Background Tocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients. Methods A multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival. Results In the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6–24.0, P = 0.52) and 22.4% (97.5% CI: 17.2–28.3, P < 0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline. Conclusions Tocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline. Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092).

We report here a case of coronavirus disease 2019 pneumonia in a 40-year-old Caucasian woman with Down syndrome admitted to the Internal Medicine Unit. She was initially treated with hydroxychloroquine and azithromycin. When respiratory conditions dramatically worsened, she was not admitted to the intensive care unit because of impaired cognitive function. Thus helmet-based continuous positive airway pressure was started. The respiratory conditions progressively improved, reaching spontaneous breathing.

Prefazione - Il ruolo del palliativista in medicina internaGino Gobber Il ruolo del medico internista nelle cure palliativeDario Manfellotto Le cure palliative nel malato non-oncologicoItalo Penco La cura del malato fragile alla fine della vitaAndrea Fontanella La scuola di specializzazione in Medicina e Cure PalliativeGino Gobber; Dario Manfellotto IntroduzioneFabio Gilioli Strumenti per identificare la complessità dei bisogni clinici-assistenziali dei malati e delle loro famiglieFilippo Canzani; Claudio Santini Gestione dei sintomi in fase avanzata: dispnea, delirium, rantolo, nausea e vomito, occlusione intestinaleMatteo Moroni Gestione dei sintomi in fase avanzata e nel fine vita: doloreGiuseppe Civardi Approccio assistenziale ai sintomi in fase avanzata e nel fine vitaGabriella Bordin; Michela Guarda De-prescrizione, rimodulazione e sospensione diagnostiche e terapeutiche in fase avanzata di malattiaCarlo Lorenzo Muzzulini; Michele Berardi; Alessandro Valle Antibioticoterapia nelle cure palliativeMatteo Moroni; Filippo Costanzo Emotrasfusioni in cure palliativeFilomena Panzone; Raffaella Antonione Terapia anticoagulante in cure palliativeMauro Silingardi; Raffaella Antonione Ventilazione non invasiva in cure palliativeFederico Lari; Raffaella Antonione Scelte terapeutiche in medicina interna: come non perdersi nella complessità del fine vitaMiriam Cappelli; Mauro Carbone Raccomandazioni conclusive

Following publication of the original article [1] the authors identified that the collaborators of the TOCIVID-19 investigators, Italy were only available in the supplementary file. The original article has been updated so that the collaborators are correctly acknowledged.For clarity, all collaborators are listed in this correction article.

Due to the increasing age of the population the number of people suffering from chronic pain has significantly increased. People with chronic pain suffer from various diseases. Often this pain is not adequately controlled and is refractory, while its neuropathic component, which requires a different treatment, is perhaps underestimated compared to more properly nociceptive pain. The purpose of this study was to evaluate the presence of a neuropathic component in a cohort of 105 patients consecutively admitted to three Internal Medicine Units in Emilia Romagna. For the identification of the component of neuropathic pain diagnostic (DN4) questionnaire, previously validated, has been used. The average age of the patients studied was 64.4 years. The group of subjects with chronic non-cancer pain (78%) was numerically higher than the group of patients suffering from cancer pain (22%). All patients had pain and, according to the visual analogue scale (VAS), pain ranged from moderate to severe (median 7). Although without reaching statistically significant data, according to the VAS scale, cancer pain had an average higher value than non-cancer pain (7 vs 6.5). The prevalence of neuropathic component of pain was higher in patients with non-cancer pain (66% vs 57%). Instead, the recorded pain intensity in patients with neuropathic component was statistically much higher than the group in which the neuropathic component was absent (6.9 vs 6.1; P<0.05). In patients suffering from chronic pain, regardless of its nature and its etiology, the presence of a neuropathic component is significant. We must become aware of it and must search for it regularly through appropriate tools, such as the DN4 questionnaire. The presence of a neuropathic component usually makes the pain more intense and more refractory to treatments commonly used. Search for it may have therapeutic implications, suggesting that doctors use drugs active on this component. Since the majority of patients suffering from chronic pain are admitted to internal medicine wards, this awareness ought to become cultural heritage for the internist.Correspondence: Giuseppe Chesi, viale Martiri della Libertà 2,