Randomized Trial of Metformin, Ivermectin, and Fluvoxamine for Covid-19

BACKGROUND Early treatment to prevent severe coronavirus disease 2019 (Covid-19) is an important component of the comprehensive response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS In this phase 3, double-blind, randomized, placebo-controlled trial, we used a 2-by-3 factorial design to test the effectiveness of three repurposed drugs - metformin, ivermectin, and fluvoxamine - in preventing serious SARS-CoV-2 infection in nonhospitalized adults who had been enrolled within 3 days after a confirmed diagnosis of infection and less than 7 days after the onset of symptoms. The patients were between the ages of 30 and 85 years, and all had either overweight or obesity. The primary composite end point was hypoxemia (≤93% oxygen saturation on home oximetry), emergency department visit, hospitalization, or death. All analyses used controls who had undergone concurrent randomization and were adjusted for SARSCoV-2 vaccination and receipt of other trial medications. RESULTS A total of 1431 patients underwent randomization; of these patients, 1323 were included in the primary analysis. The median age of the patients was 46 years; 56% were female (6% of whom were pregnant), and 52% had been vaccinated. The adjusted odds ratio for a primary event was 0.84 (95% confidence interval [CI], 0.66 to 1.09; P=0.19) with metformin, 1.05 (95% CI, 0.76 to 1.45; P=0.78) with ivermectin, and 0.94 (95% CI, 0.66 to 1.36; P=0.75) with fluvoxamine. In prespecified secondary analyses, the adjusted odds ratio for emergency department visit, hospitalization, or death was 0.58 (95% CI, 0.35 to 0.94) with metformin, 1.39 (95% CI, 0.72 to 2.69) with ivermectin, and 1.17 (95% CI, 0.57 to 2.40) with fluvoxamine. The adjusted odds ratio for hospitalization or death was 0.47 (95% CI, 0.20 to 1.11) with metformin, 0.73 (95% CI, 0.19 to 2.77) with ivermectin, and 1.11 (95% CI, 0.33 to 3.76) with fluvoxamine. CONCLUSIONS None of the three medications that were evaluated prevented the occurrence of hypoxemia, an emergency department visit, hospitalization, or death associated with Covid-19

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Deep molluscan phylogeny: synthesis of palaeontological and neontological data

The position of the earliest-derived living molluscs, the Polyplacophora (chitons) and shell-less vermiform Aplacophora, remains highly contentious despite many morphological, developmental and molecular studies of extant organisms. These two groups are thought to represent either a basal molluscan grade or a clade (Aculifera) sister to the ‘higher’ molluscs (Conchifera). These incompatible hypotheses result in very different predictions about the earliest molluscs. A new cladistic analysis incorporating both Palaeozoic and extant molluscs is presented here. Our results support the monophyly of Aculifera and suggest that extant aplacophorans and polyplacophorans both derive from a disparate group of multivalved molluscs in two major clades. Reanalysis of the critical Ordovician taxon ‘Helminthochiton’ thraivensis shows that this animal lacks a true foot despite bearing polyplacophoran-like valves. Its position within our phylogenetic reconstruction indicates that many fossil ‘polyplacophorans’ in the order Palaeoloricata are likely to represent footless stem-group aplacophorans. ‘H.’ thraivensis and similar forms such as Acaenoplax may be morphological stepping stones between chitons and the shell-less aplacophorans. Our results imply that crown-group molluscan synapomorphies include serial repetition, the presence of a foot, a mineralized scleritome and a creeping rather than worm-like mode of life

Fossilized soft tissues in a Silurian platyceratid gastropod

Gastropod shells are common in the fossil record, but their fossil soft tissues are almost unknown, and have not been reported previously from the Palaeozoic. Here, we describe a Silurian (approx. 425 Myr) platyceratid gastropod from the Herefordshire Lagerstätte that preserves the oldest soft tissues yet reported from an undoubted crown-group mollusc. The digestive system is preserved in detail, and morphological data on the gonads, digestive gland, pedal muscle, radula, mouth and foot are also available. The specimen is preserved three-dimensionally, and has been reconstructed digitally following serial grinding. Platyceratids are often found attached to echinoderms, and have been interpreted as either commensal coprophages or kleptoparasites. The new data provide support for an attached mode of life, and are suggestive of a coprophagous feeding strategy. The affinities of the platyceratids are uncertain; they have been compared to both the patellogastropods and the neritopsines. Analysis of the new material suggests that a patellogastropod affinity is the more plausible of these hypotheses

Genetic Divergence Between South African Helcion Species and North-East Atlantic H. Pellucidum (Mollusca: Patellogastropoda)

Allozyme electrophoresis was used to estimate the genetic divergence between three species of South African Helcion and the north-east Atlantic H. pellucidum (Patellidae). At a finer level the genetic relationships among South African Helcion were explored. Twenty-one loci were resolved for all the species. High values of expected heterozygosities (0·202–0·341) were found for the genus. Phenetic analysis (UPGMA (unweighted pair-group method with artihmetic averaging) and Distance Wagner Procedure) and cladistic parsimony methods (alleles as binary characters and loci as multistate unordered characters) agreed in showing the same topology for the tree which represents the genetic relationships among Helcion species. The north-east Atlantic H. pellucidum was the most divergent species showing high values of Nei's genetic distances (1·423–1·654) with its South African congeners. In the literature such values of genetic divergence have been associated with non-congeneric species. The degree of genetic divergence (0·351–0·615) found within the South African branch was characteristic for congeneric species. The results of this study supported the monophyletic condition of this branch, and showed H. pectunculus and H. pruinosus to be more closely related to each other than to H. dunkeri. Nevertheless, the monophyly of the genus Helcion is uncertain and therefore its taxonomic status was questioned. A possible independent origin for northern and southern hemisphere species of Helcion is considered