Molnupiravir versus placebo in unvaccinated and vaccinated patients with early SARS-CoV-2 infection in the UK (AGILE CST-2): a randomised, placebo-controlled, double-blind, phase 2 trial

BACKGROUND

The antiviral drug molnupiravir was licensed for treating at-risk patients with COVID-19 on the basis of data from unvaccinated adults. We aimed to evaluate the safety and virological efficacy of molnupiravir in vaccinated and unvaccinated individuals with COVID-19.

METHODS

This randomised, placebo-controlled, double-blind, phase 2 trial (AGILE CST-2) was done at five National Institute for Health and Care Research sites in the UK. Eligible participants were adult (aged ≥18 years) outpatients with PCR-confirmed, mild-to-moderate SARS-CoV-2 infection who were within 5 days of symptom onset. Using permuted blocks (block size 2 or 4) and stratifying by site, participants were randomly assigned (1:1) to receive either molnupiravir (orally; 800 mg twice daily for 5 days) plus standard of care or matching placebo plus standard of care. The primary outcome was the time from randomisation to SARS-CoV-2 PCR negativity on nasopharyngeal swabs and was analysed by use of a Bayesian Cox proportional hazards model for estimating the probability of a superior virological response (hazard ratio [HR]>1) for molnupiravir versus placebo. Our primary model used a two-point prior based on equal prior probabilities (50%) that the HR was 1·0 or 1·5. We defined a priori that if the probability of a HR of more than 1 was more than 80% molnupiravir would be recommended for further testing. The primary outcome was analysed in the intention-to-treat population and safety was analysed in the safety population, comprising participants who had received at least one dose of allocated treatment. This trial is registered in ClinicalTrials.gov, NCT04746183, and the ISRCTN registry, ISRCTN27106947, and is ongoing.

FINDINGS

Between Nov 18, 2020, and March 16, 2022, 1723 patients were assessed for eligibility, of whom 180 were randomly assigned to receive either molnupiravir (n=90) or placebo (n=90) and were included in the intention-to-treat analysis. 103 (57%) of 180 participants were female and 77 (43%) were male and 90 (50%) participants had received at least one dose of a COVID-19 vaccine. SARS-CoV-2 infections with the delta (B.1.617.2; 72 [40%] of 180), alpha (B.1.1.7; 37 [21%]), omicron (B.1.1.529; 38 [21%]), and EU1 (B.1.177; 28 [16%]) variants were represented. All 180 participants received at least one dose of treatment and four participants discontinued the study (one in the molnupiravir group and three in the placebo group). Participants in the molnupiravir group had a faster median time from randomisation to negative PCR (8 days [95% CI 8-9]) than participants in the placebo group (11 days [10-11]; HR 1·30, 95% credible interval 0·92-1·71; log-rank p=0·074). The probability of molnupiravir being superior to placebo (HR>1) was 75·4%, which was less than our threshold of 80%. 73 (81%) of 90 participants in the molnupiravir group and 68 (76%) of 90 participants in the placebo group had at least one adverse event by day 29. One participant in the molnupiravir group and three participants in the placebo group had an adverse event of a Common Terminology Criteria for Adverse Events grade 3 or higher severity. No participants died (due to any cause) during the trial.

INTERPRETATION

We found molnupiravir to be well tolerated and, although our predefined threshold was not reached, we observed some evidence that molnupiravir has antiviral activity in vaccinated and unvaccinated individuals infected with a broad range of SARS-CoV-2 variants, although this evidence is not conclusive.

FUNDING

Ridgeback Biotherapeutics, the UK National Institute for Health and Care Research, the Medical Research Council, and the Wellcome Trust.

Clinical determinants and impact of hemorrhagic lesions on intestinal pathology in preterm infants with surgical necrotizing enterocolitis

OBJECTIVE

We sought to determine the clinical and histopathological factors associated with intestinal hemorrhage and its correlation with clinical outcomes in neonates with surgical necrotizing enterocolitis (NEC).

METHODS

A retrospective study compared clinical and histopathology information in neonates following surgical NEC with severe hemorrhage and those with mild/moderate hemorrhagic lesions seen on resected intestine pathology.

RESULTS

The infants with severe hemorrhage (Grade 3-4, 81/148, 54.7%) had significantly lower exposure to antenatal steroids (52.5 % vs 76.9 % ; p = 0.004), had higher gestational age (28.5 weeks [7.14] vs. 26.58 [2.90]; p = 0.034), lost more bowel length (p = 0.045), had higher CRP levels at 2 weeks (p = 0.035), and had less intestinal failure ([30.3 % vs 52.5 %]; p = 0.014) than mild/moderate (Grade 0-2, 67/148, 45.2%) hemorrhage group. Those with severe hemorrhage had significantly higher mean inflammation score (2.67 [0.94] vs. 1.63 [0.92]; p = <0.001), higher necrosis scores (1.95 [1.28] vs. 1.49 [1.35]; p = 0.037), higher neovascularization (p = 0.01), higher fibroblasts (p = 0.023) and higher lymphocyte percentages up to 48 hours (p <  0.05) following NEC than mild/ moderate hemorrhage group.On multivariable regression, less exposure to antenatal steroids (OR 0.18 [95% CI 0.05-0.58]; p = 0.005), higher inflammation (OR 3.7 [95% CI 2.09-7.32]; p = 0.001), and lymphocyte count on the day of onset/24 hours following NEC (OR 1.06 [95% CI 1.02-1.11]; p = 0.005) were independently associated with a higher odd of severe intestinal hemorrhage.

CONCLUSION

The surgical NEC infants with intestinal hemorrhage were less likely to have antenatal steroid exposure but had higher inflammation grade and lymphocyte counts following NEC onset on multivariable regression modeling.

Nivolumab versus placebo in patients with relapsed malignant mesothelioma (CONFIRM): a multicentre, double-blind, randomised, phase 3 trial

BACKGROUND

No phase 3 trial has yet shown improved survival for patients with pleural or peritoneal malignant mesothelioma who have progressed following platinum-based chemotherapy. The aim of this study was to assess the efficacy and safety of nivolumab, an anti-PD-1 antibody, in these patients.

METHODS

This was a multicentre, placebo-controlled, double-blind, parallel group, randomised, phase 3 trial done in 24 hospitals in the UK. Adult patients (aged ≥18 years) with an Eastern Cooperative Oncology Group performance status of 0 or 1, with histologically confirmed pleural or peritoneal mesothelioma, who had received previous first-line platinum-based chemotherapy and had radiological evidence of disease progression, were randomly assigned (2:1) to receive nivolumab at a flat dose of 240 mg every 2 weeks over 30 min intravenously or placebo until disease progression or a maximum of 12 months. The randomisation sequence was generated within an interactive web response system (Alea); patients were stratified according to epithelioid versus non-epithelioid histology and were assigned in random block sizes of 3 and 6. Participants and treating clinicians were masked to group allocation. The co-primary endpoints were investigator-assessed progression-free survival and overall survival, analysed according to the treatment policy estimand (an equivalent of the intention-to-treat principle). All patients who were randomly assigned were included in the safety population, reported according to group allocation. This trial is registered with Clinicaltrials.gov, NCT03063450.

FINDINGS

Between May 10, 2017, and March 30, 2020, 332 patients were recruited, of whom 221 (67%) were randomly assigned to the nivolumab group and 111 (33%) were assigned to the placebo group). Median follow-up was 11·6 months (IQR 7·2-16·8). Median progression-free survival was 3·0 months (95% CI 2·8-4·1) in the nivolumab group versus 1·8 months (1·4-2·6) in the placebo group (adjusted hazard ratio [HR] 0·67 [95% CI 0·53-0·85; p=0·0012). Median overall survival was 10·2 months (95% CI 8·5-12·1) in the nivolumab group versus 6·9 months (5·0-8·0) in the placebo group (adjusted HR 0·69 [95% CI 0·52-0·91]; p=0·0090). The most frequently reported grade 3 or worse treatment-related adverse events were diarrhoea (six [3%] of 221 in the nivolumab group vs two [2%] of 111 in the placebo group) and infusion-related reaction (six [3%] vs none). Serious adverse events occurred in 90 (41%) patients in the nivolumab group and 49 (44%) patients in the placebo group. There were no treatment-related deaths in either group.

INTERPRETATION

Nivolumab represents a treatment that might be beneficial to patients with malignant mesothelioma who have progressed on first-line therapy.

FUNDING

Stand up to Cancer-Cancer Research UK and Bristol Myers Squibb.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p <  0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42°(sd 30) and 9° (sd 15) respectively pre-operatively to 78° (sd 39) and 24° (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching.

The Bayley–Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Cite this article: Bone Joint J 2014;96-B:936–42.

Stump ulcers and continued prosthetic limb use

Stump ulcers are common problems in amputees. Temporary discontinuation of prosthetic limb use is frequently employed to facilitate healing. Inevitably, this limits activity and may, for instance, prevent an amputee from going to work. A survey of clinical practice was carried out based on the premise that controlled continued prosthetic limb use in patients with stump ulcers will not adversely affect the ulcer nor prevent healing. The survey would also form a basis for developing future guidelines in the management of stump ulcers. All consecutive patients attending the Chapel Allerton Hospital prosthetic clinic between January 2003 and May 2004 with stump ulcers were recruited into the study. Primary outcome measures were changes in the surface area of the ulcers and in clinical photographs taken on 2 occasions 6 weeks apart. Some 102 patients with a mean age 60 years (range 18 - 88 years) were recruited. Eight patients who were established prosthetic limb users did not complete the study and were excluded from the analysis. Of the patients 52 were newly referred patients with delayed surgical wound healing while 42 were established prosthetic limb users for at least 1 year. Continued prosthetic limb was associated with a significant reduction in ulcer size (p < 0.05). Mean sizes of the ulcers at first and second observations were 3.30 cm2 (range 0.06 - 81) and 0.70 cm2 (range 0.00 - 13.00) respectively. The ulcers improved in 83 cases while two were unchanged. Deterioration was observed in nine cases. The current clinical practice is to allow most of the patients to commence or continue prosthetic limb wearing despite the presence of stump ulceration. This observational study found that, despite prosthetic use, 60 (64%) cases healed completely within the six-week study period and 23 (25%) ulcers reduced in size. The ulcers were unchanged in 2% of the cases. Deterioration was observed in nine (9%) cases. This survey suggests that the current practice of allowing patients to use their prostheses is safe. A clinical trial is now needed to establish whether this practice alters healing rate or has any other disadvantages for new or established amputees.

Conformation and orientation of the retinyl chromophore in rhodopsin: a critical evaluation of recent NMR data on the basis of theoretical calculations results in a minimum energy structure consistent with all experimental data

In the absence of a high-resolution diffraction structure, the orientation and conformation of the protonated Schiffs base retinylidinium chromophore of rhodopsin within the opsin matrix has been the subject of much speculation. There have been two recent reliable and precise NMR results that bear on this issue. One involves a determination of the C20-C10 and C20-C11 distances by Verdegem et al. [Biochemistry 38, 11316-11324 (1999)]. The other is the determination of the orientation of the methine C to methyl group vectors C5-C18, C9-C19, and C13-C20 relative to the membrane normal by Gröbner et al. [Nature 405 (6788), 810-813 (2000)]. Using molecular orbital methods that include extensive configuration interaction, we have determined what we propose to be the minimum energy conformation of this chromophore. The above NMR results permit us to check this structure in the C10-C11=C12-C13 region and then to check the global structure via the relative orientation of the three C18, C19, and C20 methyl groups. This method provides a detailed structure and also the orientation for the retinyl chromophore relative to the membrane normal and argues strongly that the protein does not appreciably alter the chromophore geometry from its minimum energy configuration that is nearly planar s-trans at the 6-7 bond. Finally, the chromophore structure and orientation presented in the recently published X-ray diffraction structure is compared with our proposed structure and with the deuterium NMR results.

Histologic comparison of regeneration in human intrabony defects when osteogenin is combined with demineralized freeze-dried bone allograft and with purified bovine collagen

A bone-inductive protein, osteogenin, has been isolated from long bones of humans and offers promise as a grafting material. Studies, however, suggest that osteogenin must be combined with a bone-derived matrix in order to initiate bone differentiation. The purpose of this study was to determine if osteogenin combined with demineralized freeze dried bone allograft (DFDBA), a bone-derived matrix, and with a bovine tendon-derived matrix will enhanced regeneration of intrabony defects in humans. The tendon-derived matrix and DFDBA used alone served as controls. The ability of each material to form a new attachment apparatus was evaluated independently in submerged and nonsubmerged environments in 2 patient populations. Lymphocyte testing was performed to assess development of an immune reaction to osteogenin. The most apical level of calculus on the root served as the histologic reference point to measure regeneration. Biopsies were obtained at 6 months and regeneration was measured histomorphometrically by 2 blinded evaluators. Serial sections from 36 submerged defects in 8 patients and 50 nonsubmerged defects in 6 patients were submitted for statistical analysis. Mean results indicate that osteogenin combined with DFDBA significantly enhanced regeneration of a new attachment apparatus and component tissues in a submerged environment. DFDBA plus osteogenin and DFDBA alone formed significantly more new attachment apparatus and component tissues than either the tendon-derived matrix plus osteogenin or the tendon-derived matrix alone in both submerged and nonsubmerged environments. There were no significant differences between the tendon-derived matrix plus osteogenin and the tendon-derived matrix alone in either the submerged or nonsubmerged environment. Osteogenin does not impair normal lymphocyte blastogenesis at 6 months postsurgical challenge.

Danazol and hepatic neoplasia: a case report

Although hepatic side-effects of danazol are well known, the occurrence of hepatic tumours is not well documented. We report a case of hepatocellular adenoma occurring in a 35-year-old woman with endometriosis who had been taking danazol over a three year period.

Malassezia furfur fungemia as a treatable cause of obscure fever in a leukemia patient receiving parenteral nutrition

We describe a 46-year-old man with acute non-lymphocytic leukemia (ANLL) and Crohn's disease who, while receiving total parenteral nutrition (TPN), developed a protracted febrile illness with thrombocytopenia, pulmonary infiltrates and jaundice. Malassezia furfur, a lipophilic fungus, was identified from blood culture on lipid-enriched media. The patient improved rapidly with cessation of TPN and removal of his central venous catheter. M. furfur may cause a severe illness in immunosuppressed patients receiving TPN.

Effects of lead acetate on DNA and RNA synthesis by intact HeLa cells, isolated nuclei and purified polymerases

The effects of lead acetate on DNA and RNA synthesis have been investigated with intact HeLa cells, isolated nuclei, and purified DNA and RNA polymerases. No inhibition of DNA or RNA synthesis in intact cells was found even after exposure to 0.5 mM lead acetate for 18 hr. In contrast, both DNA and RNA synthesis in isolated nuclei were inhibited by lead (with 50% inhibition at approximately 150 and 80 microM respectively). Similarly, both HeLa DNA polymerase alpha and RNA polymerase II were inhibited, with 50% inhibition obtained at approximately 150 and 20 microM lead acetate respectively. The inhibition of nucleic acid synthesis in isolated nuclei can thus be accounted for by inhibition of the polymerases. The sensitivity of Escherichia coli DNA polymerase I to lead acetate was found to be significantly greater than the HeLa DNA polymerase alpha (50% inhibition at only 10 microM), but the sensitivity of the E. coli RNA polymerase was the same as that of the HeLa enzyme.

Inhibition of RNA and DNA polymerases by the product of the reaction of selenite with sulfhydryl compounds

Sodium selenite has previously been shown to inhibit DNA and RNA synthesis in both intact cells and isolated nuclei. Nevertheless, DNA and RNA polymerases, the enzymes responsible for this synthesis, are insensitive to inhibition by selenite. Several DNA and RNA polymerases have now been shown to be inhibited by selenite in the presence of sulfhydryl compounds. This inhibition is due to the reaction of selenite with the sulfhydryl compounds to form selenotrisulfide derivatives which inhibit the enzymes. The selenotrisulfides decrease the Vmax of the polymerase reaction and increase the apparent Km for the triphosphates, but do not alter the apparent Km of the enzyme for the DNA template. There are differences in potency between selenotrisulfides formed from similar sulfhydryl compounds such as mercaptoethanol and mercaptoethylamine. There are also differences in the sensitivity of different polymerases to inhibition by the selenotrisulfides.

Crypts, villi and microvilli in the small intestine of the rat. A stereological study of their variability within and between animals

Small intestines from normal adult rats were quantified by optical and electron microscopy using stereological principles devised for the purpose. Five segments per bowel were examined. Baseline data characterising villi, microvilli and crypts of Lieberkühn were used to study differences between segments and between animals. Intestines fixed by in situ perfusion had, on average, 100 cm2 of primary mucosa. This basic surface was amplified to 500 cm2 by villi and to 1 m2 by the microvilli of enterocytes. Villous and microvillous surface areas may scale to body weight in the same way as metabolic requirements. Proximodistal gradients in mucosal architecture existed for the volumes and surface areas of villi and for the numbers, lengths, diameters and surface areas of microvilli. Most variables were higher proximally and declined towards the terminal ileum. The volume of crypts stayed constant throughout the entire intestine and ratios between villous dimensions (volumes and surface areas) and crypt volume did not vary between animals. Findings are discussed in the context of regional differences in bowel function and of their relevance to studies of epithelial kinetics.

Immunohistochemical localization of corticotropin releasing factor (CRF) in the hypothalamus of the squirrel monkey, Saimiri sciureus

Corticotropin releasing factor immunoreactive (CRF-IR) neuronal cell bodies and fibers have been localized in both the paraventricular and supraoptic nuclei of the hypothalamus of the squirrel monkey. The major projection from these nuclei is to the median eminence and neural stem. A few CRF-IR fibers were found in the dorsal pars nervosa primarily adjacent to the pars intermedia. A rostral projection of CRF-IR fibers is associated with the suprachiasmatic nucleus and continues to septal areas. A caudally projecting bundle of fibers was observed entering the midbrain in neuropil adjacent to the aqueduct. The location of CRF-IR components is also compared with those containing vasopressin (AVP).

Fine structure of Periplaneta americana neurons in long-term culture

A new culture technique is described for dissociated ganglia of embryos of Periplaneta americana. Neurons obtained by the mechanical dissociation of ganglia from 23-26 day old embryos were grown for seven days in a combination of Schneider's Drosophila Medium and Eagle's Basal Medium and then transferred to a combination of Leibovitz's L-15 Medium and Yunker's Modified Grace's Medium supplemented with ecdysone. Neurons cultured in this way survived for periods in excess of one month. The cells had a typically neuronal ultrastructure and produced axonal processes that associated to form fibre bundles. Within these processes neurosecretory granules, dense-core vesicles and clear vesicles were found. In some instances these vesicles aggregated at points of contact between fibres giving the appearance of presynaptic endings. These cultures would appear to be suitable for pharmacological studies of the insect nervous system.

Gadusol, an enolic derivative of cyclohexane-1,3-dione present in the roes of cod and other marine fish. Isolation, properties and occurrence compared with ascorbic acid

Gadusol, C8H12O6, has been isolated from roes of the cod (Gadus morhua L.), i.e., ovaries that contain ripe eggs just before spawning. The concentration is about 4 g/kg dry wt. It has been identified as 1,4,5-trihydroxy-5-hydroxymethyl-2-methoxycyclo-hex-1-en-3-one and this structure was confirmed by synthesis of the anhydro tetra-acetate derivative from methyl 3,5-diacetoxy-4-methoxybenzoate. Concentrations of gadusol in the roes of other marine teleost fish examined are of the same order as in cod roes. Gadusol has some properties similar to ascorbic acid and both compounds, after oxidation, react with 2,4-dinitrophenylhydrazine in the commonly-used assay procedure for ascorbic acid. Specific assays showed that the concentrations of gadusol in the roes of marine fish are severalfold greater than those of ascorbic acid. Gadusol is structurally related to the mycosporines previously reported from a number of different organisms.

Role of alcohol in the aetiology of hypertension

Hypertension is a common condition facing medical practitioners on a day-to-day basis, yet much is to be learnt regarding its cause. Excess alcohol intake has been recognized by clinicians as a causal factor on an anecdotal basis for many years now. Little evidence for this has been provided from statistical analysis of formal studies. On this basis, a study was undertaken in a population of 85 adult males to see if any correlations could be drawn between alcohol intake and standard blood pressure readings, taking into account as many other variables as possible which may contribute to blood pressure, such as age, body weight and smoking habits. In this study, a statistically significant relationship between alcohol intake and blood pressure is demonstrated, indicating a need for further investigation in this field.

Regulation of sterol synthesis in human intestinal mucosa

The effect of dietary factors and experimental manipulations designed to perturb the enterohepatic circulation on the rate of sterol synthesis were studied in freshly isolated human jejunal mucosa from normal subjects. Fasting significantly reduced the rate of sterol synthesis from [14C]acetate in jejunal mucosa obtained from normolipaemic obese subjects. A high cholesterol diet had no consistent effect on the synthesis in normal subjects. Administration of cholestyramine resulted in a marked rise in the incorporation of [14C]acetate into sterols, while the administration of chenodeoxycholic acid did not significantly reduce basal sterol synthesis in normal subjects. These results demonstrate that in man the rate of sterol synthesis in intestinal mucosa is altered in response to physiological variables. Although these findings indicate that sterol synthesis in this tissue is subject to regulation, no difference was observed in basal sterol synthesis between normal subjects and patients heterozygous for familial hypercholesterolaemia.

Studies on the nutrition of marine flatfish. The effect of different dietary fatty acids on the growth and fatty acid composition of turbot (Scophthalmus maximus)

1. Five groups of juvenile turbot (Scophthalmus maximus) which had been given a diet free of fat for 12 weeks were given diets in which the lipid component (g/kg) was: oleic acid alone 50, oleic acid 40+linoleic acid 10, oleic acid 40+linolenic acid 10, oleic acid40+arachidonic acid 10 or oleic acid 40+cod-liver oil 10. These five experimental diets were given for 16 weeks. 2. Weight gains were highest in the group given the diet containing cod-liver oil and lowest in the groups given diets containing oleic acid alone or oleic acid+linoleic acid. Weight gains in the groups given oleic acid+arachidonic acid or linolenic acid were markedly inferior to those of the group given oleic acid+cod-liver oil. It is concluded that arachidonic acid is inferior to polyunsaturated fatty acids of the omega3 series in maintaining growth rate in turbot. 3. Fatty acid analyses of neutral lipids and phospholipids of liver and extrahepatic tissues did not suggest any evidence of desaturation of dietary oleic acid, linoleic acid or linolenic acid by the turbot. These experiments confirm previous isotopic evidence that turbot lack the necessary microsomal desaturases to perform this metabolic transformation.

Elongation and desaturation of dietary fatty acids in turbot Scophtalmus maximus L., and rainbow trout, Salmo gairdnerii rich

Turbot and rainbow trout, which had previously recieved diets free of fat, were fed [1-14C] fatty acids. The distribution of radioactivity in the tissue fatty acids was examined 6 days later. In rainbow trout fed [1-14C] 18:3omega3, 70% of the radioactivity was present in 22:6omega3 fatty acid. In contrast, turbot fed [1-14C] 18:1omega9, 18:2omega6, or 18:3omega3 converted only small amounts of labeled fatty acids (3-15%) into fatty acids of longer chain length. The major product of the limited modification found in turbot was the dietary acid elongated by 2 carbon atoms.