Tocilizumab in patients hospitalised with COVID-19 pneumonia: Efficacy, safety, viral clearance, and antibody response from a randomised controlled trial (COVACTA)

BACKGROUND

In COVACTA, a randomised, placebo-controlled trial in patients hospitalised with coronavirus disease-19 (COVID-19), tocilizumab did not improve 28-day mortality, but shortened hospital and intensive care unit stay. Longer-term effects of tocilizumab in patients with COVID-19 are unknown. Therefore, the efficacy and safety of tocilizumab in COVID-19 beyond day 28 and its impact on Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) clearance and antibody response in COVACTA were investigated.

METHODS

Adults in Europe and North America hospitalised with COVID-19 (N = 452) between April 3, 2020 and May 28, 2020 were randomly assigned (2:1) to double-blind intravenous tocilizumab or placebo and assessed for efficacy and safety through day 60. Assessments included mortality, time to hospital discharge, SARS-CoV-2 viral load in nasopharyngeal swab and serum samples, and neutralising anti-SARS-CoV-2 antibodies in serum. ClinicalTrials.gov registration: NCT04320615.

FINDINGS

By day 60, 24·5% (72/294) of patients in the tocilizumab arm and 25·0% (36/144) in the placebo arm died (weighted difference -0·5% [95% CI -9·1 to 8·0]), and 67·0% (197/294) in the tocilizumab arm and 63·9% (92/144) in the placebo arm were discharged from the hospital. Serious infections occurred in 24·1% (71/295) of patients in the tocilizumab arm and 29·4% (42/143) in the placebo arm. Median time to negative reverse transcriptase-quantitative polymerase chain reaction result in nasopharyngeal/oropharyngeal samples was 15·0 days (95% CI 14·0 to 21·0) in the tocilizumab arm and 21·0 days (95% CI 14·0 to 28·0) in the placebo arm. All tested patients had positive test results for neutralising anti-SARS-CoV-2 antibodies at day 60.

INTERPRETATION

There was no mortality benefit with tocilizumab through day 60. Tocilizumab did not impair viral clearance or host immune response, and no new safety signals were observed. Future investigations may explore potential biomarkers to optimize patient selection for tocilizumab treatment and combination therapy with other treatments.

FUNDING

F. Hoffmann-La Roche Ltd and the US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority, under OT number HHSO100201800036C.

Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia

BACKGROUND

Coronavirus disease 2019 (Covid-19) is associated with immune dysregulation and hyperinflammation, including elevated interleukin-6 levels. The use of tocilizumab, a monoclonal antibody against the interleukin-6 receptor, has resulted in better outcomes in patients with severe Covid-19 pneumonia in case reports and retrospective observational cohort studies. Data are needed from randomized, placebo-controlled trials.

METHODS

In this phase 3 trial, we randomly assigned patients who were hospitalized with severe Covid-19 pneumonia in a 2:1 ratio receive a single intravenous infusion of tocilizumab (at a dose of 8 mg per kilogram of body weight) or placebo. Approximately one quarter of the participants received a second dose of tocilizumab or placebo 8 to 24 hours after the first dose. The primary outcome was clinical status at day 28 on an ordinal scale ranging from 1 (discharged or ready for discharge) to 7 (death) in the modified intention-to-treat population, which included all the patients who had received at least one dose of tocilizumab or placebo.

RESULTS

Of the 452 patients who underwent randomization, 438 (294 in the tocilizumab group and 144 in the placebo group) were included in the primary and secondary analyses. The median value for clinical status on the ordinal scale at day 28 was 1.0 (95% confidence interval [CI], 1.0 to 1.0) in the tocilizumab group and 2.0 (non-ICU hospitalization without supplemental oxygen) (95% CI, 1.0 to 4.0) in the placebo group (between-group difference, -1.0; 95% CI, -2.5 to 0; P = 0.31 by the van Elteren test). In the safety population, serious adverse events occurred in 103 of 295 patients (34.9%) in the tocilizumab group and in 55 of 143 patients (38.5%) in the placebo group. Mortality at day 28 was 19.7% in the tocilizumab group and 19.4% in the placebo group (weighted difference, 0.3 percentage points; 95% CI, -7.6 to 8.2; nominal P = 0.94).

CONCLUSIONS

In this randomized trial involving hospitalized patients with severe Covid-19 pneumonia, the use of tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days. (Funded by F. Hoffmann-La Roche and the Department of Health and Human Services; COVACTA ClinicalTrials.gov number, NCT04320615.).

Multifunction interferometry using the electron mobility visibility and mean free path relationship

A conventional Michelson interferometer is modified and used to form the various types of interferometers. The basic system consists of a conventional Michelson interferometer with silicon-graphene-gold embedded between layers on the ports. When light from the monochromatic source is input into the system via the input port (silicon waveguide), the change in optical path difference (OPD) of light traveling in the stacked layers introduces the change in the optical phase, which affects to the electron mean free path within the gold layer, induces the change in the overall electron mobility can be seen by the interferometer output visibility. Further plasmonic waves are introduced on the graphene thin film and the electron mobility occurred within the gold layer, in which the light-electron energy conversion in terms of the electron mobility can be observed, the gold layer length is 100 nm. The measurement resolution in terms of the OPD of ∼ 50 nm is achieved. In applications, the outputs of the drop port device of the modified Michelson interferometer can be arranged by the different detectors, where the polarized light outputs, the photon outputs, the electron spin outputs can be obtained by the interference fringe visibility, mobility visibility and the spin up-down splitting output energies. The modified Michelson interferometer theory and the detection schemes are given in details.

Acne vulgarism treatment using ultra-short laser pulse generated by micro- and nano-ring resonator system

Acne vulgaris is adebilitating dermatologic disease, and is conventionally treated by laser therapy using a microring resonator system. An evolving understanding of laser-tissue interactions involving Propioni bacterium acneproducing porphyrins, and the development of lasers to target the sebaceous glands, has led to the development of an escalating number of laser light for acne treatment. The results show that the full width at half maximum of the proposed laser pulse of 0.15 nm can be generated using a microring resonator system. The power of the laser is 200 W and the wavelength laser is 1,032 nm, which is proposed as a treatment of acne vulgaris diseases.

Ultra-short laser pulse generated by a microring resonator system for cancer cell treatment

A microring resonator (MRRs) system incorporated with a add/drop filter is proposed in which ultra-short single, multi-temporal, and spatial optical soliton pulses are simulated and used to kill abnormal cells, tumors, and cancer. Chaotic signals are generated by a bright soliton pulse within a nonlinear MRRs system. Gold nanoparticles and ultra-short femtosecond/picosecond laser pulses' interaction holds great interest in laser nanomedicine. By using appropriate soliton input power and MRRs parameters, desired spatial and temporal signals can be generated over the spectrum. Results show that short temporal and spatial solitons pulse with FWHM = 712 fs and FWHM = 17.5 pm could be generated. The add/drop filter system is used to generate the high-capacity, ultra-short soliton pulses in the range of nanometer/second and picometer/second.

Optical manipulation of nano-micro needle array for large volume molecular diagnosis

Optical vorticesare generated and controlled to form trapping tools in the same way as optical tweezers. By using the intense optical vortices generated within the PANDA ring resonator, the required atoms/molecules can be trapped and moved (transported) dynamically within the wavelength router or network. The advantage of the proposed system is that a transmitter and receiver can be formed within the same system, which is available for atoms/molecules storage and transportation based on methods that have been proposed to deliver drugs into cells for specific diagnosis.

Gold nanoparticle trapping and delivery for therapeutic applications

A new optical trapping design to transport gold nanoparticles using a PANDA ring resonator system is proposed. Intense optical fields in the form of dark solitons controlled by Gaussian pulses are used to trap and transport nanoscopic volumes of matter to the desired destination via an optical waveguide. Theoretically, the gradient and scattering forces are responsible for this trapping phenomenon, where in practice such systems can be fabricated and a thin-film device formed on the specific artificial medical materials, for instance, an artificial bone. The dynamic behavior of the tweezers can be tuned by controlling the optical pulse input power and parameters of the ring resonator system. Different trap sizes can be generated to trap different gold nanoparticles sizes, which is useful for gold nanoparticle therapy. In this paper, we have shown the utility of gold nanoparticle trapping and delivery for therapy, which may be useful for cosmetic therapy and related applications.

Blood cleaner on-chip design for artificial human kidney manipulation

A novel design of a blood cleaner on-chip using an optical waveguide known as a PANDA ring resonator is proposed. By controlling some suitable parameters, the optical vortices (gradient optical fields/wells) can be generated and used to form the trapping tools in the same way as optical tweezers. In operation, the trapping force is formed by the combination between the gradient field and scattering photons by using the intense optical vortices generated within the PANDA ring resonator. This can be used for blood waste trapping and moves dynamically within the blood cleaner on-chip system (artificial kidney), and is performed within the wavelength routers. Finally, the blood quality test is exploited by the external probe before sending to the destination. The advantage of the proposed kidney on-chip system is that the unwanted substances can be trapped and filtered from the artificial kidney, which can be available for blood cleaning applications.

Molecular buffer using a PANDA ring resonator for drug delivery use

A novel design of molecular buffer for molecule storage and delivery using a PANDA ring resonator is proposed. The optical vortices can be generated and controlled to form the trapping tools in the same way as the optical tweezers. In theory, the trapping force is formed by the combination between the gradient field and scattering photons, which is reviewed. By using the intense optical vortices generated within the PANDA ring resonator, the required molecules can be trapped and moved (transported) dynamically within the wavelength router or network, ie, a molecular buffer. This can be performed within the wavelength router before reaching the required destination. The advantage of the proposed system is that a transmitter and receiver can be formed within the same system, which is available for molecule storage and transportation.

Optical absorption of tetraphenylporphyrin thin films in UV-vis-NIR region

The optical absorption of thermally evaporated tetraphenylporphyrin (TPP) in the UV-vis-NIR region have been studied. The absorption spectra recorded in the UV-vis region for the as deposited and annealed films showed different absorption bands, namely the Soret(B) at region 360-490nm, Q-band region consist of four bands in the region 500-720nm and two other bands labeled N and M in UV region. The Soret band always shows its characteristic effect splitting in all the TPP thin films and the effect of annealing on the intensities of these components have been observed. The spectra of the infrared absorption allow characterization of vibrational modes for the powder, as deposited and annealed thin films. Some of the optical absorption parameters, namely molar extinction coefficient, epsilon, half band width, Deltalambda, electronic dipole strength, q(2) and oscillator strength, f, of the principle optical transitions have also been evaluated.

Optical absorption of tetraphenylporphyrin thin films in UV-vis-NIR region

The optical absorption of thermally-evaporated tetraphenylporphyrin (TPP), in the UV-vis-NIR region has been studied. The absorption spectra recorded in the UV-vis region for the as-deposited and annealed films showed different absorption bands, namely the Soret, B, at region 360-490 nm, Q-band region consist of four bands in the region 500-720 nm and two other bands labeled N and M in UV region. The Soret band always shows splitting in all the TPP thin films and the effect of annealing on the intensities of these components have been observed. The spectra of the infrared absorption allow characterization of vibrational modes for the powder, as deposited and annealed thin films. Some of the optical absorption parameters, namely molar extinction coefficient (epsilon), half band width (Deltalambda), electronic dipole strength (q2), and oscillator strength (f), of the principal optical transitions have also been evaluated.