Efficacy and safety of baricitinib in hospitalized adults with severe or critical COVID-19 (Bari-SolidAct): a randomised, double-blind, placebo-controlled phase 3 trial

BACKGROUND

Baricitinib has shown efficacy in hospitalized patients with COVID-19, but no placebo-controlled trials have focused specifically on severe/critical COVID, including vaccinated participants.

METHODS

Bari-SolidAct is a phase-3, multicentre, randomised, double-blind, placebo-controlled trial, enrolling participants from June 3, 2021 to March 7, 2022, stopped prematurely for external evidence. Patients with severe/critical COVID-19 were randomised to Baricitinib 4 mg once daily or placebo, added to standard of care. The primary endpoint was all-cause mortality within 60 days. Participants were remotely followed to day 90 for safety and patient related outcome measures.

RESULTS

Two hundred ninety-nine patients were screened, 284 randomised, and 275 received study drug or placebo and were included in the modified intent-to-treat analyses (139 receiving baricitinib and 136 placebo). Median age was 60 (IQR 49-69) years, 77% were male and 35% had received at least one dose of SARS-CoV2 vaccine. There were 21 deaths at day 60 in each group, 15.1% in the baricitinib group and 15.4% in the placebo group (adjusted absolute difference and 95% CI - 0.1% [- 8·3 to 8·0]). In sensitivity analysis censoring observations after drug discontinuation or rescue therapy (tocilizumab/increased steroid dose), proportions of death were 5.8% versus 8.8% (- 3.2% [- 9.0 to 2.7]), respectively. There were 148 serious adverse events in 46 participants (33.1%) receiving baricitinib and 155 in 51 participants (37.5%) receiving placebo. In subgroup analyses, there was a potential interaction between vaccination status and treatment allocation on 60-day mortality. In a subsequent post hoc analysis there was a significant interaction between vaccination status and treatment allocation on the occurrence of serious adverse events, with more respiratory complications and severe infections in vaccinated participants treated with baricitinib. Vaccinated participants were on average 11 years older, with more comorbidities.

CONCLUSION

This clinical trial was prematurely stopped for external evidence and therefore underpowered to conclude on a potential survival benefit of baricitinib in severe/critical COVID-19. We observed a possible safety signal in vaccinated participants, who were older with more comorbidities. Although based on a post-hoc analysis, these findings warrant further investigation in other trials and real-world studies. Trial registration Bari-SolidAct is registered at NCT04891133 (registered May 18, 2021) and EUClinicalTrials.eu ( 2022-500385-99-00 ).

Pneumatocele formation in adult Escherichia coli pneumonia revealed by pneumothorax

Pulmonary pneumatoceles are a rare complication of nosocomial pneumonia. They occur most often in staphylococcal infections and are hence more frequent in children. We report the case of an immunocompromised adult who shortly after digestive surgery developed Escherichia coli pneumonia which evolved rapidly towards pneumatocele formation revealed by pneumothorax.

Resistance to change: understanding the aides' point of view

Nursing home units are subcultures of the entire facility, with values, attitudes and norms that are passed from aide to aide. Changes in work routines may threaten your workers' effectiveness. Helping your nursing staff adapt will always remain a challenge.

Medication use by community-dwelling elderly with urinary incontinence

Medication consumption patterns among community-dwelling elderly persons with chronic urinary incontinence were examined. All health professionals, including nurses, should be knowledgeable of the potential for adverse drug reactions. Continuing education and establishment of routine monitoring systems could help to reduce the risk of potential for adverse drug reactions and prevent drug-induced UI in patients.

Noninvasive techniques to manage urinary incontinence among care-dependent persons

Approximately half of the nursing home residents in the United States are incontinent of urine, and the prevalence rates among community-dwelling elderly persons are significant. Behavioral treatments are first-line management for most cases of urinary incontinence, and these techniques are recommended in the urinary incontinence guidelines published in 1996 by the Agency for Health Care Policy and Research. This article emphasizes assessment and treatments for persons in whom urinary incontinence has been detected and who are cognitively or physically impaired that are appropriately performed by nurses with no special expertise in or knowledge of urinary incontinence.

An update on the AHCPR guideline implementation

Publication in 1992 of national Clinical Practice Guidelines for Urinary Incontinence in Adults by the US Department of Health and Human Services, Agency for Health Care Policy and Research (AHCPR) brought together in one document, for the first time, all the relevant material on the diagnosis and treatment of urinary incontinence. These guidelines also provided data about the effectiveness of various treatment options. Dissemination has been enhanced through massive distribution to professional and lay groups as well as making copies available at no charge by telephone (1-800-358-9295). Because of the volume of new research on incontinence, the guidelines are now being revised and updated with publication expected in 1995. This guideline is especially relevant for nursing because nurses are often the first, and may be the only, health professional with whom patients will discuss this embarrassing problem.

The effects of patterned urge-response toileting (PURT) on urinary incontinence among nursing home residents

OBJECTIVE

To test an individualized form of habit training for urinary incontinence (UI) among long-stay cognitively and/or physically impaired elderly nursing home residents over time.

DESIGN

Randomization of subjects occurred by nursing home unit. Baseline wet checks were done hourly for one 24-hour period at 3-week intervals over 12 weeks followed by 72 hours of continuous electronic monitoring to establish precise voiding patterns for each subject. The 12-week intervention period was administered by indigenous staff after they attended a 4-hour UI educational program. Subjects were followed an additional 12 weeks to determine the extent of maintenance of the intervention among staff and subjects.

SETTING

Four non-profit nursing homes; west, mid-west, east coast.

PATIENTS

Consent was obtained from 154 (71%) who met primary inclusion criteria. Forty-one failed the secondary inclusion criteria leaving 113 who entered the 37-week study. Eighty-eight completed the study (experimental = 51, control = 37); all were physically and/or mentally impaired, averaged age 85, and had either urge or urge/stress UI.

RESULTS

UI was significantly decreased during the 3-month period (P less than 0.001). Eighty-six percent showed improvement over baseline while one-third improved 25% or more over their baseline UI rate. The control group's UI increased during the same period of time. The volume of UI among the experimental group also decreased (P less than 0.005) while the control group's UI volume increased.

CONCLUSIONS

The training program was effective in reducing UI though compliance among nursing staff averaged only 70% of the prescribed toileting times. The success of this approach is similar to other recently described behavioral programs but achieved the reduction using only regular nursing staff. This individualized approach supports the recent regulatory thrust to individualize care to promote and maintain functional abilities and autonomy.

Effect of an incontinence training program on nursing home staff's knowledge, attitudes, and behavior

To test a behavioral approach for urinary incontinence (UI), 166 staff in four nursing homes participated in a quasi-experimental study that measured knowledge and attitudes about UI and compliance with toileting protocols. The intervention group (N = 96) showed a slight increase in knowledge; their attitudes remained positive over the four testing times. Compliance with the more critical component of the toileting protocol was only 72%, although evidence existed that the protocol reduced UI. Results are discussed in terms of the sociocultural environment of nursing homes.

Issues in implementing clinical research in nursing home settings

Researchers at four nursing home sites experienced similar problems in the informed consent process when they attempted to access a frail, cognitively impaired population to conduct a collaborative, quasi-experimental two year clinical trials study on urinary incontinence. In addition, similar institutional barriers were experienced in these geographically distant and dissimilar nursing homes. The study involved working closely with indigenous licensed nursing and nurse aide staff to implement the independent variable, an individualized toileting prescription. Successful strategies used to overcome barriers in conducting the research will be described.

Educating nurses to care for the incontinent patient

Urinary incontinence among nursing home patients is a very common problem. Until quite recently, incontinence was believed to be impossible or unnecessary to treat except through the use of absorbent pads and diapers. The cost of this type of management to the facility in terms of laundry, labor, and supplies, as well as to patients' well-being, is very high. Recent data suggest that at least some incontinent nursing home patients can benefit from treatment programs that can be taught to the nurse's aide staff and that, at the very least, will reduce laundry and supply costs. The significance of an improvement in patient morale or a decrease in the incidence of complications resulting from incontinence has yet to be assessed, but should be considered. In addition, even a partially successful treatment program may be helpful to the nurses caring for these patients as the nurses' sense of hopelessness and frustration about managing incontinent patients may be reduced. Finally, an active treatment program for continence, instituted by nurses, advances the nursing care of these patients from custodial nursing care to therapeutic nursing care.

Sleep disturbances in aging: a theoretic and empiric analysis

Empirical evidence suggests that elderly persons experience more frequent qualitative and quantitative sleep disturbances than persons of other age groups. These disruptions may be particularly detrimental to the elderly since their physiological tolerance for disequilibrium is more limited than that of younger persons. Some sleep changes, however, appear to be physiologically beneficial and adaptive and should not be inadvertently dampened with drugs or other measures. Considerably more research is needed to allow nurses to assess sleep problems and intervene to achieve the intended therapeutic effect with greater precision.