A Randomized Trial of Mesenchymal Stromal Cells for Moderate to Severe Acute Respiratory Distress Syndrome from COVID-19

Rationale: There are limited therapeutic options for patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome with inflammation-mediated lung injury. Mesenchymal stromal cells offer promise as immunomodulatory agents. Objectives: Evaluation of efficacy and safety of allogeneic mesenchymal cells in mechanically-ventilated patients with moderate or severe COVID-19-induced respiratory failure. Methods: Patients were randomized to two infusions of 2 million cells/kg or sham infusions, in addition to the standard of care. We hypothesized that cell therapy would be superior to sham control for the primary endpoint of 30-day mortality. The key secondary endpoint was ventilator-free survival within 60 days, accounting for deaths and withdrawals in a ranked analysis. Measurements and Main Results: At the third interim analysis, the data and safety monitoring board recommended that the trial halt enrollment as the prespecified mortality reduction from 40% to 23% was unlikely to be achieved (n = 222 out of planned 300). Thirty-day mortality was 37.5% (42/112) in cell recipients versus 42.7% (47/110) in control patients (relative risk [RR], 0.88; 95% confidence interval, 0.64-1.21; P = 0.43). There were no significant differences in days alive off ventilation within 60 days (median rank, 117.3 [interquartile range, 60.0-169.5] in cell patients and 102.0 [interquartile range, 54.0-162.5] in control subjects; higher is better). Resolution or improvement of acute respiratory distress syndrome at 30 days was observed in 51/104 (49.0%) cell recipients and 46/106 (43.4%) control patients (odds ratio, 1.36; 95% confidence interval, 0.57-3.21). There were no infusion-related toxicities and overall serious adverse events over 30 days were similar. Conclusions: Mesenchymal cells, while safe, did not improve 30-day survival or 60-day ventilator-free days in patients with moderate and/or severe COVID-19-related acute respiratory distress syndrome.

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

External Support for Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Clinical Trial

Importance

Intimal hyperplasia and subsequent saphenous vein graft failure may have significant adverse clinical effects in patients undergoing coronary artery bypass surgery. External support of saphenous vein grafts has the potential to prevent vein graft dilation and hence slow the rate of intimal hyperplasia and increase long-term vein patency.

Objective

To determine efficacy, as measured by intimal hyperplasia, and safety of an external saphenous vein graft support device in patients undergoing a coronary bypass graft procedure.

Design, Setting, and Participants

This within-patient randomized, open-label, multicenter study was conducted at 17 Cardiothoracic Surgical Trials Network centers in North America. Between January 2018 and February 2019, 224 patients with multivessel coronary artery disease undergoing isolated bypass surgery were enrolled. For each patient, 1 of 2 vein grafts was randomized to receive external support or no support.

Interventions

External vein graft support or no support.

Main Outcomes and Measures

The primary efficacy end point was intimal hyperplasia area assessed by intravascular ultrasound at 12 months postrandomization for each study graft. Secondary confirmatory end points were lumen diameter uniformity assessed by angiography and graft failure (≥50% stenosis) by quantitative coronary angiography. Major cardiac and cerebrovascular events were collected through month 12.

Results

Among 224 patients (mean [SD] age, 65.8 [8.3] years; 178 [79.5%] male), 203 (90.6%) were eligible for intravascular ultrasound, of which 85 (41.9%) had at least 1 study graft occluded or severely diseased at 12 months (55 supported, 56 unsupported). After imputation of data missing because of graft occlusion or severe disease, the estimated mean (SE) intimal hyperplasia area was 5.11 (0.16) mm2 in supported grafts and 5.79 (0.20) mm2 in unsupported grafts (P = .07). In a sensitivity analysis of 113 patients with both grafts imaged, the mean intimal hyperplasia area was 4.58 (0.18) mm2 and 5.12 (0.23) mm2 in supported and unsupported grafts, respectively (P = .04). By 12 months, 5 patients (2.2%) died and 16 patients (7.1%) experienced a major cardiac or cerebrovascular event.

Conclusions and Relevance

The 12-month difference in intimal hyperplasia area between supported and unsupported grafts did not achieve statistical significance. Cumulative mortality and major cardiac or cerebrovascular events rates were similar to those in other randomized coronary artery bypass trials. Further investigation to assess the effect of external graft support devices on long-term graft patency and clinical outcomes is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT03209609.

Making community pharmacies psychologically informed environments: a pilot study to improve delivery of care for people with a drug problem

Introduction

Community pharmacies are key in the delivery of care to people who use drugs (PWUD), providing specialist harm reduction, and treatment interventions such as naloxone, Injecting Equipment Provision and opiate replacement treatment. PWUD are disproportionately burdened with mental ill-health and frequently report trauma history which impacts on engagement. A successful approach in the homeless sector, is that of Psychologically Informed Environments (PIE). The core elements of a PIE are: creating a space which engenders a sense of safety and wellbeing; reflective practice so staff can develop a shared model of working; training and support for staff; and considering the therapeutic aspects of service provision to vulnerable people (1).

Aim

This pilot study tested training pharmacy staff in applying a psychologically informed environments approach to improve the delivery of care to PWUD.

Methods

Three pharmacies were recruited from those with high involvement with PWUD. A range of location and type of pharmacy were included. Whole pharmacy teams were invited to an evening training session. Bespoke training was provided by clinical psychologists with PIE expertise.

Training was assessed by anonymous quantitative questionnaires using rating scales. Changes in the attitudes of staff were assessed by questionnaire before and 6 months after training. Descriptive statistics were applied. Qualitative interviews with staff at 6 months (planned for 3 months) explored what changes, were made after PIE training to adapt the delivery of care. The study used peer researcher-led telephone interviews for patient/client feedback on observed changes and experiences in participating pharmacies. Recruitment was via the three pharmacy teams due to covid restrictions. Thematic analysis was applied to qualitative data. Normalisation Process Theory provided a framework for assessing change.

Results

Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rating training structure and delivery as very good or excellent. Covid-19 lockdowns restricted follow-up data collection which took place at six months rather than three. Attitude scores were positive (>0) for all participants at baseline (median 15.0) increasing to 20.0 at 6 months. This was not statistically significant (S=4, p=0.549).

Staff interviews revealed training had encouraged staff to reflect on communication and considered the impact of current practice which could be discriminatory e.g. their use of first names, use of private areas and level of explanation to people. The increased mental health challenges for patients from Covid-19 restrictions gave an opportunity for staff to apply their new skills to this patient group and others who were struggling with isolation, as staff across pharmacies noted mental health challenges for patients. Five patients from two pharmacies were interviewed but time delays in data collection meant changes in delivery of care were difficult to recall.

Conclusion

The study was limited by small sample size and covid-related delays. However, findings indicated that training whole pharmacy teams in PIE was well received and justifies a larger study. The approach allowed staff to reflect on practice and identify previous, potentially discriminatory practice. The importance of clear and compassionate communication was evident.

Reference

(1) Johnson R, Haigh R. Social psychiatry and social policy for the 21st century ‐ new concepts for new needs: the ‘psychologically‐informed environment.’ Ment Heal Soc Incl. 2010;14(4):30–5.

Dietitians’ Attitudes and Experiences of Blended Tube Feeding in Paediatrics

Aims To examine; (a) the number of registered dietitians (RDs) with blended tube fed (BTF) patients, work setting and caseload; (b) attitudes and experiences towards BTF; (c) current BTF supports and future resources required. Methods An online survey collected information from Irish RDs over one month. Data was examined using cross-tabulations and Mann-Whitney U tests. Free-text was categorized into thematic domains. Results A significant number of RDs with HEN paediatric patients concurrently managed BTF patients (n = 27/48, 56.3%, p<0.05). The majority were based in tertiary hospitals (HEN; n = 20/48, 41.7%, BTF; n = 12/27, 44.4%). Equal numbers were willing to support BTF or on a patient-case basis (n = 36/77, 46.8%). International guidelines were most used to inform RDs (n = 40/69, 58.0%). Professional training workshops were the preferred learning method (n = 60/73, 82.2%). Conclusion Overall, BTF appears to be a growing practice. Community services, professional guidelines, training and information are needed.

Exploring the Effectiveness of an Integrated Mixed Martial Arts and Psychotherapy Intervention for Young Men's Mental Health

This research sought to establish the impact of a 10-week program combining mixed martial arts (MMA) and one-to-one psychotherapy on young males’ mental health and determine factors that predict help-seeking behavior in at-risk males. Preparticipation and post-participation interviews were employed as the method of data collection. Seven males (20–35 years; M = 24.57) completed preparticipation interviews and five completed follow-up interviews. Thematic analysis of preparticipation revealed that help-seeking behavior in at-risk males is impeded by the presence of male gender stereotypes, the absence of positive role models, as well as difficulty navigating challenging social landscapes. Post-participation interviews revealed that the sport provided structure and fitness for at-risk males, while the counseling was pivotal for personal growth. Improved relationships, work life, and self-esteem were also observed. The sporting element of the program helped to reduce stigma associated with engaging in psychotherapy, and positive male relationships were noted as particularly impactful. Findings support previous research indicating that combining sports and psychotherapy positively impacts young males’ mental health. Sport provides an acceptable doorway to psychotherapy, providing space to explore personal issues.