Acceptability and tolerability of long-acting injectable cabotegravir or rilpivirine in the first cohort of virologically suppressed adolescents living with HIV (IMPAACT 2017/MOCHA): a secondary analysis of a phase 1/2, multicentre, open-label, non-comparative dose-finding study

BACKGROUND

Long-acting injectable cabotegravir and rilpivirine have demonstrated safety, acceptability, and efficacy in adults living with HIV-1. The IMPAACT 2017 study (MOCHA study) was the first to use these injectable formulations in adolescents (aged 12-17 years) living with HIV-1. Herein, we report acceptability and tolerability outcomes in cohort 1 of the study.

METHODS

In this a secondary analysis of a phase 1/2, multicentre, open-label, non-comparative dose-finding study, with continuation of pre-study oral combination antiretroviral treatment (ART), 55 adolescents living with HIV-1 were enrolled to receive sequential doses of either long-acting cabotegravir or rilpivirine and 52 received at least two injections. Participants had a body weight greater than 35 kg and BMI less than 31·5 kg/m2 and had been on stable ART for at least 90 consecutive days with an HIV-1 viral load of less than 50 copies per mL at a participating IMPAACT study site. Participants had to be willing to continue their pre-study ART during cohort 1. The primary objectives of the study were to confirm doses for oral and injectable cabotegravir and for injectable rilpivirine in adolescents living with HIV. This analysis of participant-reported outcomes included a face scale assessment of pain at each injection and a Pediatric Quality of Life Inventory (PedsQL) at baseline and week 16 for participants in the USA, South Africa, Botswana, and Thailand. A subset of 11 adolescents and 11 parents or caregivers in the USA underwent in-depth interviews after receipt of one or two injections. This trial is registered at ClinicalTrials.gov, NCT03497676.

FINDINGS

Between March 19, 2019, and Nov 25, 2021, 55 participants were enrolled into cohort 1. Using the six-point face scale, 43 (83%) of participants at week 4 and 38 (73%) at week 8 reported that the injection caused "no hurt" or "hurts little bit", while only a single (2%) participant for each week rated the pain as one of the two highest pain levels. Quality of life was not diminished by the addition of one injectable antiretroviral. In-depth interviews revealed that parents and caregivers in the USA frequently had more hesitancy than adolescents about use of long-acting formulations, but parental acceptance was higher after their children received injections.

INTERPRETATION

High acceptability and tolerability of long-acting cabotegravir or rilpivirine injections suggests that these are likely to be favoured treatment options for some adolescents living with HIV.

FUNDING

National Institutes of Health and ViiV Healthcare.

Safety and pharmacokinetics of oral and long-acting injectable cabotegravir or long-acting injectable rilpivirine in virologically suppressed adolescents with HIV (IMPAACT 2017/MOCHA): a phase 1/2, multicentre, open-label, non-comparative, dose-finding study

BACKGROUND

Combined intramuscular long-acting cabotegravir and long-acting rilpivirine constitute the first long-acting combination antiretroviral therapy (ART) regimen approved for adults with HIV. The goal of the IMPAACT 2017 study (MOCHA [More Options for Children and Adolescents]) was to assess the safety and pharmacokinetics of these drugs in adolescents.

METHODS

In this phase 1/2, multicentre, open-label, non-comparative, dose-finding study, virologically suppressed adolescents (aged 12-17 years; weight ≥35 kg; BMI ≤31·5 kg/m2) with HIV-1 on daily oral ART were enrolled at 15 centres in four countries (Botswana, South Africa, Thailand, and the USA). After 4-6 weeks of oral cabotegravir (cohort 1C) or rilpivirine (cohort 1R), participants received intramuscular long-acting cabotegravir or long-acting rilpivirine every 4 weeks or 8 weeks per the adult dosing regimens, while continuing pre-study ART. The primary outcomes were assessments of safety measures, including all adverse events, until week 4 for oral cabotegravir and until week 16 for long-acting cabotegravir and long-acting rilpivirine, and pharmacokinetic measures, including the area under the plasma concentration versus time curve during the dosing interval (AUC0-tau) and drug concentrations, at week 2 for oral dosing of cabotegravir and at week 16 for intramuscular dosing of cabotegravir and rilpivirine. Enrolment into cohort 1C or cohort 1R was based on the participant's pre-study ART, meaning that masking was not done. For pharmacokinetic analyses, blood samples were drawn at weeks 2-4 after oral dosing and weeks 4-16 after intramuscular dosing. Safety outcome measures were summarised using frequencies, percentages, and exact 95% CIs; pharmacokinetic parameters were summarised using descriptive statistics. This trial is registered at ClinicalTrials.gov, NCT03497676, and is closed to enrolment.

FINDINGS

Between March 19, 2019, and Nov 25, 2021, 55 participants were enrolled: 30 in cohort 1C and 25 in cohort 1R. At week 16, 28 (97%, 95% CI 82-100) of the 29 dose-evaluable participants in cohort 1C and 21 (91%; 72-99) of the 23 dose-evaluable participants in cohort 1R had reported at least one adverse event, with the most common being injection-site pain (nine [31%] in cohort 1C; nine [39%] in cohort 1R; none were severe). One (4%, 95% CI 0-22) participant in cohort 1R had an adverse event of grade 3 or higher, leading to treatment discontinuation, which was defined as acute rilpivirine-related allergic reaction (self-limiting generalised urticaria) after the first oral dose. No deaths or life-threatening events occurred. In cohort 1C, the week 2 median cabotegravir AUC0-tau was 148·5 (range 37·2-433·1) μg·h/mL. The week 16 median concentrations for the every-4-weeks and every-8-weeks dosing was 3·11 μg/mL (range 1·22-6·19) and 1·15 μg/mL (<0·025-5·29) for cabotegravir and 52·9 ng/mL (31·9-148·0) and 39·1 ng/mL (27·2-81·3) for rilpivirine, respectively. These concentrations were similar to those in adults.

INTERPRETATION

Study data support using long-acting cabotegravir or long-acting rilpivirine, given every 4 weeks or 8 weeks, per the adult dosing regimens, in virologically suppressed adolescents aged 12 years and older and weighing at least 35 kg.

FUNDING

The National Institutes of Health and ViiV Healthcare.

Pre-operative localisation of axillary lymph nodes using radiofrequency identification (RFID) tags: a feasibility assessment in 75 cases

AIM

To evaluate the safety and feasibility of using radiofrequency identification (RFID) tags for the localisation of axillary nodes prior to targeted excision in a National Health Service (NHS) breast unit.

MATERIALS AND METHODS

Retrospective data collection was carried out to analyse the first 75 cases of RFID-targeted axillary nodes inserted between 12 June 2019 and 27 October 2022, during which an overall total of 1,296 breast and axillary tags were deployed in 1,120 patients.

RESULTS

Of the 75 axillary tags, 70 (93%) had a primary breast cancer and five (7%) had no known breast cancer but had an abnormal node targeted for diagnostic excision. Of the 70 with breast cancer, 20 (29%) underwent neoadjuvant chemotherapy (NAC) including one neoadjuvant endocrine therapy. Localisations were performed an average of 11 days before surgery (median 6, range 1-95; n=75). Patients undergoing NAC had their tags inserted after completing treatment due to the artefact caused by the tags on magnetic resonance imaging (MRI). Tag deployment had a 100% success rate, with 62 tags (83%) lying within the node and 13 tags (17%) lying directly adjacent to the node, either in direct contact (nine of 13), or a maximum of 8 mm from the target (four of 13). All tags and their respective nodes were excised successfully at surgery with no significant complications. There were four cases of tag dislodgement during excision, but overall, this did not compromise retrieval of the tag or the node.

CONCLUSIONS

The use of RFID tags for the preoperative localisation of axillary nodes is safe and feasible.

The SARS-CoV-2 Spike protein alters human cardiac pericyte function and interaction with endothelial cells through a non-infective mechanism involving activation of CD147 receptor signalling

Background

Human cardiac pericytes (PC) were proposed as the main cellular target for SARS-CoV-2 in the heart due to high transcriptional levels of the angiotensin-converting enzyme 2 (ACE2) receptor. Emerging reports indicate CD147/Basigin (BSG), highly expressed in endothelial cells (EC), is an alternative SARS-CoV-2 receptor. To date, the mechanism by which the virus infects and disrupts the heart vascular cells was not identified yet. Moreover, cleaved Spike (S) protein molecules could be released into the bloodstream from the leaking pulmonary epithelial-endothelial barrier in patients with severe COVID-19, opening to the possibility of non-infective diseases in organs distant from the primary site of infection.

Purposes

(1) to confirm that human primary cardiac PC express ACE2 and CD147; (2) to verify if PC are permissible to SARS-CoV-2 infection; (3) to investigate if the recombinant SARS-CoV-2 S protein alone, without the other viral elements, can trigger molecular signalling and induce functional alterations in PC; (4) to explore which viral receptor is responsible for the observed events.

Methods and results

Cardiac PC express both the ACE2 and CD147 receptors at mRNA and protein level. Incubation of PC for up to 5 days with SARS-CoV-2 expressing the green fluorescent protein (GFP) did not show any evidence of cell infection or viral replication. Next, we exposed the PC to the recombinant S protein (5.8 nM) and confirmed that the protein engaged with cellular receptors (western blot analysis of S protein in treated and control PC). Incubation with the S protein increased PC migration (wound closure assay, P&lt;0.01 vs ctrl) and reduced the formation of tubular structures between PC and EC in a Matrigel assay (P&lt;0.01 vs ctrl). Moreover, the S protein promoted the production of pro-inflammatory factors typical of the cytokine storm in PC (ELISA measurement of MCP1, IL-6, IL-1β, TNFα, P&lt;0.05 vs ctrl), and induced the secretion of pro-apoptotic factors responsible for EC death (Caspase 3/7 assay, P&lt;0.05 vs ctrl). Signalling studies revealed that the S protein triggers the phosphorylation/activation of the extracellular signal-regulated kinase 1/2 (ERK1/2) through the CD147 receptor, but not ACE2, in cardiac PC. The neutralization of CD147, using a blocking antibody, prevented ERK1/2 activation in PC, and was reflected into a partial rescue of the cell functional behaviour (migration and pro-angiogenic capacity). In contrast, blockage of CD147 failed to prevent the pro-inflammatory response in PC.

Conclusions

We propose the novel hypothesis that COVID-19 associated heart's microvascular dysfunction is prompted by circulating S protein molecules rather than by the direct coronavirus infection of PC. Besides, we propose CD147, and not ACE2, as the leading receptor mediating S protein signalling in cardiac PC.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): BHF project grant “Targeting the SARS-CoV-2 S-protein binding to the ACE2 receptor to preserve human cardiac pericytes function in COVID-19” BHF Centre for Vascular Regeneration II

Use of Hologic LOCalizer radiofrequency identification (RFID) tags to localise impalpable breast lesions and axillary nodes: experience of the first 150 cases in a UK breast unit

AIM

To report the outcome of 150 patients using the Hologic LOCalizer RFID (radiofrequency identification) tag system, including the first reported use of RFID tags in the axilla.

MATERIALS AND METHODS

Data were collected prospectively from the first tag insertion (12 June 2019) until 150 consecutive patients had undergone surgery (excision date 9 January 2020).

RESULTS

A total of 177 tags were targeted to 177 malignant lesions in 150 women. Tags were inserted an average of 7.8 days before surgery (range 0-71 days). One hundred and twenty-six tags were targeted to a single lesion in one breast only; the remainder of tags were targeted to multiple lesions in one or both breasts, as well as to axillary lymph nodes. In addition, two cases involved the use of two tags to bracket microcalcification. All except three tags were satisfactorily deployed at their initial intended target. The majority of target lesions were masses (n=142, mean size 13.8 mm), with a range of other targets including post-vacuum-assisted biopsy cavities, marker clips post-neoadjuvant chemotherapy, architectural distortions, and clipped metastatic lymph nodes. All tags were successfully retrieved at surgical excision. Re-excision rate was 8.7%. There were no tag-specific surgical complications.

CONCLUSIONS

The RFID tag system demonstrates many advantages over guidewires, and is effective at targeting axillary lymph nodes and multiple sites within the same breast.

Nursing and medical student teaming for service learning in partnership with the community: an emerging holistic model for interdisciplinary education and practice

To meet the health needs of communities today, health professionals need to be trained in working with persons from various cultural backgrounds, practicing disease prevention and health promotion in community-based settings, and working in teams with other professionals. The article focuses on interdisciplinary teaming for education and practice. In this model, medical and nursing students partner with communities to plan and deliver health promotion education programs and activities. Four service learning projects providing collaborative teaming opportunities as part of the Health Professions Schools in Service to the Nation Program are described. Interdisciplinary service learning has benefits for the community, students, and faculty and will prepare nurses and physicians to have a positive impact on care through future interdisciplinary collaboration in community-based settings.

Clinical approaches in the assessment of childbearing fatigue

Modifications of the Fatigue Symptoms Checklist can be used clinically to assess fatigue during the childbearing year. Data from a series of studies provide beginning norms that can be used to interpret clinical scores and point to the potential importance of assessments to pregnancy complications and maternal performance. Consistent with North American Nursing Diagnosis Association (NANDA) definition of fatigue and the theory of unpleasant symptoms, fatigue and performance are important phenomena critical to the experience of pregnancy and assumption of the maternal role.

Strategies for prevention of adult hypertension and cardiovascular risk behaviour in childhood. An Australian perspective

This paper addresses approaches to evaluating the importance of different childhood behaviours on subsequent risk of high blood pressure and related cardiovascular risk factors and outlines results of a randomised controlled trial of nutrition and exercise interventions in schoolchildren. Clustering of cardiovascular risk factors was studied in relation to diet, blood pressure, fitness, fatness and blood cholesterol in a representative sample of 555 Perth schoolchildren aged 15 years. Twenty-one percent of males and females had high risk profiles associated with dietary excesses, particularly in fat, cholesterol and sodium intake, and deficiencies of minerals, vitamins and dietary fibre. Socio-economic status was inversely associated with cardiovascular risk and undernutrition in girls. Thus 21% of the school children shared unhealthy lifestyles putting them at substantial risk of subsequent cardiovascular disease. A randomised controlled trial designed to reduce cardiovascular risk was conducted in 1147 children 10-12 years old, assigned to one of six groups for a year. The groups were fitness, fitness and school nutrition, school nutrition, school and home nutrition, home nutrition or controls. On cluster analysis 30% of the children were at higher risk at baseline in terms of blood pressure, blood cholesterol levels, fitness and body fat. With the fitness programmes fitness increased in both high and low risk girls but only in high risk cluster boys. Systolic pressure fell more in the high risk boys in the fitness group than in low risk boys, while diastolic pressure fell in girls regardless of initial risk. Triceps skinfold thickness fell more in higher than lower risk girls in the school and home nutrition group, and more in high risk boys in the home nutrition group. Higher risk girls showed a greater reduction in fat intake and increase in dietary fibre with home nutrition programmes. We concluded that higher risk children do show greater responses to lifestyle intervention programmes in general, with the greatest effects seen with home nutrition or fitness programmes. The results indicate the need for different approaches to prevention of hypertension and cardiovascular risk in higher and lower risk children and for boys and girls.

Postpartum fatigue: clarifying a concept

This paper describes the multifaceted approach employed to clarify the concept of postpartum fatigue. The process began with a literary analysis, which gave rise to questions about the defining characteristics of postpartum fatigue and its differentiation from related concepts such as tiredness and depression. A series of qualitative and quantitative studies were carried out to examine new mothers' characterizations of their fatigue, the indicators and predictors of postpartum fatigue, and the differences between fatigue and depression. The evolving concept clarification suggests that postpartum fatigue is most effectively conceptualized as a multidimensional concept with physical and mental aspects that is different from tiredness and can be differentiated from postpartal depression or milder "baby blues," with which there is some overlap.

Implementing the COACH relationship model: health promotion for mothers and children

Program designers and nurses developed and implemented the COACH Relationship Model to help low-income mothers change health-related behaviors as part of a clinical trial conducted from 1990 to 1994 of the impact of nurse home visitation. By first orienting the program nurses to the theoretical underpinnings (caring, ecological, role supplementation, and self-efficacy theories) and then involving them in developing program materials to translate the theoretical and philosophical concepts into nursing interventions, the essential features of the relationship model were retained through the implementation process.

Assessment of nutrition and physical activity education programmes in children

1. Studies in children relating blood lipids to the extent of atherosclerosis at post-mortem suggest a link between risk factors for cardiovascular disease in childhood and adult life. Tracking of blood pressure (BP) and cholesterol from childhood also supports this association. However, prospective studies have not yet established the outcome in children with increased levels of risk factors. 2. In a controlled trial in Perth, Western Australia, involving over 1000 10-12 year old children, fitness was improved by physical activity programmes which were associated with a greater fall in diastolic BP and triceps skinfolds in girls compared with controls. Sugar intake decreased in boys and fat intake fell in girls, mainly affecting participants in home nutrition programmes. 3. In higher risk children, identified by cluster analysis, major benefits were associated with the fitness and home nutrition programmes. Physical activity combined with involvement of the family in nutrition education is likely to be the most successful approach to modifying lifestyle in children, including those with higher levels of risk. 4. Undernutrition by too rigid restriction of fat intake must be avoided in young children who need calorie-dense foods. Undernutrition, in itself, may predispose to cardiovascular disease in later life. Programmes should aim to establish a prudent diet appropriate to the age of the child combined with physical activity. As regular activity and a healthy diet in adult life will reduce risks of cardiovascular disease it is likely that childhood education will establish lifestyle habits of potential long-term benefit.

A framework for the study of childbearing fatigue

Accounts of fatigue in childbearing women are identified in clinical reports, maternity textbooks, and studies. However, limited conceptual clarification or empiric research directed at mothers' fatigue during childbearing has been undertaken. To better understand fatigue, factors in the childbearing woman's life that are thought to predispose her to fatigue were identified; also delineated were the potential effects of fatigue on maternal performance. The framework that emerged, representing insights from childbearing and fatigue literature, is designed to serve as a guide to research that will add to understanding of childbearing fatigue and how it can be prevented or ameliorated.