grade increase on an ordinal clinical scale, based on the World Health Organization R&D Blueprint Ordinal Clinical Scale,9 as used in previously published studies,10 within a time frame of 3 weeks after randomization or until hospital discharge (whichever occurred first). The 7-grade ordinal scale consisted of the following levels: 1, ambulatory, normal activities; 2, ambulatory but unable to resume normal activities; 3, hospitalized, not requiring supplemental oxygen; 4, hospitalized, requiring supplemental oxygen; 5, hospitalized, requiring nasal high-flow oxygen therapy, noninvasive mechanical ventilation, or both; 6, hospitalized, requiring extracorporeal membrane oxygenation, invasive mechanical ventilation, or both; and 7, death. Secondary end points were the percentage of participants requiring mechanical ventilation, all-cause mortality at the end of follow-up, and the number, type, severity, and seriousness of total adverse events and treatment-related adverse events.

all-cause mortality

all-cause mortality

at the end of follow-up


 Intervention, primary and secondary endpoints
Patients were randomly assigned via a web-based system at a 1:1 ratio to the current standard of care at each hospital with or without the addition of 300ml of ConvP, the standard volume of one plasma unit produced by Sanquin Blood Supply, was administered intravenously on the day of inclusion. Patients without a clinical response and a persistently positive RT-PCR could receive a second plasma unit after five days. Off-label use of EMA-approved drugs (e.g. chloroquine, azithromycin, lopinavir/ritonavir, tocilizumab, anakinra) as a treatment for COVID-19 was allowed in hospitals were this was part of the standard of care. We scored the clinical status with the ordinal 8-point WHO COVID-19 disease severity scale on days 1, 15 and 30. 16 Serum samples and nasopharyngeal swabs were collected at inclusion preceding treatment and thereafter. The primary endpoint of the study was overall mortality until discharge from the hospital or a maximum of 60 days after admission whichever came first.
Key secondary clinical endpoint we describe here are the improvement on the 8-point WHO COVID-19 disease severity scale from inclusion to day 15, hospital length of stay and safety.

overall mortality

from inclusion to day 15

hospital length of stay

safety

on days 1, 15 and 30


 End Points
The primary end point was viral clearance rate at day 7 after randomization. After randomization, respiratory samples were collected every 1–2 days until viral clearance. Viral clearance was defined as reverse transcriptase polymerase chain reaction (RT-PCR) negative on at least 2 consecutive oropharyngeal swabs collected at least 1–2 days apart. Secondary end points included viral clearance at day 3 and day 5, the critical illness rate of subjects during the 14 days after randomization, the mortality rate of subjects at day 14, and the number of participants with treatment-related adverse events.

viral clearance rate

at day 7 after randomization

viral clearance

at day 3 and day 5

critical illness rate of subjects

during the 14 days after randomization

the mortality rate of subjects

at day 14


Outcome measures
Outcomes were assessed at 28 days after randomization, with further analyses specified at 6 months. The primary outcome was all-cause mortality. Secondary outcomes were time to discharge from hospital and, among patients not on invasive mechanical ventilation at randomization, invasive mechanical ventilation (including extra-corporal membrane oxygenation) or death. Subsidiary clinical outcomes included cause-specific mortality, use of hemodialysis or hemofiltration, major cardiac arrhythmia (recorded in a subset), and receipt and duration of ventilation

all-cause mortality

time to discharge from hospital

cause-specific mortality

use of hemodialysis or hemofiltration

major cardiac arrhythmia

receipt and duration of ventilation


 Outcomes

The primary outcome was the reduction of viral RNA load in nasopharyngeal swabs at days 3 and 7 after treatment start. The secondary outcomes were clinical progression measured using a simplified version of the WHO progression scale [17] (1, not hospitalized with or without resumption of normal activities; 2, hospitalized, requiring supplemental oxygen; 3, hospitalized, requiring invasive mechanical ventilation; and 4, death) and time from randomization to complete resolution of symptoms within the 28-day follow-up period. Resolution of symptoms was assessed sequentially using a symptoms questionnaire designed to gather information on the type of symptom and last day experienced; complete resolution was considered when no COVID-19–related symptoms were reported at all. Safety outcomes included AEs that occurred during treatment, SAEs, AEs of special interest (ie, cardiac), and premature discontinuation of therapy. AEs were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. All unexpected SAEs were notified through Eudravigilance.

reduction of viral RNA load

at days 3 and 7 after treatment start

clinical progression

within the 28-day follow-up period

AEs that occurred during treatment

SAEs

AEs of special interest (ie, cardiac)

premature discontinuation of therapy

WHO progression scale


Abstract

Objective: To evaluate the efficacy and safety of hydroxychloroquine (HCQ) in the treatment of patients with moderate coronavirus disease 2019 (COVID-19). Methods: We prospectively enrolled 30 treatment-naïve patients with confirmed COVID-19 after informed consent at Shanghai Public Health Clinical Center. The patients were randomized 1:1 to HCQ group and the control group. Patients in HCQ group were given HCQ 400 mg per day for 5 days plus conventional treatments, while those in the control group were given conventional treatment only. The primary endpoint was negative conversion rate of SARS-CoV-2 nucleic acid in respiratory pharyngeal swab on days 7 after randomization. This study has been approved by the Ethics Committee of Shanghai Public Health Clinical Center and registered online (NCT04261517). Results: One patient in HCQ group developed to severe during the treatment. On day 7, nucleic acid of throat swabs was negative in 13 (86.7%) cases in the HCQ group and 14 (93.3%) cases in the control group (P>0.05). The median duration from hospitalization to virus nucleic acid negative conservation was 4 (1, 9) days in HCQ group, which is comparable to that in the control group [2 (1, 4) days, Z=1.27, P>0.05]. The median time for body temperature normalization in HCQ group was 1 (0, 2) day after hospitalization, which was also comparable to that in the control group [1 (0, 3) day]. Radiological progression was shown on CT images in 5 cases (33.3%) of the HCQ group and 7 cases (46.7%) of the control group, and all patients showed improvement in follow-up examinations. Four cases (26.7%) of the HCQ group and 3 cases (20%) of the control group had transient diarrhea and abnormal liver function (P>0.05). Conclusions: The prognosis of COVID-19 moderate patients is good. Larger sample size study are needed to investigate the effects of HCQ in the treatment of COVID-19. Subsequent research should determine better endpoint and fully consider the feasibility of experiments such as sample size.

on days 7 after randomization

median duration from hospitalization


Measurements:

Symptoms and severity at baseline and then at days 3, 5, 10, and 14 using a 10-point visual analogue scale. The primary end point was change in overall symptom severity over 14 days.

Study End Points

The initial primary outcome was an ordinal outcome by day 14 of not hospitalized, hospitalized, or intensive care unit stay or death. Secondary end points were symptom severity at day 5 and day 14 by 10-point visual analogue scale, nominal incidence of all hospitalizations and deaths, and incidence of study medicine withdrawal.

Changes in End Point and Sample Sizes

Before the first interim analysis on 24 April 2020, it became apparent that the pooled event rate of hospitalization or death was substantially lower than our initial 10% expectation (original sample size calculations as described in Statistical Analysis section). Without unblinding of treatment allocation or analysis of the data, the principal investigator proposed to the data and safety monitoring board (DSMB) that we modify the primary end point to the change in overall symptom severity over 14 days as longitudinally measured on a 10-point visual analogue scale. The DSMB approved the change on 24 April 2020. The change was necessary because the low event rate of hospitalizations or deaths in the trial would have required increasing the sample size to 6000 participants, which was not attainable. With enrollment of at least 200 participants per group, we determined that the revised trial would have 90% power (with a 2-sided α level of 0.05) to detect a statistically significant difference between the groups for a change in symptom severity score as small as 0.25 point on the 10-point visual analogue scale. The trial halted at the second DSMB meeting on 6 May 2020, when the DSMB determined that sufficient statistical power had been achieved to evaluate the primary outcome.

Outcomes and Follow-up

We collected self-reported survey data using the Research Electronic Data Capture (REDCap) system (13). We e-mailed participants follow-up surveys on days 1 (medication start date), 3, 5 (medication stop date), 10, and 14 to assess study medication adherence, adverse effects, presence and severity of COVID-19 symptoms, COVID-19 test results, and hospitalization status. If participants were hospitalized within 14 days, we continued follow-up past study completion to assess outcomes. We assessed symptom severity on a 10-point visual analogue scale, where 0 indicated no symptoms and 10 indicated severe symptoms (Supplement). Medication-related adverse events were collected with directed questioning on the most common adverse effects and an open-ended free-text field. For participants who did not respond to follow-up surveys, investigators used text messages, e-mails, or telephone calls to ascertain outcomes from them or their designated third-party contacts. If this was unsuccessful, investigators searched the internet for obituaries or other evidence of vital status.

change in overall symptom severity

over 14 days

by day 14

symptom severity

at day 5 and day 14

incidence of study medicine withdrawal

medication adherence

adverse effects

COVID-19 test results

hospitalization status

Medication-related adverse events


 Outcomes

The primary outcome was clinical status at 15 days, evaluated with the use of a seven-level ordinal scale. Scores on the scale were defined as follows: a score of 1 indicated not hospitalized with no limitations on activities; 2, not hospitalized but with limitations on activities; 3, hospitalized and not receiving supplemental oxygen; 4, hospitalized and receiving supplemental oxygen; 5, hospitalized and receiving oxygen supplementation administered by a high-flow nasal cannula or noninvasive ventilation; 6, hospitalized and receiving mechanical ventilation; and 7, death.

Secondary outcomes included clinical status at 7 days, evaluated with the use of a six-level ordinal scale (see below and see the Supplementary Appendix); an indication for intubation within 15 days; the receipt of supplemental oxygen administered by a high-flow nasal cannula or noninvasive ventilation between randomization and 15 days; duration of hospital stay; in-hospital death; thromboembolic complications; acute kidney injury; and the number of days alive and free from respiratory support up to 15 days. A day alive and free from respiratory support was defined as any day in which the patient did not receive supplemental oxygen or invasive or noninvasive mechanical ventilation, from randomization to day 15. Patients who died during the 15-day window were assigned a value of 0 days alive and free from respiratory support in this assessment. Safety outcomes are listed in the Supplementary Appendix. All the trial outcomes were assessed by the site investigators, who were aware of the trial-group assignments (except as noted above for patients who had been discharged before day 15 and who were assessed for the primary outcome by means of a blinded telephone interview). No formal adjudication of trial outcomes was performed.

clinical status

at 15 days

clinical status

at 7 days

indication for intubation

within 15 days

receipt of supplemental oxygen

between randomization and 15 days

duration of hospital stay

in-hospital death

thromboembolic complications

acute kidney injury

up to 15 days


 Abstract
Background. Interventions mitigating progression to mechanical ventilation in COVID 19 would markedly improve outcome and reduce healthcare utilization. We hypothesized that immunomodulation with IVIG would improve oxygenation and reduce length of hospital stay and progression to mechanical ventilation in COVID 19 pneumonia.
Methods. Patients with COVID 19 were randomized 1:1 to prospectively receive standard of care (SOC) plus IVIG 0.5 g/kg/day x 3 days with methylprednisolone 40 mg 30 minutes before infusion versus SOC alone.

Clinical data extraction and analysis. Relevant clinical and laboratory information was captured to allow for group comparisons, including the calculation of Charlson comorbidity index (https://www.mdcalc.com/charlson comorbidity index cci) and APACHE II acute illness severity score (https://www.mdcalc.com/apache ii score#next steps). The alveolar arterial (A a) gradient was calculated (https://www.mdcalc.com/a a o2 gradient) for each subject at the time of enrollment based on arterial blood gases when available or based on PaO2 extrapolated SpO2 and fraction of inspired oxygen (FiO2). Interleukin 6 was measured from blood 24 48 hours after enrollment (https://ltd.aruplab.com/Tests/Pub/0051537).

Clinical outcomes. The two patient groups were well matched with respect to their
Charlson comorbidity index and severity of illness APACHE 2 scores (Figure 2). Median
Charlson index was 2 for both groups. Median APACHE 2 score was 7 for SOC and 7.5 the IVIG study group. Figure 2 demonstrates the subjects in the control SOC and treatment IVIG group that developed a need for mechanical ventilation after study enrollment, denoted as the red data points. An overall trend is for receipt of mechanical ventilation in the IVIG group in the 2 patients with highest comorbidity and illness severity scores, whereas in the SOC group mechanical ventilation requirement developed across the entire spectrum of scores.
Among the entire enrolled and evaluated subjects in each arm, 2 patients in the IVIG arm and 7 patients in the control SOC arm developed a need for mechanical ventilation.
Among these 7 SOC patients, 6 received ventilation and 1 was made a ‘do not intubate’ and the patient expired within 24 hours. The difference in receipt of mechanical ventilation was not statistically significant between the two groups (p=0.12, Fisher exact test). Among subjects whose respiratory failure progressed to the need for mechanical ventilation, 1 of 2 IVIG subjects and 2 of 3 control subjects also received concomitant convalescent plasma. Concomitant glucocorticoid therapy was given to 5 of the 7 control subjects who progressed to mechanical ventilation. The use of remdesivir was .CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)
The copyright holder for this preprintthis version posted July 25, 2020.;https://doi.org/10.1101/2020.07.20.20157891doi:medRxiv preprint 11 dependent on its availability after May 13, 2020 and therefore all patients admitted after that date whose respiratory failure progressed to needing mechanical ventilation received it. This resulted in 1 of 2 IVIG patients and 3 of 7 SOC subjects that required ventilation receiving remdesivir.
Alveolar arterial (A a) gradients were calculated directly from arterial blood gas or estimated based on PaO2 and FiO2 measurement. Based on an increase in APACHE II severity of illness scoring associated with achieving and A a gradient of > 200 mm Hg (+2 points), subjects were stratified into those with A a gradient < 200 mm Hg or >200 mm Hg, corresponding to a PaO2/FiO2 of <140, or the approximate requirement of 6 liters O2 by nasal cannula for a PaO2 of <92%. As shown in Figure 3A, none of the 7 subjects (5 SOC, 2 IVIG) with A a gradient < 200 mm Hg progressed to mechanical ventilation, but for subjects with A a gradient of > 200 mm Hg at enrollment, the progression to mechanical ventilation was 7/12 (58%) in the SOC control arm vs 2/14 (14%) in the IVIG, a difference that was statistically significant (p=0.038, Fisher Exact test).
Evaluation of overall hospital course, including length of hospital stay and length of ICU stay also was highly dependent on A a gradient stratification. Among the 7 patients with A a gradient < 200 mm Hg, no patient required ICU stay during their illness and length of hospital stay were 3 8 days. However, for the subjects with A a gradient > 200 at enrollment, median length of hospital stay was 19 (range 4 30) and 11 (range 5 22) days for SOC and IVIG groups, respectively (p=0.013, Mann Whitney U test, Figure 3B).
Median ICU stay were 12.5 days (range 1 29) and 2.5 days (range 0 16) for SOC and IVIG, respectively (p=0.006, Mann Whitney U test, Figure 3C). Total ventilator patient .CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)
The copyright holder for this preprintthis version posted July 25, 2020.;https://doi.org/10.1101/2020.07.20.20157891doi:medRxiv preprint 12 days were 98 days for SOC (5.8 days/patient enrolled) and 23 days for the IVIG group (1.4 days/patient enrolled). The supplementary Figure shows schematically the hospital stays from the time of admission of the 33 enrolled patients with respect to medical floor and ICU stays with and without mechanical ventilation.
Improvement in oxygenation was evaluated by examining the PaO2/FiO2 ratio at the day of enrollment and 7 days after enrollment in individual subjects for SOC (Figure 4A) and IVIG (Figure 4B). Differences in day 7 PaO2/FiO2 minus enrollment PaO2/FiO2 are shown in Figure 4C for both groups, with negative numbers representing worsening in oxygenation. Among the entire subject population, median improvement PaO2/FiO2 for IVIG was +153 (range +35 to + 330) and was better than SOC +90 (range 115 to
+280), but did not reach statistical significance (p=0·057, Mann Whitney U test).
However, when refocusing on the higher risk patients with A a gradient >200 at enrollment, median improvement of PaO2/FiO2 for IVIG was significantly greater than SOC, with median (range) of +131 (+35 to +330) versus +44·5 ( 115 to +157) (p=0·01,
Mann Whitney U test).
Figure 4C denotes subjects in the SOC group who did not receive any glucocorticoid therapy as red data points. Seven subjects in SOC did not receive glucocorticoids, 4 of whom were in the low risk group with A a gradient < 200. Of the remaining 3 patients, 2 progressed to requiring mechanical ventilation, one of which was made do not intubate and died. PaO2/FiO2 changes between enrollment and day 7 of the 10 SOC patients who received glucocorticoid therapy (median 11 days) was median +53 (range 115 to
+216), a difference that remained significantly lower than the IVIG group (p=0.0057,
Mann Whiney U test). .CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)
The copyright holder for this preprintthis version posted July 25, 2020.;https://doi.org/10.1101/2020.07.20.20157891doi:medRxiv preprint

mechanical ventilation

Alveolar arterial (A a) gradients

Median ICU stay

median length of hospital stay

Improvement in oxygenation

receive any glucocorticoid therapy


 Outcomes assessment: The primary outcomes included virological and clinical evaluations.
Time to SARS-CoV-2 RNA negativization (absence of the virus according to the RT-PCR) in positive patients after starting antiviral therapy was the virological endpoint. It was expressed as the percentage of patients negative to SARS-CoV-2 by RT-PCR in throat exudate tissue calculated at 48, 72, 96 and 120 hours. Days to reach the viral negativization were analyzed by Kaplan-Meier plots and compared with a Log-rank test. Hazard Ratio with 95% CI of ratio was also calculated.
The clinical evaluation considered the time to progression to severe COVID-19 and it was calculated by the percentage of patients who became severely ill after the end of the antiviral treatment under investigation.

Time to SARS-CoV-2 RNA negativization

at 48, 72, 96 and 120 hours

clinical evaluation

time to progression to severe COVID-19


The objective of the pilot stage of the study was a preliminary assessment of the efficacy and safety of AVIFAVIR, and to select the optimal dosing regimen for further evaluation at the pivotal stage (Phase III). The primary efficacy endpoint at the pilot stage was the elimination of SARS-CoV-2 by Day 10 (defined as two negative PCR tests with at least a 24-hour interval). Qualitative Real-Time RT-PCR tests were performed at local laboratories of the clinical sites or in the central laboratory of Rospotrebnadzor.

The study assessments included daily vital signs, SpO2 and WHO Ordinal Scale for Clinical Improvement (WHO-OSCI); PCR for SARS-CoV-2 detection in nasopharyngeal and/or oropharyngeal swabs at baseline and on Days 5, 10, and 15; chest computed tomography (CT) scan at baseline and on Day 15; physical examination, complete blood count, biochemistry, C-reactive protein (CRP), urinalysis, and electrocardiogram at baseline and on Days 5 and 15. If not discharged from the hospital earlier, the patients attended follow-up visits on Day 22 and Day 29. All patients were followed until Day 29.

The “go-no-go” decision to start the pivotal stage of the study was based on the exact single-stage Phase II assessment at one-sided α = 0.05 and 80% power [8]. 13/18 (72.2%) or more patients would have been sufficient to demonstrate that the viral clearance in 80% of patients by Day 10 was plausible, and that the response was greater than the presumably noneffective level of 50%. The secondary endpoints that were assessed during the interim analysis were the rate of viral clearance by Day 5, time to normalization of clinical symptoms (ie, body temperature), changes on CT scan by Day 15, and incidence and severity of adverse events related to the study drug.

elimination of SARS-CoV-2

by Day 10

daily vital signs

PCR for SARS-CoV-2 detection

on Days 5, 10, and 15

chest computed tomography (CT) scan

at baseline and on Day 15

physical examination

complete blood count

biochemistry

C-reactive protein (CRP)

urinalysis

electrocardiogram

at baseline and on Days 5 and 15

rate of viral clearance

by Day 5

changes on CT scan

by Day 15


 Outcome measurement
The primary endpoint was to evaluate the efficacy of HCQ with respect to time to negative rRT-PCR assessments from randomization up to 14 days. The secondary endpoints were to evaluate the proportion of negative viral rRT-PCR on hospital day 14, the resolution of clinical symptoms (time to clinical recovery), the proportion of discharges by day 14, and the mortality rate. HCQ safety and tolerability were also evaluated.

from randomization up to 14 days

proportion of negative viral rRT-PCR

on hospital day 14

proportion of discharges

by day 14

mortality rate

HCQ safety

tolerability


Outcomes

The primary outcome was the difference in the interval from baseline (initiation of antiviral treatment) to SARS-CoV-2 nucleic acid negativity by nasopharyngeal swab among the three antiviral treatment groups, with each of these two tests at least 24 h apart. The secondary outcomes included the differences among the three groups in the proportion of patients with SARS-CoV-2 nucleic acid negativity at day 14, the mortality rate at day 28, the proportion of patients re-classified as severe cases during the study period, the incidence of adverse events during the study period, and the proportion of therapeutic discontinuations due to adverse events during the study period.  SARS-CoV-2 nucleic acid negativity was defined as the presence of negative SARS-COV-2 results in at least two consecutive nasopharyngeal swabs by reverse transcriptase polymerase chain reaction (RT-PCR), with an interval of at least 24 h between the two time points of swab-taking. Of the two consecutive negative RT-PCR test results, the first negative result was used to calculate the interval between baseline and SARS-COV-2 nucleic acid negativity.

mortality rate

at day 14

at day 28


 Methods:
Trial Design and Participants:
It is an open label, randomized clinical trial conducted at Bahria International Hospital, Lahore, to evaluate the effects of a combination therapy including Dexamethasone and Aprepitant in hospitalized patients with Covid-19. The trial was conducted in accordance with the principles of the
International Conference on Harmonization Good Clinical Practice guidelines and approved by the
Bahria International Hospital Ethic Committee and informed consent was obtained from the patients.
Randomization:
Case report form included demographics, major comorbidities, medication already being administered. Patients were divided randomly into two arms Control (A) and Interventioanl (B). Both the arms received routine management including Dexamethasone 20mg, but one arm received
Aprepitant capsule 80mg once a day as an addition for 3-5 days depending on the condition of patient.
Inclusion criteria was admitted patients above 18 years, both genders, lab confirmed Covid-19 positive based on PCR, more than 72 hours since the appearance of first symptoms. Patients with moderate to critical stages were included. Patients with respiratory diseases other than Covid-19 infection and pregnant females were excluded. Primary endpoint was total in hospital days and the duration of disease. Patients and care givers were not blinded to the allocated treatment. Lab investigations including total blood cell count, total leukocyte count, C-reactive protein, D-dimers, lactate dehydrogenase, oxygen saturation was performed on daily basis to monitor the status of patient.

total in hospital days

duration of disease

total blood cell count

total leukocyte count

C-reactive protein

D-dimers

lactate dehydrogenase

oxygen saturation


 Outcomes

The primary outcome was 28-day mortality. Secondary endpoints included early mortality (Days 7 and 14), the need for orotracheal intubation by Day 7, and the proportion of patients with an oxygenation index (PaO2/FiO2) < 100 by Day 7. Post hoc exploratory analyses were for mortality rates in subgroups (whether enrolled already in IMV or not, age, and some laboratorial predictors of severity). Subgroup analyses were based on the same direction of prespecified hypotheses (benefit of MP), consistency across other studies, and a strong preexisting biological rationale supporting the apparent subgroup effect [18]. We also analyzed the length of hospitalization, the radiological presence of fibrosis or Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) after Day 7 [19], a need for insulin or an increase in the dosage in diabetic patients, a positive blood culture (Bactec), and the presence of viral RNA in the naso-/oropharyngeal swab at Day 7. As per protocol, the Day 120 visit will focus on the respiratory sequelae of surviving patients; therefore, those data will not be presented here.

mortality

early mortality

Days 7 and 14

need for orotracheal intubation

by Day 7

by Day 7

length of hospitalization

after Day 7

a positive blood culture (Bactec)

at Day 7


Endpoints
 5 days after enrollment or severe adverse reactions appeared was the observation endpoint. Changes in time to clinical recovery (TTCR) and clinical characteristics of patients were evaluated after administration. TTCR is defined as the return of body temperature and cough relief, maintained for more than 72 h. Normalization and mitigation criteria included the following: a. Body temperature ≤ 36.6 °C on the surface, ≤ 37.2 °C under the armpit and mouth or ≤ 37.8 °C in the rectum and tympanic membrane; b. Cough from patients’ reports, slight or no cough was in the asymptomatic range. Body temperature, cough check three times daily to calculate the average level. For radiological changes, the chest CT results in one day before (Day 0) and one day after (Day 6) the study for evaluation. Pulmonary recovery is defined as three levels: exacerbated, unchanged, and improved, moderately improved when less than 50 % of pneumonia were absorbed, and more than 50 % means significantly improved.

clinical characteristics of patients

chest CT results


Outcomes

The primary outcomes were the rate of nucleic acid negativity conversion of SARS-CoV-2 and the negativity conversion time. Nucleic acid conversion rate was defined as the ratio of patients with negativity nucleic acid testing in FNC group to all patients in FNC group at a certain point in the follow-up process. Secondary outcomes were the improvement rate of chest CT images, the time required for the body temperature returning to normal and the improvement in respiratory symptoms and signs. The improvement of chest CT images was defined as a significant reduction in the range of lesions and inflammation. The results for this outcome were double-checked by two radiologists.

Safety was regularly assessed by monitoring vital signs (heart rate, respiratory rate, systolic pressure, diastolic pressure), changes in laboratory values (liver function, renal function), and adverse events (including type, incidence, severity, time and drug correlation, and assessment of severity according to the National Cancer Institute Common Terminology Criteria for Adverse Events [NCI CTCAE], version 5.0).

negativity conversion time

improvement rate of chest CT images


 End points
All AEs, serious and non-serious, were to be reported. Immediately reportable serious adverse events included adverse events that resulted in death and new life-threatening events. The primary outcome was defined as relative change (%) from baseline (day 1 prior to study drug administration at ± 1h of randomization) in PaO2/FiO2 ratio in supine position at day five. During the study it became clear that several patients in prone position could not be assessed regularly in supine position because of severe hypoxemia. It was therefore decided to focus on all
PaO2/FiO2 ratioassessments (irrespective of position) and perform an analysis of supine position values for sensitivity. Various additional secondary and other outcomes were pre-defined in line with the exploratory nature of the initial phase of the clinical study. Subgroup and sensitivity analyses for patients intubated at or within six hours after randomization was performed.

All AEs, serious and non-serious

at day five


 Outcomes
Reductions of C reactive protein levels at day 5 and 8 after randomization were chosen as primary outcome. Secondary outcomes included admission to ICU within 15 and 30 days from randomization, occurrence of mechanical ventilation within 15 and 30 days from randomization, death within 15 and 30 days from randomization, composite occurrence of admission to ICU, mechanical ventilation or death within 15 and 30 days from randomization, proportion of patients requiring supplemental oxygen at day 15 (or with an oxygen saturation lower than 96% while breathing room air), time from randomization to discharge up to day 15 from randomization, and significative differences in serum lactate dehydrogenase levels at day 5 and 8. All the trial outcomes were assessed by the site investigators, who were aware of the trial-group assignments.

Reductions of C reactive protein levels

at day 5 and 8 after randomization

admission to ICU

occurrence of mechanical ventilation

death

at day 15

time from randomization to discharge

up to day 15 from randomization

at day 5 and 8


Outcomes. The primary outcome was the time to clinical improvement (TTCI) as defined by the Cap-China Network 57, which was employed in the LOTUS China trial 11 and recommended by the World Health Organization. TTCI refers to the time from randomization to an improvement of two points on the seven-category ordinal scale as follows 58 (or discharge alive from the hospital): 1, not hospitalized with resumption of normal activities; 2, not hospitalized, but unable to resume normal activities; 3, hospitalized, not requiring supplemental oxygen; 4, hospitalized, requiring supplemental oxygen; 5, hospitalized, requiring nasal high-flow oxygen therapy, noninvasive mechanical ventilation; 6, hospitalized, requiring ECMO, invasive mechanical ventilation, or both; or 7, death. The secondary outcomes were as follows: percentage of patients on seven-category scale on days 7, 14 and 21; time on mechanical ventilation; time of hospitalization of survivors; time on oxygen support; time from randomization to hospital discharge; time from randomization to death; and frequency of severe adverse events as defined by National Cancer Institute Common

time to clinical improvement (TTCI)

on days 7, 14 and 21

time on mechanical ventilation

time of hospitalization of survivors

time on oxygen support

time from randomization to death

frequency of severe adverse events

National Cancer Institute Common


 Main Outcomes and Measures  The primary end point was clinical status on day 11 on a 7-point ordinal scale ranging from death (category 1) to discharged (category 7). Differences between remdesivir treatment groups and standard care were calculated using proportional odds models and expressed as odds ratios. An odds ratio greater than 1 indicates difference in clinical status distribution toward category 7 for the remdesivir group vs the standard care group.

End Points

The primary efficacy end point was the distribution of clinical status assessed on the 7-point ordinal scale on study day 11. If remdesivir treatment improves outcomes, the distribution of scores among patients who received remdesivir should shift more toward the higher values of the scale than the distribution of scores among patients who received standard care.

The secondary end point was the proportion of patients with adverse events throughout the duration of the study. Prespecified exploratory end points were (1) time to recovery (improvement from a baseline score of 2-5 to a score of 6 or 7 or from a baseline score of 6 to a score of 7); (2) time to modified recovery (improvement from a baseline score of 2-4 to a score of 5-7, improvement from a baseline score of 5 to a score of 6-7, or improvement from a baseline score of 6 to a score of 7); (3) time to clinical improvement (≥2-point improvement from baseline on the 7-point ordinal scale); (4) time to 1-point or larger improvement; and (5) time to discontinuation of any oxygen support. The proportion of patients with these end points was also assessed on days 5, 7, and 11. Other exploratory end points were duration of hospitalization, duration of different modes of respiratory support, and all-cause mortality. Due to logistical issues at the time of study implementation, virological and pharmacokinetic measurements were limited, including SARS-CoV-2 polymerase chain reaction tests on day 5 and day 10, and are not presented.

clinical status

on day 11

on study day 11

throughout the duration of the study

time to recovery

time to modified recovery

time to clinical improvement

time to 1-point or larger improvement

duration of hospitalization

on days 5, 7, and 11

all-cause mortality


Methods  A randomized, controlled, open-label study of Auxora was conducted in adults with severe or critical COVID-19 pneumonia. Patients were randomized 2:1 to receive three doses of once-daily Auxora versus standard of care (SOC) alone. The primary objective was to assess the safety and tolerability of Auxora. Following FDA guidance, study enrollment was halted early to allow for transition to a randomized, blinded, placebo-controlled study.

safety and tolerability of Auxora


 Outcomes

The primary endpoint of this trial was clinical recovery within 14 days of enrolment. Clinical recovery was defined as normalization of fever (≤37.2°C), respiratory rate (≤24/min) and oxygen saturation (≥94%) without supplementary oxygen therapy sustained for at least 24 h. If patients maintained these criteria for over 24 h they were safely discharged from hospital. Other secondary endpoints included all-cause mortality, requirement for mechanical ventilation, duration of hospital stay and time to hospital discharge. Safety endpoints were measured as frequencies of serious adverse events. Outcomes were extracted from patient files and medical progress notes by a researcher blinded to the allocation of patients.

clinical recovery

within 14 days of enrolment

all-cause mortality

requirement for mechanical ventilation

duration of hospital stay

time to hospital discharge

frequencies of serious adverse events


 Outcome
The primary outcome measure was a composite endpoint that included in-hospital all-cause mortality, escalation to ICU admission, or progression of respiratory insufficiency that required non-invasive ventilation (NIV).
The secondary outcomes were the effects on the individual components of the composite endpoint and laboratory biomarkers at baseline and 6 days after inclusion (time window 4-8 days).

laboratory biomarkers


 Clinical outcome assessment

The patients were observed for 2 weeks after hUC-MSC infusion, and clinical symptoms, laboratory tests, and radiological results were recorded and confirmed by experienced physicians. The primary clinical outcomes included the incidence of progression from severe to critical illness and the time to a clinical improvement of two points on a seven-category ordinal scale that has been used widely in clinical symptom assessment or discharge from the hospital [27]. In our study, the NEWS2 score and seven-category ordinal scale were used to assess the clinical symptoms and conditions of the enrolled patients [28]. The secondary clinical outcomes included patient status at days 7 and 14 assessed with a seven-category ordinal scale, hospital stay, changes in oxygenation index, hematological inflammatory factors, and imaging.

patient status

at days 7 and 14

hospital stay

changes in oxygenation index

hematological inflammatory factors

imaging


 Outcomes

The primary outcome of the study was length of hospital stay. Secondary outcomes included the frequency of ICU admission, invasive mechanical ventilation, duration of ICU admission, mechanical ventilation and, finally, the frequency and time to recovery, defined as hospital discharge alive.

length of hospital stay

frequency of ICU admission

invasive mechanical ventilation

duration of ICU admission

mechanical ventilation

frequency and time to recovery

defined as hospital discharge alive


 Data collection and management

Baseline data, which included demographics, anthropometrics, comorbid conditions, vital signs, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and Glasgow coma scale (GCS) scores, were obtained on the day of randomization. Laboratory data, sequential organ failure assessment (SOFA) scores, PaO2/FiO2, and other treatments used were monitored on days 1, 3, and 7 (day 1 was defined as the day of the first administration of vitamin C).

The primary outcome of the study was IMV- free days in 28 days (IMVFD28). Secondary outcomes included 28-day mortality, organ functions and inflammatory parameters, including white blood cell counts, neutrophil counts, lymphocyte counts, procalcitonin, interleukin-6 (IL-6), and C-reactive protein (CRP). Multi-organ dysfunction was assessed using SOFA scores.Additionally, vasopressor days, respiratory support days, invasive mechanical ventilation (IMV)-free days, patient condition improvement rate, patient condition deterioration rate, length of ICU and hospital stay, ICU and in-hospital mortality were recorded as additional secondary outcomes of this research. IMV-free days were defined as the number of days a patient was extubated after recruitment to day 28. If the patient died with MV, a value of zero was assigned. Deterioration of the patient’s condition was defined as the patient requiring HFNC or NIV on day 1 and requiring ECMO or IMV, or dying, after 7 days of treatment. Improvement of the patient’s condition was defined as the patient requiring ECMO or IMV on day 1 and switching to HFNC, NIV, or discharged from the ICU after 7 days of treatment. The P/F was calculated based on the PaO2/FiO2, and we choose the lowest values recorded on the specific day. All the data were collected from the clinical information system of three ICUs.

IMV- free days

in 28 days

mortality

organ functions

vasopressor days

respiratory support days

patient condition improvement rate

patient condition deterioration rate

length of ICU and hospital stay

ICU and in-hospital mortality

number of days a patient was extubated

after recruitment to day 28


Main Outcomes and Measures  The primary outcome, treatment failure on day 21, was defined as death or persistent dependency on mechanical ventilation or high-flow oxygen therapy. Prespecified secondary outcomes included the need for tracheal intubation (among patients not intubated at baseline); cumulative incidences (until day 21) of prone position sessions, extracorporeal membrane oxygenation, and inhaled nitric oxide; Pao2:Fio2 ratio measured daily from day 1 to day 7, then on days 14 and 21; and the proportion of patients with secondary infections during their ICU stay.

Outcome Measures and Data Collection

The primary outcome was treatment failure on day 21, defined as death or persistent dependency on mechanical ventilation or high-flow oxygen therapy.

Prespecified secondary outcomes included the use of tracheal intubation (for patients not intubated at inclusion); the use of prone position (with the number of sessions), extracorporeal membrane oxygenation or inhaled nitric oxide (with the number of days the treatment was used); the Pao2:Fio2 ratio recorded daily from day 1 to day 7 and then on days 14 and 21; and the proportion of patients with and the number of episodes of nosocomial infections recorded during the ICU stay. Because some patients were still hospitalized in the ICU when the data were analyzed, nosocomial infections were recorded up to day 28 (which was a post hoc decision). The diagnosis of nosocomial infection was made by the clinician in charge and provided that an antibiotic therapy had been prescribed.

Death on day 21 and status on day 21 (determined using a 5-item scale: death, presence in the ICU on mechanical ventilation, high-flow or low-flow oxygen therapy, ICU discharge) were post hoc outcomes.

Apart from death, the adverse events expected in this context (such as the need for intubation in a patient breathing spontaneously at baseline) were only reported if the clinician thought they might be related to the study treatment.

treatment failure

on day 21

need for tracheal intubation

Pao2:Fio2 ratio

Death

on day 21

status

on day 21

adverse events

during their ICU stay


 Main Outcomes and Measures  The primary end point was organ support–free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned –1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

Outcomes

The primary outcome was respiratory and cardiovascular organ support–free days up to day 21, an ordinal end point with death within the hospital as the worst outcome (labeled –1), then the length of time free of both respiratory and cardiovascular organ support, such that the best outcome would be 21 organ support–free days. Organ support was defined using the same criteria as those for study entry. This outcome was used in a recent registration trial in septic shock approved by the Food and Drug Administration (although up to 28 days), with a 1.5-day difference (7.5%-15% relative difference) considered to be the minimal clinically important difference.18

Secondary outcomes were in-hospital mortality, ICU and hospital length of stay, respiratory support–free days, cardiovascular organ support–free days, a composite outcome of progression to invasive mechanical ventilation, extracorporeal membrane oxygenation (ECMO) or death among those not ventilated at baseline, and the WHO ordinal scale (range, 0-8, where 0 = no illness, 1-7 = increasing level of care, and 8 = death) assessed at day 14.19,20 This scale was used in a recent COVID-19 RCT of remdesivir, where an odds ratio of 1.32 was considered clinically important, although few data support that assumption.20

organ support–free days

within 21 days

in-hospital mortality

ICU and hospital length of stay

respiratory support–free days

cardiovascular organ support–free days

WHO ordinal scale

at day 14.19,20