Effect of tocilizumab on clinical outcomes at 15 days in patients with severe or critical coronavirus disease 2019: randomised controlled trial

OBJECTIVE

To determine whether tocilizumab improves clinical outcomes for patients with severe or critical coronavirus disease 2019 (covid-19).

DESIGN

Randomised, open label trial.

SETTING

Nine hospitals in Brazil, 8 May to 17 July 2020.

PARTICIPANTS

Adults with confirmed covid-19 who were receiving supplemental oxygen or mechanical ventilation and had abnormal levels of at least two serum biomarkers (C reactive protein, D dimer, lactate dehydrogenase, or ferritin). The data monitoring committee recommended stopping the trial early, after 129 patients had been enrolled, because of an increased number of deaths at 15 days in the tocilizumab group.

INTERVENTIONS

Tocilizumab (single intravenous infusion of 8 mg/kg) plus standard care (n=65) versus standard care alone (n=64).

MAIN OUTCOME MEASURE

The primary outcome, clinical status measured at 15 days using a seven level ordinal scale, was analysed as a composite of death or mechanical ventilation because the assumption of odds proportionality was not met.

RESULTS

A total of 129 patients were enrolled (mean age 57 (SD 14) years; 68% men) and all completed follow-up. All patients in the tocilizumab group and two in the standard care group received tocilizumab. 18 of 65 (28%) patients in the tocilizumab group and 13 of 64 (20%) in the standard care group were receiving mechanical ventilation or died at day 15 (odds ratio 1.54, 95% confidence interval 0.66 to 3.66; P=0.32). Death at 15 days occurred in 11 (17%) patients in the tocilizumab group compared with 2 (3%) in the standard care group (odds ratio 6.42, 95% confidence interval 1.59 to 43.2). Adverse events were reported in 29 of 67 (43%) patients who received tocilizumab and 21 of 62 (34%) who did not receive tocilizumab.

CONCLUSIONS

In patients with severe or critical covid-19, tocilizumab plus standard care was not superior to standard care alone in improving clinical outcomes at 15 days, and it might increase mortality.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04403685.

The effect of bone marrow transplantation on oxidative stress in X-linked adrenoleukodystrophy

Oxidative stress plays an important role in the pathophysiology of neurodegenerative diseases, including X-linked adrenoleukodystrophy (X-ALD). In the present work, we evaluated lipid (malondialdehyde [MDA] content) and protein (sulfhydryl and carbonyl contents) oxidative damage parameters in plasma from X-ALD patients before and after bone marrow transplant (BMT), in order to verify if this treatment is capable to alter the oxidative parameters studied. We also evaluated the plasma concentration of hexacosanoic acid (C26:0) from X-ALD patients and correlated it with the oxidative damage parameters investigated. We observed that MDA content was significantly increased in plasma of X-ALD patients before BMT and after BMT when compared to controls, and that it was significantly reduced in plasma of X-ALD after BMT when compared to the before BMT group. These results indicate that lipid peroxidation is stimulated in X-ALD patients but there is a significant reduction of lipid peroxidation after BMT. Next, we observed a significant reduction of sulfhydryl content in plasma of X-ALD patients before BMT compared to controls indicating protein oxidative damage and that this measurement was increased in these patients after BMT as compared to before BMT. We found no significant differences in plasma carbonyl content in X-ALD patients before and after BMT as compared to controls. However, we observed a significant reduction in this parameter in X-ALD patients after BMT compared to before BMT. Finally, C26:0 plasma concentration was significantly reduced in X-ALD patients after BMT when compared to before BMT. We found no significant correlations between MDA and carbonyl values with C26:0 levels of the patients before BMT and after BMT, but a significant inverse correlation between sulfhydryl content and C26:0 levels was detected. In conclusion, the present study reinforces the hypothesis that lipid peroxidation and protein damage are induced in plasma of X-ALD patients and, in addition, demonstrates that BMT treatment is capable to reduce this pathogenic process. Taken together, the data obtained from plasma of X-ALD patients before and after BMT showing induction and protection, respectively, of oxidative stress, allowed to suggest that BMT, when well succeeded and under the recommendations, is effective to reduce C26:0 plasma levels and the increased lipid and protein oxidative damage in X-ALD.

Fracture resistance and mode of failure of various types of root filled teeth

AIM

To investigate ex vivo the influence of the post system on fracture resistance and failure mode of root filled incisor, canine, premolar and molar teeth.

METHODOLOGY

Eighty human teeth were divided into eight groups (n = 10) resulting from the interaction between the two study factors: post system (glass fibre post; cast Ni-Cr alloy post and core) and type of tooth (maxillary incisors, maxillary canines, maxillary premolars and mandibular molars). All roots were prepared with a 2-mm ferrule and restored with metal crown. Fracture resistance (N) was assessed in a mechanical testing device, and the data were analysed by two-way anova (4 × 2) followed by Tukey's test (α = 0.05). The failure mode was evaluated using an optical stereomicroscope and classified according to the location of the failure. Failure mode data were analysed by two-factor anova and Student-Newman-Keuls (SNK) tests (α = 0.05). Correlation between fracture resistance and failure mode was analysed by linear regression.

RESULTS

Glass fibre and cast posts and cores had similar fracture resistance, regardless of the type of tooth. Canines and molars had significantly higher fracture resistance (P < 0.001) than premolars. Incisors teeth had significantly lower fracture resistance (P < 0.001) than premolars. The fracture mode for incisors, premolars and molars was more amenable to restoration when the teeth were restored with glass fibre posts. Fracture resistance had no correlation with fracture mode, regardless of the post system and type of tooth analysed.

CONCLUSIONS

Post system had no significant effect on fracture resistance, regardless of the type of tooth. The mode of fracture was more restorable with glass fibre posts.

Effect of gamma irradiation on ultimate tensile strength of enamel and dentin

The effect of gamma irradiation therapy on the ultimate tensile strength (UTS) of enamel and dentin in relation to prism orientation, dentin tubule orientation, and location is unknown. It was hypothesized that tubule and prism orientation, location, and irradiation have an effect on the UTS of dental structures. Forty human third molars were used, half of which were subjected to 60 Gy of gamma irradiation, in daily increments of 2 Gy. The specimens were evaluated by microtensile testing. Results showed that irradiation treatment significantly decreased the UTS of coronal and radicular dentin and of enamel, regardless of tubule or prism orientation. With or without irradiation, enamel was significantly stronger when tested parallel to its prismatic orientation. Coronal and radicular dentin of non-irradiated specimens presented significantly higher UTS when tested perpendicularly to tubule orientation. However, when the teeth were irradiated, the influence of tubule orientation disappeared, demonstrating that irradiation is more harmful to organic components.

Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines

Hospital-prepared tube feedings from four Philippine acute-care hospitals were analysed for microbial contamination. Two feedings were prepared on three separate days at each hospital. The tube feedings were either blended natural whole foods or a reconstituted commercial powdered nutritional product. Samples of each feeding were collected for coliform count and standard plate count at the time of preparation and at 1, 2 and 4 h after preparation after maintenance at room temperature (26-31 degrees C). At the time of preparation, mean coliform and standard plate counts for all samples were 10.3 most probable number per gram (MPN/g) and 7.4x10(4)colony-forming units per gram (cfu/g), respectively. Nine of 24 samples (38%) had coliform counts greater than 10 MPN/g, and 22/24 (92%) samples had standard plate counts greater than 10(3) cfu/g. There were significant increases in mean coliform and standard plate counts over 4 h (P=0.0005 and P=0.008, respectively). At 4 h after preparation, the mean coliform and standard plate counts were 18.2 MPN/g and 2.1x10(5) cfu/g, respectively. At this time, 18/24 (75%) samples had coliform counts greater than 10 MPN/g and 20/24 (83%) samples had standard plate counts greater than 10(5) cfu/g. The results of this study show that the microbial quality of the majority of the hospital-prepared enteral tube feedings analysed were not within published guidelines for safety.

von Willebrand factor antigen levels in plasma of patients with malignant breast disease

von Willebrand factor (vWF) is a protein that mediates platelet adherence to the subendothelium during primary hemostasis. High plasma vWF concentrations have been reported in patients with various types of cancer, such as head and neck, laryngeal and prostatic cancer, probably representing an acute phase reactant. In the present study we determined the plasma levels of vWF antigen (vWF:Ag) by quantitative immunoelectrophoresis in 128 female patients with breast cancer as well as in 47 women with benign breast disease and in 27 healthy female controls. The levels of vWF:Ag were 170.7 +/- 78 U/dl in patients with cancer, 148.4 +/- 59 U/dl in patients with benign disease and 130.6 +/- 45 U/dl in controls (P<0.005). We also detected a significant increase in the levels of vWF:Ag (P<0.0001) in patients with advanced stages of the disease (stage IV = 263.3 +/- 113 U/dl, stage IIIB = 194.0 +/- 44 U/dl) as compared to those with earlier stages of the disease (stage I = 155.3 +/- 65 U/dl, stage IIA = 146.9 +/- 75 U/dl). In conclusion, vWF levels were increased in plasma of patients with malignant breast disease, and these levels correlated with tumor progression.

[Interaction between prescribers, dispensers, and patients: shared information as a possible therapeutic benefit]

The article presents a critical view of the interaction between prescribers, dispensers, and patients, considering information one of the key issues in enhancing the qualitative aspects involved in this complex relationship. It describes the acquisition of information by health professionals, possible sources of this information, and the process involved in transforming it into knowledge. Briefly discussed are the physician's and pharmacist's roles, the patient's expectations as recipient, and consequences of pertinent health interventions.

[Pharmaceutical procurement by the public sector: the quality/cost relationship]

The authors discuss procurement and provision of pharmaceutical products from the perspective of supply management in the public health sector, focusing on two main aspects: quality and cost. The article analyzes issues to be considered by buyers when evaluating drug quality, especially formulation stability, bioequivalence, and the role of generics. Also discussed are factors involving costs and cost management in relation to technological innovations and consumer demands. New alternatives and suggestions are examined and presented for procurement of high-quality, cost-effective drug products.

[Food and nutrition knowledge of school-age children's mothers from elementary and high school from different socioeconomic levels]

The objective of this study was to determine the degree of knowledge on food and nutrition of school-age children's mothers from Chile's Metropolitan Region and to measure the impact of socioeconomic, sociocultural and demographic variables on knowledge. A representative and proportional sample of 4,509 school-age children was chosen from Chile's Metropolitan Region and the degree of knowledge on food and nutrition on mothers of 1,985 of them was determined. The sample was stratified according to grade (I, II, IV, VI, VIII elementary school grades and I and IV high school grades), sex, type of school and geographic area. Socioeconomic status (SES) was determined through Graffar's modified method. The degree of knowledge on food and nutrition was assessed by a test based on the specific objectives pursued by the elementary school curriculum programs of the Ministry of Education and submitted to adequate statistical proofs for its content validity and reliability. Mother's schooling level mean was 9.7 +/- 4.0 y. The field study was carried out on 1986-1987. Statistical procedures included analysis of variance, Student "t" test for comparison of the means, correlation and regression. Results revealed that mothers did not know food and nutrition matters in fundamental aspects related to the observance of a healthy lifestyle, both, for themselves and their family. The degree of knowledge of food and nutrition significantly and positively correlated with SES, mother's schooling and occupation level, housing conditions (quality and sanitation) and age, and significantly and inversely correlated with the number of sons and crowding, besides of being significantly higher in urban than rural mothers. Mother's schooling level and geographic area were the independent variables with the greatest explanatory power in the food and nutrition knowledge variance (r2 = 0.1723), but mother's schooling level explains 93.2% of the explained variance. Results suggest the need to introduce, during school age, nutrition education programs focused on mother and children to improve the population life quality.

[Food and nutrition knowledge of elementary and high school-age children from Chile's Metropolitan Region]

BACKGROUND

In Chile there is scarce food and nutrition knowledge among school age children.

AIM

To determine the degree of food and nutrition knowledge of elementary and high school children and its relationship to socioeconomic status, sex, type of school and geographic area.

SUBJECTS AND METHODS

Between 1986 and 1987, a representative and proportional sample of 4509 children was chosen from the Metropolitan Region. This sample was stratified according to school grade, sex, type of school and geographical area. Graffar's modified method was used to measure socioeconomic status. Food and nutrition knowledge was assessed by a specific test for each grade, based on the objectives pursued by the curricular programs of the Ministry of Education.

RESULTS

The test was applied to 4197 children. Food and nutrition knowledge was significantly lower in the second subcycle of elementary school, in males, in older children from each grade, in rural areas, in children of low socioeconomic status and in public schools.

CONCLUSIONS

School age children were unaware of fundamental aspects related to food and nutrition and curriculum programs of the Ministry of Education should be reformulated to overcome these deficiencies.

Nutrition and learning in Chilean school age children: Chile's Metropolitan Region Survey 1986-1987

The objective of this study was to determine the interrelationship between the scholastic achievement (SA) test and nutritional status of a representative sample of 4,509 elementary and high school children from Chile's Metropolitan Region. Percentages of weight/age (W/A), height/age (H/A), and weight/height (W/H) were compared to WHO (World Health Organization) Tables, head circumference/age (HC/A) to the Tanner Tables, and brachial anthropometry to Frisancho's norms. Socioeconomic status (SES) was measured by means of Graffar's Modified Method; SA by means of a language and mathematics test. Statistical analysis included correlation, regression, and WHO risk-approach methodology. Results showed that HC/A was the anthropometric parameter with the greatest explanatory power in SA variance and was significantly greater in high school graduates who were 17 y old (r = 0.350; p < 0.001; r2 = 0.122) than in elementary school children, who were 6 y old (r = 0.227; p < 0.001; r2 = 0.049), with a relative risk of 2.1 and 1.5, respectively. The explanatory power of W/A and H/A in SA variance was significantly decreased, and no significant differences were observed among high school students. These findings confirm that HC/A is the most important anthropometric parameter associated with SA. Educational selectivity apparently relates to HC/A, and not to W/A or H/A. These results may be useful in planning nutritional and educational policies.

Evolution of ambulatory pharmacy services at a public health department

This article is a narrative of the development of several key pharmacy services at a public health department in a metropolitan area fraught with many urban problems and obstacles for delivery of health services to the underserved. The pharmacy operation evolved from a traditional dispensing role to fully integrated clinical pharmacy services.