Marcus Aurelius said:

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Thx for caring. She passed last night unfortunately. Multi-organ failure. Her husband is 2 beds down COVID-19 and very ill as well.

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• Trials of hydroxychloroquine given at the acute onset of disease occurring there in NY (less than 48 hours of first symptoms) to determine if hospitalization % can be decreased
• Working with FDA for an indication to prescribe plaquenil to patients with symptoms early once trial results are known
• Potential and appropriate use of well-time and dosed steroids -- starting steroids when the respiratory rate is around 30, given around second week of symptom onset when patients have begun to have trouble breathing (IV steroid)
• Possible that orally administered prednizone during this second week and keep patients out of hospital due to breathing issues
• Starting steroids there at Columbia when patients are needing more oxygen -- keeping them off a ventilator and getting them through toughest part
• Giving anti IL6 receptor tocilizumab to intubated patients
• May be benefit to giving steroids PRIOR to tocilizumab -- discharging first group of patients today that followed this treatment protocol and more data coming
• Anticoagulant treatment being used (heparin)
• Numbers still accelerating there locally (NY), no slowdown yet
• will be out of ventilators at end of this week
• at lab capacity to get blood test results for patients
• discharging patients that still have fevers and need oxygen, but seemed to have made it through the 2nd week (once neutrophil / lymphocyte ratio is below 6)
• these patients are still shedding virus, suggested they stay at home and don't go out for 72 hours until all symptoms (coughing) has STOPPED
• update to Irish patient that had NLR > 20 -- was doing well, about to come off ventilator, but now has another fever, possible secondary infection (bacterial)

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The patients enrolled in the trial averaged 56.8 years of age, ranging from 25 to 88, and most were men. Each patient had received a week of standard treatment before receiving tocilizumab. Fever was present in all, dry cough in two-thirds, and fatigue or dyspnea in one-quarter. Twenty patients required oxygen therapy.
All patients had increased levels of C-reactive protein, at a mean of 75 mg/L, and lymphocyte decreases were observed in 85%.
Chest CT scans were abnormal in all patients, typically involving ground-glass opacities and focal consolidation, particularly in the subpleural region.
Within a day of receiving tocilizumab, all patients showed normalization of their temperature. Peripheral oxygen saturation also improved rapidly, and 15 of the patients had a decrease in their requirement for oxygen. Normalization of lymphocyte levels was seen in 10 patients, and C-reactive protein levels also were reduced to normal levels within 5 days. Post-treatment CT scans showed clearance of lesions in 19 patients.
One dose of tocilizumab was given to 18 patients, and an additional dose was given to three patients when fever persisted for 12 hours.

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Marcus Aurelius said:

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The authorization to use tocilizumab in our hospital has been given to pulmonary docs like myself. So question to those using it for these patients. Timing? Anyone who requires ICU care? Upon intubation? I don't think it's judicious to use it for all admitted patients.

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On admission, the patient's arterial oxygen saturation increased to 96% with oxygen supplementation via nasal cannula (3 L/min). Chest CT imaging on hospital day 2 showed bilateral, multiple ground-glass opacities (Figure 1A-C). Considering his sustained chest tightness and shortness of breath, 40 mg of methylprednisolone, administered IV daily, was given on days 2 to 6. The patient then reported that his breathing had improved, but he still felt chest tightness. Chest CT imaging on hospital day 8 showed that the bilateral, multiple ground-glass opacities from the first scan remained (Figure 1D-F), and laboratory investigations revealed a high level of serum IL-6. On hospital day 9 (illness day 24), the patient was given 8 mg/kg tocilizumab, administered IV, 1 time. On hospital day 12, his chest tightness disappeared. After tocilizumab administration, the IL-6 level decreased gradually over the following 10 days (from 121.59 to 20.81 pg/mL), then increased rapidly to the peak (317.38 pg/mL), and then decreased to a low level (117.10 pg/mL) (Figure 2). The transient rebounding of the IL-6 level to the peak does not mean COVID-19 relapse: instead, this might be attributed to the recovery of the normal T cells. On hospital day 19, the patient had a third chest CT scan, which showed that the range of ground-glass opacities had obviously decreased (Figure 1G-I). The patient was declared to be cured and was discharged from the hospital on 13 March 2020. He had no symptoms of MM, and related laboratory findings were all in normal ranges

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If nothing else this pandemic has again revealed how incredible human ingenuity and willpower really is. Every once in a while we see a global event that tests our limits as a species and we seem to consistently rise to the challenge.

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