The Use of Corticosteroids or Tocilizumab in COVID-19 Based on Inflammatory Markers.

BACKGROUND: The inflammatory cascade is the main cause of death in COVID-19 patients. Corticosteroids (CS) and tocilizumab (TCZ) are available to treat this escalation but which patients to administer it remains undefined. OBJECTIVE: We aimed to evaluate the efficacy of immunosuppressive/anti-inflammatory therapy in COVID-19, based on the degree of inflammation. DESIGN: A retrospective cohort study with data on patients collected and followed up from March 1st, 2020, to May 1st, 2021, from the nationwide Spanish SEMI-COVID-19 Registry. Patients under treatment with CS vs. those under CS plus TCZ were compared. Effectiveness was explored in 3 risk categories (low, intermediate, high) based on lymphocyte count, C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, and D-dimer values. PATIENTS: A total of 21,962 patients were included in the Registry by May 2021. Of these, 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). MAIN MEASURES: The primary outcome of the study was in-hospital mortality. Secondary outcomes were the composite variable of in-hospital mortality, requirement for high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), or intensive care unit (ICU) admission. KEY RESULTS: A total of 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). No significant differences were observed in either the low/intermediate-risk category (1.5% vs. 7.4%, p=0.175) or the high-risk category (23.1% vs. 20%, p=0.223) after propensity score matching. A statistically significant lower mortality was observed in the very high-risk category (31.9% vs. 23.9%, p=0.049). CONCLUSIONS: The prescription of CS alone or in combination with TCZ should be based on the degrees of inflammation and reserve the CS plus TCZ combination for patients at high and especially very high risk.

Early use of tocilizumab in patients with severe pneumonia secondary to severe acute respiratory syndrome coronavirus 2 infection and poor prognostic criteria: Impact on mortality rate and intensive care unit admission.

ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, keeps spreading globally. Evidence suggests that a subgroup of patients with severe symptomatology might have cytokine storms, which increases mortality. The use of interleukin-6 (IL-6) inhibitors may help in controlling the pathological immune response to the virus. Tocilizumab, a monoclonal antibody against IL-6, stands as an optional treatment for COVID-19 patients presenting this inflammatory hyper-response.We conducted a retrospective, observational, cohort study including 50 patients affected by COVID-19 with severe pneumonia and poor prognosis criteria, who have also undergone standard treatment; 36 of these patients additionally received tocilizumab in an early stage. The need for intensive care unit (ICU) admission, mortality, recovery of respiratory function, and improvement of biochemical and hematological parameters were compared between cohorts.Most patients were men, non-smokers and the most frequently reported comorbidities were hypertension and diabetes. Recurrent symptoms were fever, cough, and dyspnoea. 54.8% of patients from the tocilizumab group needed intubation, while in the control group 85.7% needed it. Treatment with tocilizumab significatively increased IL-6 levels, (554.45; CI 95% 186.69, 1032.93; P < .05) while C-reactive protein mean levels were reduced (-108.19; CI 95% -140.15, -75.33; P < .05), but no significant difference was found between cohorts. In comparison with the controls, tocilizumab reduced mortality (25.0% vs 42.9%, P = .021) and the number of ICU admissions (63.9% vs 100.0%, P = .021). 44.1% of patients treated with tocilizumab showed favorable radiological evolution, when compared with 15.4% of patients from the control group.Tocilizumab may improve clinical symptoms and mitigate deterioration observed in severe COVID-19 patients, and could be considered as an effective therapeutic option in subjects experiencing a significant inflammatory response to the disease.

Eosinophilic fasciitis in a pregnant woman with corticosteroid dependence and good response to infliximab.

Eosinophilic fasciitis (EF) is characterized by symmetrical thickening of subcutaneous muscular fascia, causing skin induration with wrinkles and prominent hair follicles: the classic peau d'orange. Eosinophilia is a characteristic-albeit not universal-finding. We present the case of a 43-year-old pregnant woman diagnosed with EF during pregnancy who had extensive cutaneous involvement and severe functional repercussions, including worsening of lung function and intrauterine growth restriction as a possible complication. Treatment with prednisone was initiated during gestation and it was necessary to increase the dose. After delivery, methotrexate treatment was initiated and the corticosteroid dose progressively decreased, with progressive worsening in the torso and abdomen and secondary dyspnea due to thoracic pressure. Treatment with infliximab was then initiated, with favorable progress, though residual ankle and tarsal joint stiffness and significant muscular atrophy in the limbs continued. The triggering factor of EF was not identified. In a systematic search of the medical literature, three cases of EF in pregnant woman without clear triggers were found. Interestingly, all three cases progressed favorably with steroid treatment. Apart from this case, there are only seven published cases of infliximab use in the literature, all with moderate or complete response. Infliximab could be an option for corticosteroid-dependent EF with no response to other options.

Combination of Tocilizumab and Steroids to Improve Mortality in Patients with Severe COVID-19 Infection: A Spanish, Multicenter, Cohort Study.

BACKGROUND: We aimed to determine the impact of tocilizumab use on severe COVID-19 (coronavirus disease 19) pneumonia mortality. METHODS: We performed a multicentre retrospective cohort study in 18 tertiary hospitals in Spain from March to April 2020. Consecutive patients admitted with severe COVID-19 treated with tocilizumab were compared to patients not treated with tocilizumab, adjusting by inverse probability of the treatment weights (IPTW). Tocilizumab's effect in patients receiving steroids during the 48 h following inclusion was analysed. RESULTS: During the study period, 506 patients with severe COVID-19 fulfilled the inclusion criteria. Among them, 268 were treated with tocilizumab and 238 patients were not. Median time to tocilizumab treatment from onset of symptoms was 11 days [interquartile range (IQR) 8-14]. Global mortality was 23.7%. Mortality was lower in patients treated with tocilizumab than in controls: 16.8% versus 31.5%, hazard ratio (HR) 0.514 [95% confidence interval (95% CI) 0.355-0.744], p < 0.001; weighted HR 0.741 (95% CI 0.619-0.887), p = 0.001. Tocilizumab treatment reduced mortality by 14.7% relative to no tocilizumab treatment [relative risk reduction (RRR) 46.7%]. We calculated a number necessary to treat of 7. Among patients treated with steroids, mortality was lower in those treated with tocilizumab than in those treated with steroids alone [10.9% versus 40.2%, HR 0.511 (95% CI 0.352-0.741), p = 0.036; weighted HR 0.6 (95% CI 0.449-0.804), p < 0.001] (interaction p = 0.094). CONCLUSIONS: These results show that survival of patients with severe COVID-19 is higher in those treated with tocilizumab than in those not treated and that tocilizumab's effect adds to that of steroids administered to non-intubated patients with COVID-19 during the first 48 h of presenting with respiratory failure despite oxygen therapy. Randomised controlled studies are needed to confirm these results. TRIAL REGISTRATION: European Union electronic Register of Post-Authorization Studies (EU PAS Register) identifier, EUPAS34415.

Shock cardiogénico y embolia de pulmón / Cardiogenic Shock and Pulmonary Embolism

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Metástasis craneal de carcinoma folicular de tiroides / Follicular thyroid carcinoma with cranial metastasis

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Predictores de fragilidad en el anciano / No disponible

Objetivo: Identificar predictores de fragilidad en el anciano. Material y métodos: Se realizó una revisión sistemática para obtener posibles predictores de fragilidad en el anciano que, posteriormente, fueron evaluados por un panel multidisciplinar de expertos mediante metodología Delphi en tres rondas. De la revisión sistemática de la literatura se obtuvieron 16 predictores de fragilidad en el anciano, cada uno de ellos se concretó en un capítulo, en total se elaboraron 271 preguntas respecto a los predictores repartidas en estos 16 capítulos. Cada experto calificó los predictores de fragilidad mediante una escala tipo Likert del 1 al 9 (1 = predecía MUY MAL la fragilidad y 9 = predecía MUY BIEN la fragilidad). Los predictores de fragilidad que obtuvieron una puntuación con una mediana mayor de 7 fueron considerados como buenos predictores. Resultados: Los expertos coincidieron que algunas variables eran, por sí mismas y de forma independiente, predictoras de fragilidad: trastorno de la movilidad, caídas y alteración de las actividades básicas de la vida diaria, deterioro cognitivo, riesgo de sufrir úlceras por presión, pluripatología, aspectos sociodemográficos y ambientales (sólo existió consenso en la infraestructura del lugar de residencia), trastorno del ánimo (depresión, ansiedad y trastornos del sueño), deterioro visual y/o auditivo. Conclusión: No se ha encontrado una herramienta validada para identificar fragilidad, aunque se pueden agrupar en 16 categorías los posibles predictores y ello podría proporcionarnos una herramienta de detección de fragilidad en el anciano(AU)

Objectives: To define predictors of frailty in the elderly. Methods: A systematic review had been conducted in order to obtain possible predictors of frailty in the elderly. The predictors were evaluated by an expert in older adult’s care panel by three rounds of Delphi methodology. As a result of the systematic review of literature, 16 frailty predictors were obtained, and each predictor was included in a chapter. We have elaborated 271 questions about the frailty predictors. Every expert in the panel used a Likert scale from 1 to 9 (1 = predicted VERY BAD frailty, while 9 = predicted VERY GOOD frailty). Frailty predictors that obtained a median score higher than 7, were considered as good predictors. Results: Experts agreed that some variables were frailty predictors, by themselves and independently: mobility disorder, falls and limitation to basic activities of daily living, cognitive impairment, risk of pressure ulcers, multiple pathologies, socio-demographic features and environmental factors (there was consensus only regarding residence infrastructure), mood disorder (depression, anxiety and sleep disorders), and visual/hearing impairment. Conclusions: There is no single validated tool to identify frailty, though we found the possibility to group into 16 categories the possible predictors, and it would be helpful for the detection of frailty in the elderly(AU)

Síndrome de reconstitución inmune en pacientes con infección VIH. Estudio prospectivo de una serie de casos / Immune reconstitution in HIV-infected patients. A prospective analysis

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