Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19.

OBJECTIVES: No agent has yet been proven to be effective for the treatment of patients with severe COVID-19. METHODS: We conducted a pilot prospective open, single-arm multicentre study on off-label use of tocilizumab (TCZ) involving 63 hospitalised adult patients (56 males, age 62.6±12.5) with severe COVID-19. Clinical and laboratory parameters were prospectively collected at baseline, day 1, 2, 7 and 14. No moderate-to-severe adverse events attributable to TCZ were recorded. RESULTS: We observed a significant improvement in the levels of ferritin, C-reactive protein, D-dimer. The ratio of the partial pressure of oxygen (Pa02) to the fraction of inspired oxygen (Fi02) improved (mean±SD Pa02/Fi02 at admission: 152±53; at day 7: 283.73±115.9, at day 14: 302.2±126, p<0.05). The overall mortality was 11%; D-dimer level at baseline, but not IL-6 levels were predictors of mortality. TCZ administration within 6 days from admission in the hospital was associated with an increased likelihood of survival (HR 2.2 95%CI 1.3-6.7, p<0.05). CONCLUSIONS: In hospitalised adult patients with severe COVID-19, TCZ could be a safe option. An improvement in respiratory and laboratory parameters was observed. Future controlled trials in patients with severe illness are urgently needed to confirm the definite benefit with IL-6 target therapy.

Deep impact of ultrasound in the intensive care unit: the "ICU-sound" protocol.

BACKGROUND: Ultrasound can influence the diagnosis and impact the treatment plan in critical patients. The aim of this study was to determine whether, without encountering major environment- or patient-related limitations, ultrasound examination under a critical care ultrasonography protocol can be performed to detect occult anomalies, to prompt urgent changes in therapy or induce further testing or interventions, and to confirm or modify diagnosis. METHODS: One hundred and twenty-five consecutive patients admitted to a general intensive care unit were assessed under a critical care ultrasonography protocol, and the data were analyzed prospectively. Systematic ultrasound examination of the optic nerve, thorax, heart, abdomen, and venous system was performed at the bedside. RESULTS: Environmental conditions hampered the examination slightly in 101/125 patients (80.8%), moderately in 20/125 patients (16%), and strongly in 4/125 patients (3.2%). Ultrasonographic findings modified the admitting diagnosis in 32/125 patients (25.6%), confirmed it in 73/125 patients (58.4%), were not effective in confirming or modifying it in 17/125 patients (13.6%), and missed it in 3/125 patients (2.4%). Ultrasonographic findings prompted further testing in 23/125 patients (18.4%), led to changes in medical therapy in 22/125 patients (17.6%), and to invasive procedures in 27/125 patients (21.6%). CONCLUSIONS: In this series of patients consecutively admitted to an intensive care unit, ultrasound examination revealed a high prevalence of unsuspected clinical abnormalities, with the highest number of new ultrasound abnormalities detected in patients with septic shock. As part of rapid global assessment of the patient on admission, our ultrasound protocol holds potential for improving healthcare quality.

The Burden of Carbapenem-Resistant Acinetobacter baumannii in ICU COVID-19 Patients: A Regional Experience.

Since the beginning of the COVID-19 pandemic, the impact of superinfections in intensive care units (ICUs) has progressively increased, especially carbapenem-resistant Acinetobacter baumannii (CR-Ab). This observational, multicenter, retrospective study was designed to investigate the characteristics of COVID-19 ICU patients developing CR-Ab colonization/infection during an ICU stay and evaluate mortality risk factors in a regional ICU network. A total of 913 COVID-19 patients were admitted to the participating ICUs; 19% became positive for CR-Ab, either colonization or infection (n = 176). The ICU mortality rate in CR-Ab patients was 64.7%. On average, patients developed colonization or infection within 10 ± 8.4 days from ICU admission. Scores of SAPS II and SOFA were significantly higher in the deceased patients (43.8 ± 13.5, p = 0.006 and 9.5 ± 3.6, p < 0.001, respectively). The mortality rate was significantly higher in patients with extracorporeal membrane oxygenation (12; 7%, p = 0.03), septic shock (61; 35%, p < 0.001), and in elders (66 ± 10, p < 0.001). Among the 176 patients, 129 (73%) had invasive infection with CR-Ab: 105 (60.7%) Ventilator-Associated Pneumonia (VAP), and 46 (26.6%) Bloodstream Infections (BSIs). In 22 cases (6.5%), VAP was associated with concomitant BSI. Colonization was reported in 165 patients (93.7%). Mortality was significantly higher in patients with VAP (p = 0.009). Colonized patients who did not develop invasive infections had a higher survival rate (p < 0.001). Being colonized by CR-Ab was associated with a higher risk of developing invasive infections (p < 0.001). In a multivariate analysis, risk factors significantly associated with mortality were age (OR = 1.070; 95% CI (1.028−1.115) p = 0.001) and CR-Ab colonization (OR = 5.463 IC95% 1.572−18.988, p = 0.008). Constant infection-control measures are necessary to stop the spread of A. baumannii in the hospital environment, especially at this time of the SARS-CoV-2 pandemic, with active surveillance cultures and the efficient performance of a multidisciplinary team.

Tracheobronchopathia osteochondroplastica in recurrent retrosternal goiter. Surgical management.

Tracheobronchopathia osteochondroplastica (TPO) is a rare pathology characterized by a progressive segmentary stenosis of the respiratory tract due to proliferation of osteocartilagineous nodules in the lumen of the distal part of the trachea and large bronchial trunks. Prognosis is usually benign, but some cases with an acute progression and a lethal outcome have been described. Clinical presentation is non specific, the chest x-ray is generally normal and there are not typical radiological signs of suspicion: diagnosis of TPO is usually incidental. We report a case of TPO associated with a retrosternal recurrent goiter. The CT scan conducted to evaluate the extension and the vascular relationships showed the characteristic lesions of the TPO with a segmental stenosis of the trachea greater than 70%. A bronchofiberoscopy confirmed the suspect of TPO. To date, the clinical studies carried out do not show a certain etiology, but all agree that chronic damage or chronic inflammations could be the cause of the onset of structural anomalies of the respiratory tract In literature, there is only a report which describes an association between TPO and thyroid pathology. It is obscure whatever these disease could be etiologically or fortuitously associated but a relationship cannot be completely excluded. Surgeons, anesthetists and radiologists which deal with thyroid pathology must recognize the disease, especially in the presence of bulky retrosternal goiters, to make a correct diagnosis and provide adequate perioperative management. KEY WORDS: Mediastinal goiter, Osteocartilagineous Nodules, Tracheal Stenosis, Total Thyroidectomy, Tracheobronchopathia Osteochondroplastica.