Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers

Introduction

Cytokine-release syndrome (CRS) in COVID-19 patients can cause multiorgan failure and higher mortality. We used a structured protocol based on clinical, biochemical, and interleukin 6 (IL-6) criteria for the identification of the subset of patients with CRS and analyzed the use of tocilizumab for their treatment.

Materials and methods

We did a retrospective case-control analysis of all COVID-19 patients between 15 March and 15 May 2020 with severe to critical disease in ICU. They were evaluated for CRS, and 22 patients who met the criterion were given tocilizumab. The primary objective was to evaluate the effect of tocilizumab on escalation of respiratory support and ICU mortality. The secondary objectives were ICU length of stay, trends of inflammatory markers, and any adverse effects.

Results

The need for escalation of respiratory support was significantly lower in the tocilizumab group as compared to standard treatment (p = 0.001). The mortality at day 7 and 28 was also significantly lower in the tocilizumab group (p = 0.007 and p = 0.001 respectively). There was a significant reduction in C-reactive protein (CRP) who received tocilizumab (p = 0.033).

Conclusion

In our limited number of patients, timely intervention with tocilizumab in COVID-19 patients with CRS significantly improved overall ICU outcome by reducing the need for invasive ventilation and mortality.

How to cite this article

Nasa P, Singh A, Upadhyay S, Bagadia S, Polumuru S, Shrivastava PK, et al. Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers. Indian J Crit Care Med 2020;24(9):771-776.

Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers

INTRODUCTION

Cytokine-release syndrome (CRS) in COVID-19 patients can cause multiorgan failure and higher mortality. We used a structured protocol based on clinical, biochemical, and interleukin 6 (IL-6) criteria for the identification of the subset of patients with CRS and analyzed the use of tocilizumab for their treatment.

MATERIALS AND METHODS

We did a retrospective case-control analysis of all COVID-19 patients between 15 March and 15 May 2020 with severe to critical disease in ICU. They were evaluated for CRS, and 22 patients who met the criterion were given tocilizumab. The primary objective was to evaluate the effect of tocilizumab on escalation of respiratory support and ICU mortality. The secondary objectives were ICU length of stay, trends of inflammatory markers, and any adverse effects.

RESULTS

The need for escalation of respiratory support was significantly lower in the tocilizumab group as compared to standard treatment (p = 0.001). The mortality at day 7 and 28 was also significantly lower in the tocilizumab group (p = 0.007 and p = 0.001 respectively). There was a significant reduction in C-reactive protein (CRP) who received tocilizumab (p = 0.033).

CONCLUSION

In our limited number of patients, timely intervention with tocilizumab in COVID-19 patients with CRS significantly improved overall ICU outcome by reducing the need for invasive ventilation and mortality.

HOW TO CITE THIS ARTICLE

Nasa P, Singh A, Upadhyay S, Bagadia S, Polumuru S, Shrivastava PK, et al. Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers. Indian J Crit Care Med 2020;24(9):771-776.

Application of Horton’s infiltration model for the soil of Dediapada (Gujarat), India

The design and evaluation of surface irrigation systems of a site requires reliable data of infiltration which could be provided by an infiltration model. In this study, Horton’s infiltration model has been estimated for the soil located in a field of College of Agricultural Engineering and Technology, Dediapada, Gujarat using the infiltration data obtained from several locations in the field using double ring infiltrometer. The decay constant of the Horton’s infiltration model was obtained using graphical method and also by using semi-log plot of t (time) vs. (f – fc), where f is the infiltration rate (mm/hr) and fc is the initial rate of infiltration capacity (mm/hr). The potential of the Horton’s infiltration model so obtained was evaluated by least square fitting with the observed infiltration data. The Horton’s infiltration model was used to estimate infiltration rate (mm/hr) and cumulative infiltration (cm). The Horton’s model for infiltration rate obtained by semi-log plot method was obtained as i=20 + 94 e-1.02t, where i=infiltration rate (mm/hr) and t= time (min). The coefficient of determination obtained when the infiltration model was applied to observation data taken at various points in the field were found to 0.96. Therefore, it could be inferred that the Horton’s infiltration model could give a reliable estimate of infiltration for the soil of Dediapada.  

Dextran Carrier Macromolecules for Colon-specific Delivery of 5-Aminosalicylic Acid

Present manuscript describes the sustained and targeted delivery of 5-aminosalicylic acid to the distal ileum and proximal colon, using dextran (40 kDa) as a carrier for targeting 5-aminosalicylic acid at the colonic site by attaching p-aminobenzoic acid and benzoic acid as linkers. Prepared conjugate were characterized by UV, HPLC, FT-IR, and ¹H NMR. The degree of substitution was estimated by complete hydrolysis of conjugates in borate buffer and in vitro hydrolysis study of conjugates was performed in different biological media. It was observed that 5-aminosalicylic acid alone have produced high incidence of gastric ulcer with high ulcer index whereas lower ulcer index was found for the dextran conjugates of 5-aminosalicylic acid. The release pattern of conjugates in 3% w/v rat caecal content was confirmed the colon specificity of 5-aminosalicylic acid conjugates.

Concurrent Estimation of Clopidogrel Bisulfate and Aspirin in Tablets by Validated RP-HPLC Method

A simple, rapid, precise RP-HPLC method was developed for simultaneous estimation of aspirin and clopidogrel bisulphate in tablet dosage form used in the treatment of cardiovascular diseases. To achieve the maximum resolution, acetonitrile:50 mM potassium dihydrogen phosphate buffer:methanol, solution pH adjusted to 3, in the ratio 50:30:20; v/v was selected as mobile phase. This mixture was found to be appropriate allowing good separation of both the components at a flow rate of 1.5 ml/min and detection wavelength 240 nm. In these conditions clopidogrel bisulfate and aspirin were eluated at the 7.47 and 2.2 min. The linearity was found in the concentration range 1.5-7.5 and 3.5-15.0 μg/ml, respectively. All the analytical validation parameters were determined and found with in the limit as per ICH guideline, which indicates the validity of method.

Hydrolytic Degradation Profile and RP-HPLC Estimation of Cilostazol in Tablet Dosage Form

A simple, selective, precise and stability-indicating high-performance liquid-chromatographic method of analysis of cilostazol in pharmaceutical dosage form was developed and validated. The solvent system consisted of 10 mM phosphate buffer (pH 6.0):acetonitrile:methanol (20:40:40). Retention time of cilostazol in C18 column was 5.7 ± 0.1 min at the flow rate 1.3 ml/min. Cilostazol was detected at 248 nm at room temperature. The linear regression analysis data for the calibration plots showed good linear relationship with correlation coefficient value, r ² =0.9998 in the concentration range 100–3200 ng/ml with slope 43.45 intercept 156.75. The method was validated for linearity, range, accuracy, precision and specificity. Cilostazol was determined in tablet dosage form in range of 99.58-100.67% with 0.4600 standard deviation. Stress studies were conducted in acid and alkali hydrolysis with gradual increasing concentration. Cilostazol was found to be stable in various concentrations of acidic and alkaline.

The distribution of AB0 and LH blood groups in some north Indian populations

The distribution of AB0 and LH blood groups among five Punjabi populations from North India (Jat Sikh, Bania, Brahmin, Sikh Khatri and Hindu Khatri) is reported. Significant differences have been found in many cases regarding the distribution of AB0 and LH systems, especially between Sikh Khatris and Hindu Khatris, who are usually pooled for population genetic studies.

Serum protein polymorphisms in breast cancer

Serum haptoglobin, transferrin and albumin were studied electrophoretically in 50 patients with carcinoma of breast and in 50 normal healthy women. Results on haptoglobin show a preponderance of products of gene Hp1 (0.26) in patients as compared to controls (0.14). No variation was observed at the transferrin locus in either sample. The most notable finding was the detection of four cases of alloalbuminaemia (8%) in breast cancer Patients. The high incidence of alloalbuminaemia prompted us to extend our observations further. For this purpose sera from 41 patients was collected. One more case of alloalbuminaemia of the fast type was detected. However, in contrast to our first series of patients, quite high incidence (12.2%) of transferrin variants was recorded in this sample. Family studies were conducted on all the patients with protein anomalies.

Studies on the Dd antigen-antibody system. II. Antigen Dd reactivity in some north indian populations

The frequency of antigen Dd-reactors has been recorded in Muslims and Buddhists from Ladakh, in Rana Tharus from Uttar Pradesh and in two samples of largely Jat Sikh origin from Punjab, all in India. The results show a wide range of variation, from 0% in the Rana Tharus to 25% in the Punjabi blood donors, of incidence of antigen Dd-reactivity in these populations.

Alloalbuminemia in North India

Electrophoretic screening of sera from 550 individuals from Punjab, North India, revealed four cases of alloalbuminemia. Two albumin variants migrated slower and two migrated faster than the common albumin A. These variants were further analyzed by electrophoresis of their cyanogen bromide fragments to localize their molecular differences. One of the slow variants appears similar to, if not identical with, albumin B, with an altered cyanogen bromide fragment CNBr VII. The other slow variant appears to be a new variant (proposed name albumin Punjab) differing from albumin A in an altered fragment CNBr VI (which also occurs in albumins Kashmir and Adana) and in an altered fragment CNBr I. Among the fast variants, one has the same altered fragment CNBr V as albumin Naskapi, while the other appears to be a new variant (proposed name albumin Patiala) having an altered fragment CNBr VI. The presence of albumin Naskapi in Punjabis, North American Indians, and Eti Turks (previously reported) is consistent with the existence of a common ancestral population in which the mutation to Naskapi occurred before the migrations eastward and westward.

Distribution of some genetic traits in three populations from Punjab, North India

Three population groups, viz. Jat Sikh (192), Khatri (105) and Balmiki (108) were screened for haptoglobins, transferrins, Australia antigen, antigen Dd-reactivity and the ABO blood groups. The frequencies in Jat Sikhs, Khatris and Balmikis were 0.232, 0.186 and 0.140 respectively for Hp1 allele, 0.52%, 0.95% and 1.85% for Australia antigen, and 17.30%, 21.90% and 19.44% for antibodies against antigen Dd. The transferrins were all of type Tf C. The frequencies for the alleles A, B and O of the ABO system were 0.216, 0.239 and 0.545 in Jat Sikhs, 0.238, 0.320 and 0.442 in Khatris, and 0.196, 0.274 and 0.530 in Balmikis. Our tests showed these populations to be in Hardy-Weinberg equilibrium.

Secondary neotympanic membrane and total ossicular chain reconstruction. A preliminary report

This new tympanoplasty technique with homo-ossicles (25 cases) has evolved as a reliable, effective, and durable technique to construct the middle ear conduction system when the total ossicular chain is missing. The isolated footplate is driven by two (primary and secondary) neotympanic membranes; hence this new technique is designated as "twin tympanoplasty." The initial hearing results (air-bone gap closure to 10 dB or less in 88% of the cases) have been good, and follow-up (six to 14 months) audiograms suggest that the hearing gain may survive the test of time. Toenail autograft could be one substitute for the ossicle as proved by satisfactory results in five cases.

Some biochemical polymorphisms in members of the Gaddi tribe of Himachal Pradesh

This study was carried out among members of the Gaddi tribe of Himachal Pradesh in north India. The genetic traits reported here include ABO blood groups, haptoglobin, transferrin, albumin, Gc, Australia antigen and antigen Dd. The frequencies of genes p, q and r for the ABO system were 0.212, 0.290 and 0.428. The Hp1 allele frequency (0.331) was markedly higher and that of Gc1 (0.700) somewhat lower than in most north Indian populations. The incidence of Australia antigen was 1.25%. There were no antigen Dd reactors.

Haptoglobin polymorphism in the Ladakhi population

Haptoglobin polymorphism has been studied in 148 Ladakhis -- a Mongoloid population inhabiting the northern-most region of India. With a frequency of 0.270 for the allele Hp1 the Ladakhis compare favourably with other Mongoloid populations.

Functional eustachian tuboplasty: a new surgical technique

Until recently, there was no answer for the "physiologic" stenosis of the Eustachian tube (occurring in 20% of all cases of tubal occlusion). We describe a newly devised surgical procedure-tensor palati tendon "strengthening"-for the management of physiologic stenosis of the Eustachian tube. After the initial dissection of 20 cadavers, the basic surgical procedure was worked out. Then, the experimental study was conducted in four dogs to evaluate the effects of this new operation on the Eustachian tube functions as well as on the soft palate movements. Finally, four patients with physiologic tubal stenosis were treated successfully. The follow-up period ranged from 16 to 20 months. Strict selection of patients is encouraged.

Antigen Dd reactors in an Indian population

Saline extracts of human dandruff contain a factor, antigen Dd, which precipitates human sera selectively. There is a significant excess (p < 0.001) of antigen Dd reactors among the Punjabi blood donors of India as compared to the blood donors of Poland. Laboratory analysis of assorted hospital sample shows that antibodies to antigen Dd are present more often in autoimmune than in other diseases.