Tocilizumab therapy reduced intensive care unit admissions and/or mortality in COVID-19 patients

INTRODUCTION

No therapy has yet proven effective in COVID-19. Tocilizumab (TCZ) in patients with severe COVID-19 could be an effective treatment.

METHOD

We conducted a retrospective case-control study in the Nord Franche-Comté Hospital, France. We compared the outcome of patients treated with TCZ and patients without TCZ considering a combined primary endpoint: death and/or ICU admissions.

RESULTS

Patients with TCZ (n=20) had a higher Charlson comorbidity index (5.3 [±2.4] vs 3.4 [±2.6], P=0.014), presented with more severe forms (higher level of oxygen therapy at 13L/min vs 6L/min, P<0.001), and had poorer biological findings (severe lymphopenia: 676/mm³ vs 914/mm³, P=0.037 and higher CRP level: 158mg/L vs 105mg/L, P=0.017) than patients without TCZ (n=25). However, death and/or ICU admissions were higher in patients without TCZ than in the TCZ group (72% vs 25%, P=0.002).

CONCLUSION

Despite the small sample size and retrospective nature of the work, this result strongly suggests that TCZ may reduce the number of ICU admissions and/or mortality in patients with severe SARS-CoV-2 pneumonia.

Intake, milk yield and grazing behaviour of strip-grazing Alpine dairy goats in response to daily pasture allowance

Grazing management has an important impact on dairy ruminants' performance. References on the intake and milk yield of dairy goats under strip-grazing systems in temperate regions are scarce. In order to study the effect of pasture allowance on pasture intake (PI), milk yield and grazing behaviour, a trial was carried out in spring with 36 Alpine goats in mid-lactation. Three daily pasture allowances (PA=1.7, 2.6 and 3.5 kg dry matter (DM)/day, namely Low, Medium and High, respectively) were compared in a 3 × 3 Latin square design replicated six times during three successive 14-day periods. Goats individually received 268 g DM of concentrate twice daily at each milking and had access 11 h/day to pasture (from 0830 to 1600 h and from 1730 to 2100 h). Pasture intake increased with PA, and more so between Low and Medium than between Medium and High (+216 v. +101 g DM/kg DM of PA). Milk yield was lower on Low than on Medium and High (2.79 v. 3.13 kg/day), as were milk fat and protein yields. Grazing time averaged 476 min/day and was lowest on Low and greatest on Medium. Pasture intake rate was 30 g DM/h lower on Low and Medium than on High. It is concluded that under temperate conditions, when goats are supplemented with 536 g DM of concentrate and have enough access time to pasture (11 h/day), a medium pasture allowance close to 2.6 kg DM/day may be sufficient to maximise milk yield.

Fatal case of Reye's syndrome associated with H3N2 influenza virus infection and salicylate intake in a 12-year-old patient

We describe a fatal case of Reye's syndrome in a 12-year-old male patient during an influenza A (H3N2) infection for which he received salicylates. In the current situation of the novel A/H1N1 virus pandemic, we believe that it is of high importance to emphasize the risks associated with salicylate intake to avoid the reappearance of Reye's syndrome.

[Extracorporeal membranous oxygenation in severe infant pertussis: a case report]

Pertussis is a leading cause of death from community infections in infant. Life-threatening clinical presentations of pertussis can associate multiple organ system failure with respiratory distress. The question of the optimal management of these severe forms of pertussis, in order to reduce the high mortality rate, is raised by the clinicians caring for such patients. We report the case of a 1 month infant who was admitted to the pediatric intensive care unit (PICU) for a severe pertussis. He presented with an acute respiratory distress syndrome, a severe pulmonary hypertension was treated initially with mechanical ventilation and nitric oxide. At day 4 (D4), a cardiogenic shock occurred and, despite epinephrine and norepinephrine infusion, fluid expansion, the hemodynamic condition worsened with two episodes of cardiac arrest. The child was then successfully resuscitated, and, facing the extreme hemodynamic instability, extracorporeal membrane oxygenation (ECMO) was considered. ECMO allowed epinephrine and norepinephrine to be progressively discontinued, and protective mechanical ventilation. ECMO withdrawal was possible at D9, with milrinone as the sole inotropic agent. Weaning from mechanical ventilation was possible on D15 and the total length of stay in PICU was 20days. While the analysis of the literature, through limited experiences on the use of ECMO in children with severe pertussis does not allow concluding definitively on the utility of ECMO in this situation, the contribution of ECMO in the favourable outcome for our patient was considerable. This is an argument, to our opinion, for considering ECMO in the management of those very instable patients.

[Steroids in the critical care children with septic shock and other conditions]

Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. In neonates, AI occurs frequently after cardiac surgery and the administration of steroids can improve haemodynamic condition. The recommended dose of hydrocortisone during septic shock or after cardiac surgery is 30 to 100 mg/m(2)/d. Dexamethasone is efficient to reduce postextubation stridor in children and neonate and the rate of reintubations in neonate. During croup, oral or parenteral steroids reduce clinical symptoms. Dexamethasone also reduces the incidence of severe chronic lung disease and the duration of tracheal intubation in premature infants. However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis.

From humoral rejection to generalized thrombotic microangiopathy--role of acquired ADAMTS13 deficiency in a renal allograft recipient

A 9-year-old renal transplant recipient presented with elevated serum creatinine levels 4 years post-transplant renal biopsy revealed humoral rejection including lesions suggestive for thrombotic microangiopathy (TMA). He received methylprednisolone pulses followed by a normalization of serum creatinine. Two more steroid responsive acute rejection episodes occurred. Two months later he presented rapidly progressive life threatening symptoms including bilateral pyramidal syndrome and hemoptysis. Serum haptoglobin became undetectable at this time and platelet count decreased (70000/microl), suggesting TMA. Cerebral MRI revealed generalized ischemic white matter lesions. ADAMTS13 activity decreased to < 5%. Daily plasma exchanges (PE) resulted in immediate improvement. All attempts to discontinue PE were unsuccessful. Transplantectomy resulted in normalization of generalized symptoms, hemolysis and ADAMTS13 activity (110%). Multi-organ involvement has never been reported in acquired ADAMTS13 deficiency post-transplant. Rapid resolution after transplantectomy might suggest that renal TMA was responsible for acquired ADAMTS13 deficiency and thereby triggered the generalization of TMA lesions.

[Extracorporeal assistance in paediatric intensive care]

OBJECTIVE

For 3 years we have used extracorporeal assistance in intensive care frequently. This study evaluates our results.

METHOD

We studied the patient records for those treated between January 2002 and January 2005. The method used, indications and morbidity/mortality were analysed.

RESULTS

We performed 24 circulatory assistance procedures in 20 patients (median age: 5 months), arterio-venous with oxygenation (n=18), veino-venous with oxygenation (n=3) or biventricular (n=3). The indications were post cardiotomy cardio-respiratory failure (Group I; n=20, 16 patients), pure respiratory failure (Group II: n=1), or pre-transplant/recovery (Group III: n=3). Five procedures (4 from group I and 1 from group III) required cardiac massage (no fatalities). The average duration of assistance was 7 +/- 6 days (2 to 20 days). Treatment was successfully discontinued in sixteen patients 80%), one of them thanks to heart transplant. Four (20%) died during assistance. The morbidity essentially consisted of further surgery for haemostasis, multiple transfusions, and infections. Three patients (15%) died later (1 at 17 months after discontinuation) from complications unrelated to the assistance. No neurological sequelae were noted in the survivors.

CONCLUSION

These results confirm the usefulness of circulatory assistance when medical treatment has failed, particularly in the post-operative period of paediatric cardiac surgery or while awaiting transplantation.

Specific dose-response effects of TGF-beta1 on developmentally distinct hematopoietic stem/progenitor cells from human umbilical cord blood

INTRODUCTION

Transforming Growth Factor-beta1 is known to maintain primitive human hematopoietic stem/progenitor cells in a quiescent state. However, its specific role in the control of distinct progenitor cell types needs to be further elucidated. In this study, we have investigated the dose-response effect of TGF-beta1 on progenitors ranging from primitive high proliferative potential (HPP)-Mix, -GM or -BFU-E to later BFU-E, CFU-G or CFU-M.

MATERIALS AND METHODS

A clonal semi-solid assay has been used to analyze the effects of a TGF-beta1 blocking antibody (anti-TGF-beta1) or that of active TGF-beta1 added to the medium at concentrations from 10-3000 pg/ml, on these different hematopoietic stem/progenitor cell types.

RESULTS AND CONCLUSION

A preferential growth inhibitory effect on the earlier progenitors was observed when low concentrations of TGF-beta1 (10-300 pg/ml) were used. Concentrations of 10-30 pg/ml TGF-beta1 were sufficient to inhibit 90% of the primitive multipotent HPP-Mix, while 100-300 pg/ml TGF-beta1 were required to inhibit 70% of the bipotent HPP-GM and early HPP-BFU-E. TGF-beta1 did not significantly inhibit or activate the growth of later CFU-G and CFU-M, even when added at concentrations 10-100 fold higher. In contrast, a significant growth-inducing effect of very low TGF-beta1 concentrations (< or =30 pg/ml) on a subset of later BFU-E was observed and cannot be explained by a switch of early into later BFU-E. These results emphasize the polyfunctional role of TGF-beta1 in the regulation of hematopoiesis and the need for low, physiological concentrations of TGF-beta1, when studying both the stem cell compartment and more mature progenitor cell subpopulations.