Me and My Money…a child’s story of diabetes

M&M Cover 300 small

Copyrighted in 2012, Me & My Money…a child’s story of diabetes, took two years to write…

From birthing thoughts, jotting ideas, typing a manuscript, carrying a daily journal, contacting an illustrator,  building the manuscript, proofreading and editing again and again and again and…you get the idea…this dream came to fruition.  It had do be done.  There is no other book like it — as far as my research goes — that reflects, mimics, or encourages diabetic children, T1Ds.  The book is now available to the general public in paperback form.  Celebrate!!

Submitting to a marketable world with a targeted audience, networking, promoting, speaking, through the main character, Kali with her dog, Money, brings attention to the increase of diabetes in animals – up 300% this past decade!

Through the wonderful insightfulness of illustrator Amy Pichly-Meyer who is responsible for the clarity of expression with the cover design, along with all 37 colored  illustrations, this book was built for you.  I am thankful for her friendship and abilities.

Briefly, the main character, Kali, is presently a fourth grader.  She was diagnosed with diabetes at the age of two.  Her rapid growth with blooming and wizened independence results from learning how to take care of herself.  Wayne, a best friend, knows her very well and together they embark on adventures through Wayne’s hobby, their separate and shared responsibilities, mutual friends, and more.  But Kali cannot forget her special pack!  She must carry this with her everyday, everywhere.

This book, along with the recent publication of Me & My Money Too…a child’s story with diabetes, are tools to understanding this disease.  Minute-by-minute self-care is introduced and forthcoming in this illustrated, easy-to-read chapter book, 104 pages long, appropriate for 8 years olds and available at Amazon.com in paperback edition as well as Kindle e-readers.   Local bookstores carry copies as well as local libraries with requests.  Please enjoy the following Chapter excerpts…

Chapter 1, Book One

Due to keeping up with my chores, I occasionally have some change in my pocket.  That’s because my parents give me a weekly allowance that I can spend when I want.

“Make sure you spend wisely,’ Dad says.  I’m not quite sure what “spend wisely” means, but I think I do okay with what I have.  For instance, one of my friends from school, Wayne, asked me to go to the hobby store one Saturday afternoon.  Because it is school summer vacation time, we could go almost any time, depending on our parents.  However, Saturday’s are best.

Wayne and I go way back, to kindergarten.  He is the only red-head kid in our whole grammar school, never mind our fourth grade.  He’s a full blown carrot top with thick hair in wavy curls.  This makes him real easy to spot in a crowd.  The girls in our class like Wayne more than the boys do.  I think this is because he has good manners and is polite.  It is either that or his clear sky blue eyes that sparkle.  Even his eyelashes are orange, matching his hair.  Most girls I know like blue eyes.  I never thought about it much.  My eyes are dark brown to match my light brown and blonde streaky hair.

Wayne is a pale looking kid.  Most of the time, the only color on Wayne’s face is because of his tannish-brown colored freckles.  I swear, if he didn’t have freckles, he would be white as a ghost!  I tease him about that, pretending that I can’t see him sometimes.  We laugh.  He blushes all red and pink.  It’s funny to see.  Wayne is shorter than I am — for now.  He teases me about my long brown hair — so flat, so straight and thin.  “There’s nothing to your hair,” he tells me as he quickly flicks it in the air.  “You don’t even have to brush it.  Your hair just hangs there off your fat head,” he often tells me as if I need to be reminded. 

I think Wayne is jealous of my straight hair.  Brushing his hair is a struggle because it is very thick.  Mine is a lot easier because it is stick straight.  He hates when his mother brushes his hair because “she always pulls it out of my head,” he told me one time.  “And you have a chubby little pug-nose.  Not like my pointy one at all,” he compares.  “But you get a tan in the summer.  I don’t tan, I burn.  It’s awful,” he explains.  That is true.

One summer that I remember, his mother covered his face and arms with white suntan lotion so  he wouldn’t get burned while playing with me in my back yard.  He looked so funny.  That stuff made him smell like the beach.  I laughed at him.  He didn’t like that.  And after a while, the suntan lotion disappeared.  But we stayed friends.  He wears that stuff all the time.  Sure, I use it too, but when I forget to rub it on my skin, I don’t get too worried.

“I guess you look like your father,” I told him because I think he does.  “I look like my mother,” I said.  And that’s okay with me because my mother is beautiful.  My Dad’s okay looking — for a Dad.  Sometimes he has a moustache.  Mom told him to shave it off because it made her sneeze when they kiss.  Eeeuu!  Sneezing and kissing, yuck!

“Kali,” my mom called up the stairs.  “Wayne is on the phone for you.”

“Okay.  Thanks.  I’ll get it up here,” I told her.

“Hi Wayne.  Wassup?”

“Hey.  Can you come to the train store with me today or what?  I’m looking for a certain model train engine and I think the Viking Hobby Store will have it.”

Well, I have no particular interest in model trains, so I knew I wouldn’t buy anything but I would go along with him anyway.  This is a wise decision.  After all, he is my very best friend.  Very best friends do things for each other whether we need to or like to or not.  It was Saturday morning anyway.  Cleaning my room could wait until I got back.  I was thinking, planning.

“Mom, Dad, is it okay with you if I go to the hoppy store with Wayne today?  He thinks he found the perfect train engine for his set.  He wants me to go and help him check it out.”

“I don’t mind.  Is your room picked up?” Mom asked.

“Not all the way yet, Mom,” I replied.  “I can finish when I get back.  All I have to do is fold my clothes and put them away.  A load of my socks and some t-shirts are still in the dryer.”

“Well, all right.  Did you ask your father?” Mom wanted to know.  “And don’t forget to take a snack and some juice boxes with you.”

“I know.  I already have a pack of peanut butter nabs in my sack with some water.  I don’t know where Dad is.  I thought he was in the kitchen with you.  Maybe he’s in the garage.”

“Okay,” continued my mother.  “If you don’t see your father on your way out, I’ll tell him.  If you do, please remind him that we’re going shopping today.  Oh, are you and Wayne taking your bikes or walking?”

“I think we’ll walk.”  And out the back door I went.

Chapter 2

Wayne lives four houses away from me.  I took the short-cut over to his house through a wildflower field.  I often come here to pick my mother some flowers.  I like to pick flowers for her.  There are all kinds of wildflowers in this field: yellow ones, pink ones, purple ones with yellow centers.  I don’t know the names of these flowers, I just know they are pretty and Mom likes them.

After I met Wayne on the front porch of his house, we proceeded to walk to this particular ‘train store’ as he calls it.  It is really a hobby store that has lots of other things of interest besides trains.  I’ve been in there with one of my older cousins.  She was looking for some particular, special types of paint brushes made with camel’s hair.  I thought that was cool — paint brushes made out of a camel’s hair!  There are small glider planes in this store with hand-held motor devices; there are different kinds of wood burners and wood carving tools; there are even lots of different colored rubber fish bait things — lures.  I liked those because they are shiny, squishy, and they squiggle.  Things that would attract a fish — go figure!  Wayne had been going on about a certain model train engine he saw in here a while ago.  It took him weeks and weeks to save up his allowance money to buy it.

“Hey, before we walk too far, is your insulin pump filled up?” Wayne asked.  “I hope it doesn’t beep like crazy while we are out.  I would hate to have to leave early so you could fix it.”

“Yes, it’s fine.  I filled it up with insulin yesterday morning and changed the needle site.  We are good to go!”  I planned this on purpose.  I knew he would ask.  I am diabetic.  Wayne knows.  Among many other things, I do take care of myself and my diabetes.  I have to test my blood sugar levels many times each day.  Diabetes is a disease that causes me not to digest food properly.  Because of that, I wear an insulin pump.  I used to have to take insulin shots before I got the pump.  Having the pump is much easier.  An insulin pump squirts insulin into my body, automatically, a tiny bit at a time.  A “squirt” is maybe the size of a pencil tip or the size of a period at the end of a sentence.  My parents had to give me insulin shots before I learned to give them myself.  I still keep syringes handy, in case the pump breaks down for whatever reason.  This is called having “Plan B” which is important. 

Read more of Kali’s young life with diabetes in “Me & My Money…a child’s story of diabetes.”  Available at Amazon.com.

Wait, there’s more science!

“Given the ongoing struggle to find new therapeutic cancer drug targets, I have long believed that a more rapid approach for discovery would consist of reversing the question,” stated Stine. “Rather than the conventional route of interrogating the tumor at the genomic and proteomic level in order to reveal disease-associated targets, why not ask the patient? The readout for differences in self and non-self antigens manifests itself in the form of antibodies, and our approach assumes that the answers to our drug and target discovery questions are contained within this response.” – J.T. Stine, Seattle Times, 2005

Applications in Humans

The statement above was the founding question addressed by Spaltudaq (today known as Theraclone Sciences).  The result of sampling a cancer patient’s immune repertoire led to the discovery of a broadly reactive and specific IgG antibody using the iSTAR method (a precursor to BLAST).

Discovery:

Screen normal/exposed and disease individuals for

  1. Neutralizing anti-infective antibodies (viral, bacterial)

  2. Tumor specific antibodies/epitopes from host B-cells

Immune monitoring

  1. Vaccine evaluations prior or during clinical trials – associate epitopes with efficacy

  2. Monitor immune response during tolerance block therapeutics such as anti-CTLA-4 or anti-PD1

Auto-immune patient B-cell screening

  1. Discover antibodies in auto-immune patient repertoire which can be therapeutic in other diseases where the eliciting target exists.

Applications in other mammals:

Discovery:

Immunize with tumor lines or clinical isolates

  1. Screen for novel tumor-specific or -selective epitopes or targets for naked antibody targeted ADCC

  2. Screen for novel internalization targets for antibody/drug conjugates

  3. Screen for functional antibodies that have a deleterious effect on tumor growth

Immunize with viral or bacterial targets

  1. Upfront functional screens can reveal novel or additional antibody epitope pairs for neutralization

  2. Use neutralization data to engineer more efficacious vaccines

Target extracellular domains of 7TM’s/GPCR’s

  1. The most “drugable” target is easily targeted with BLAST

  2. Discover antibodies that are agonists, antagonists or neutral

  3. Discover a more specific cell set to deplete due to the selective expression of GPCR’s on various cell types

An example of the use of BLAST in Type 1 diabetes (T!D) to interrogate the immunological history of their disease in order to determine the most relevant first-response cell surface proteins which were targeted on pancreatic islets cells by T-cells or other effector mechanisms.  A discovery here may lead to another use of BLAST which would consist of understanding the TCR’s responsible for this detection and selectively eliminating them with anti-TCR-specific antibodies.

Whole-cell immunization & BLAST

  1. Antibody generation in a massive scale

  2. Below is an example of the fraction of antibodies created en masse

BLAST

Functional Screen

Hit Selection

IgG Memory B-cells

Hits

Molecular

Reconstitution

V-gene

sequence

matching

  1. Reveals:

  2. v-gene epitope bias and overall immune response to target

  3. alternative target-specific hypermutated related sequences that may have other desirable properties that weren’t revealed in the screen and can now be synthesized

“North Coast Biologics…”read it here….

http://www.northcoastbio.com/NCB/Applications.html?fbclid=IwAR3YiFthAtFWMBZoFVxwnkdBkvBQgSzRGk-4ApyaJkqh4zT_Qdtz2vlBcps

Our Purpose:

The Technology:  BLAST

Mab in-license opportunities:

“Applications of BLAST

“BLAST is a method that physically displays an entire, native IgG immune response in an easily assayable format for discovering antibodies with desired function or features.  For the first time, immune responses from various mammals (humans included) can be sampled thoroughly and efficiently for rare antibodies of high affinity or function for therapeutic antibody discovery.  BLAST has been configured for speed (7 days to see results from B-cells to screens) and flexibility in that it has been industrialized to the degree that you can “work at the speed of thought”.  An entire immunological history of acute or chronic disease can be assayed or monitored for both efficacious antibodies and their associated targets or epitopes.  All antibodies are delivered humanized when non-human species are used.

“The Technology >>

“North Coast Bio is an antibody company committed to the discovery and generation of antibody therapeutics for serving unmet medical needs and/or to replace antibodies to known, validated targets that under perform either via partnerships or our own internal efforts.

“The company was founded for the sole purpose of free and creative deployment of the main technology into the typical areas, but also to include those that traditional venture backed companies cannot serve.  Our goal is to choose disease indications based on unmet need rather than market size alone while simultaneously partnering BLAST with biotech companies or pharma’s who wish to co-discover and subsequently develop antibodies that suit their clinical interests.

Read more… >>

“The BLAST platform has been engineered for flexibility and for speed.

“BLAST in humans can sample the native immune repertoire for:

  1. anti-infective antibodies against viruses or bacteria from individuals infected (titer+) or vaccinated

  2. tumor-specific antibodies from “normal” individuals as well as those currently with cancer

  3. therapeutic antibodies from auto-immune patients where those antibodies that are part of the pathology of their disease are actually efficacious in another

  4. antibodies that reveal epitopes that are either responsible for an auto-immune disease (for targeting) or reveal neutralizing epitopes that can be used to engineer new vaccines.

“BLAST in other immune animals such as rabbits, mice, or macaque creates the opportunity to find antibodies with exceptional therapeutic qualities by producing a treasure trove of selectable antibodies due to access to millions of IgG’s afforded by the BLAST approach.

The Applications >>

Personalized Medicine:  Compassionate Use of BLAST

Partnering:

“North Coast Bio is funded solely via partnerships with pharma, biotech companies, and academic institutions.  We are soliciting partnerships to take advantage of BLAST for discovery of novel therapeutic antibodies/targets or generation of therapeutic antibodies to known targets that out perform the respective current sub-par approved antibodies.  Our areas of focus are cancer, infectious disease, auto-immunity, and vaccine monitoring (reverse vaccinology).  BLAST is readily used to either discover new epitopes for vaccine development, or to monitor vaccine responses down to the epitope which provide the greatest therapeutic effect either pre-clinically or in clinical trials.

More about partnering >>

“It’s time for our local biotech community to get off our collective asses and make things happen.  Do you have an idea for a therapeutic antibody but are forbidden to pursue it?  Conforming to the current conservative way is killing our industry.  There are so many therapeutics waiting to be discovered and generated using antibodies.  We’ve given our local physicians virtually nothing to work with since the mid 90’s with Rituxan, Herceptin, and Erbitux.  While these are great drugs, we don’t need more of the same.  If you have a great idea, take some risk, get your work plan together and come to North Coast and execute the plan.  We’ve let far too many cancer patients die from tumors that are very treatable with antibodies.  If the established companies won’t pursue discovery of new targets in these areas,…..we will.  Bring it…..

North Coast Stimulus >>

Economic stimulus with antibodies:

Announcements/Announcements.html
 http://www.northcoastbio.com/NCB/Applications.html?fbclid=IwAR3YiFthAtFWMBZoFVxwnkdBkvBQgSzRGk-4ApyaJkqh4zT_Qdtz2vlBcps

T1D Management Complexities Explained and Enhanced Through Dr. Jody Stanislaw

A T1D friend on the other side of the U.S. continent shared this story with me. I am a T1D. Because I have found this to be an absolutely remarkable, newsworthy, descriptive, helpful and realistic share…I share it – have to share it – with you. It’s long. But listening is most beneficial.

Type Ones and Type Twos, listen up!

“The Disorder Formerly Known as Juvenile Diabetes: The Complexity of Type 1 Diabetes”

“Are Type 1 Diabetes symptoms the same as Type 2 Diabetes symptoms? Can Type 1 Diabetes treatments be applied successfully to Type 2 Diabetes? Dr. Jody Stanislaw, whose Tedx Talk entitled Sugar is Not a Treat has surpassed one million views, breaks down the differences between Type 1 and Type 2 Diabetes.”

“Tune in to discover:

  • The connection between dietary fat and insulin resistance
  • Nutrition and fitness facts to help with effective Diabetes management
  • The ideal Type 1 Diabetes diet

“Jody is a naturopathic doctor and a Certified Diabetes Educator, who specializes in training Type 1 Diabetes patients to properly adjust and administer their insulin without fear or guesswork. She also suffers from the disease herself and has since her early childhood. Unlike Type 2 Diabetes, Type 1 is an irreversible auto-immune disorder. There is currently no Type 1 Diabetes cure.

“Managing Type 1 Diabetes is much more complex than simply monitoring sugar intake. Hormone levels, genetics, body mass index, activity levels, and dozens of other factors actively contribute to a person’s blood sugar range each day. Contrary to popular belief, obesity is not associated with Type 1 Diabetes causes. In fact, no specific causes have been identified to date.

“Jody embraces a mostly plant based food diet and educates her patients on plant-based diet benefits as well. She also acknowledges that most people will not be capable of realistically adhering to a very strict diet 100% of the time. She offers specific advice to her patients and on her website for how a Type 1 Diabetes patient can adjust their insulin and blood sugar testing in order to indulge safely for special occasions.

“To learn more about Jody’s personal Diabetes journey, sign up for her classes, or try out her one-on-one services visit https://www.drjodynd.com/ Available on Apple Podcasts: apple.co/2Os0myK.”

Just keepin’ you informed, as always!

A. K. Buckroth, www.mydiabeticsoul.com

 

 

T1D Specialty Books to Include a Dog with Diabetes

As a living testament to a lifetime with diabetes, my authorship with numerous books on the subject have come to fruition. “Me and My Dog Named Money…a child’s story of diabetes, Book One,” copyright in 2019:
“Me & My Money Too, Book Two,” copyright 2019; and
“Kisses for Cash…T1D meets T2D” copyright 2016,
continue to inspire readers aged 8 – 108.

Handsomely illustrated by Amy Pichly Meyer and author A. K. Buckroth, such drawings help bring a visual to the management of diabetes. These elementary grade children’s books delicately bring up the subject of diabetes with animals. Such diagnoses have risen over 300% in the last decade. So, “Money & Cash,” are family pets. Read about their lives with their loving humans.

Available through Amazon, Smashwords, Goodreads through e-readers and paperbacks, look up and ask for “A. K. Buckroth.” You’ll be happy you did!

“Authoritative Stem Cell Information,” MmmHmm.

New post on The Stem Cellar

Tipping our hat to the good guys (& gals)

by Kevin McCormack

A search on Google using the term “stem cell blogs” quickly produces a host of sites offering treatments for everything from ankle, hip and knee problems, to Parkinson’s disease and asthma. Amazingly the therapies for those very different conditions all use the same kind of cells produced in the same way. It’s like magic. Sadly, it’s magic that is less hocus pocus and more bogus bogus.

The good news is there are blogs out there (besides us, of course) that do offer good, accurate, reliable information about stem cells. The people behind them are not in this to make a quick buck selling snake oil. They are in this to educate, inform, engage and enlighten people about what stem cells can, and cannot do.

So, here’s some of our favorites.

The Niche

This blog has just undergone a face lift and is now as colorful and easy to read as it is informative. It bills itself as the longest running stem cell blog around. It’s run by UC Davis stem cell biologist Dr. Paul Knoepfler – full disclosure, we have funded some of Paul’s work – and it’s a constant source of amazement to me how Paul manages to run a busy research lab and post regular updates on his blog.

The power of The Niche is that it’s easy for non-science folk – like me – to read and understand without having to do a deep dive into Google search or Wikipedia. It’s well written, informative and often very witty. If you are looking for a good website to check whether some news about stem cells is real or suspect, this is a great place to start.

Stem Cell Battles

This site is run by another old friend of CIRM’s, Don Reed. Don has written extensively about stem cell research in general, and CIRM in particular. His motivation to do this work is clear. Don says he’s not a doctor or scientist, he’s something much simpler:

“No. I am just a father fighting for his paralyzed son, and the only way to fix him is to advance cures for everyone. Also, my mother died of breast cancer, my sister from leukemia, and I myself am a prostate cancer survivor. So, I have some very personal reasons to support the California Institute for Regenerative Medicine and to want state funding for stem cell and other regenerative medicine research to continue in California!”

The power of Don’s writing is that he always tells human stories, real tales about real people. He makes everything he does accessible, memorable and often very funny. If I’m looking for ways to explain something complex and translate it into everyday English, I’ll often look at Don’s work, he knows how to talk to people about the science without having their eyes cloud over.

A Closer Look at Stem Cells

This is published by the International Society for Stem Cell Research (ISSCR), the leading professional organization for stem cell scientists. You might expect a blog from such a science-focused organization to be heavy going for the ordinary person, but you’d be wrong.

A Closer Look at Stem Cells is specifically designed for people who want to learn more about stem cells but don’t have the time to get a PhD. They have sections explaining what stem cells are, what they can and can’t do, even a glossary explaining different terms used in the field (I used to think the Islets of Langerhans were small islands off the coast of Germany till I went to this site).

One of the best, and most important, parts of the site is the section on clinical trials, helping people understand what’s involved in these trials and the kinds of things you need to consider before signing up for one.

Signals

Of course, the US doesn’t have a monopoly on stem cell research and that’s reflected in the next two choices. One is the Signals Blog from our friends to the north in Canada. This is an easy-to-read site that describes itself as the “Insiders perspective on the world of stem cells and regenerative medicine.” The ‘Categories ‘dropdown menu allows you to choose what you want to read, and it gives you lots of options from the latest news to a special section for patients, even a section on ethical and legal issues.

EuroStemCell

As you may have guessed from the title this is by our chums across the pond in Europe. They lay out their mission on page one saying they want to help people make sense of stem cells:

“As a network of scientists and academics, we provide independent, expert-reviewed information and road-tested educational resources on stem cells and their impact on society. We also work with people affected by conditions, educators, regulators, media, healthcare professionals and policymakers to foster engagement and develop material that meets their needs.”

True to their word they have great information on the latest research, broken down by different types of disease, different types of stem cell etc. And like CIRM they also have some great educational resources for teachers to use in the classroom.

Latest T1D Books…by Yerachmiel Altman

…”I Can Help Take Care Of Me: A book about

Type 1 diabetes (Learning to Live with

Diabetes for Children).”

“…is a poetic introduction for children living with diabetes. The book goes through the standard methods of care that a child will be living with, demonstrates how the equipment works and what it does. The book should help a child to see that his diagnosis is not the end of the world and is something that he’ll live and work with. The book is also an excellent teaching tool for family members, teachers, classmates and others that need to become knowledgeable in diabetes.

I’ve written this book to help children diagnosed with type 1 diabetes learn the “basics”. It begins with the child’s diagnosis, gives simple explanations of what type 1 diabetes is, and then proceeds to show meters, pumps and CGMS sensors. It describes activities of daily living.

The aim is to familiarize children with the hardware and issues that they will be living with. This is NOT to be used as a medical book. I am NOT working with dosing, carbohydrate counting, or other specific medical issues as these must be handled by the medical team.”

AND…

The Moose with the Pump: A book for children with type 1 diabetes (Type 1 diabetes for children) by [Yerachmiel Altman, Moose Pump, Sara Chana Altman]Available at Amazon.com! Because you need to know. 🙂

Stem Cell News: Acute Respiratory Distress Syndrome

Human Clinical Articles

Open Access

Umbilical cord mesenchymal stem cells for COVID‐19 acute respiratory distress syndrome: A double‐blind, phase 1/2a, randomized controlled trial

Abstract

Acute respiratory distress syndrome (ARDS) in COVID‐19 is associated with high mortality. Mesenchymal stem cells are known to exert immunomodulatory and anti‐inflammatory effects and could yield beneficial effects in COVID‐19 ARDS. The objective of this study was to determine safety and explore efficacy of umbilical cord mesenchymal stem cell (UC‐MSC) infusions in subjects with COVID‐19 ARDS. A double‐blind, phase 1/2a, randomized, controlled trial was performed. Randomization and stratification by ARDS severity was used to foster balance among groups. All subjects were analyzed under intention to treat design. Twenty‐four subjects were randomized 1:1 to either UC‐MSC treatment (n = 12) or the control group (n = 12). Subjects in the UC‐MSC treatment group received two intravenous infusions (at day 0 and 3) of 100 ± 20 × 106 UC‐MSCs; controls received two infusions of vehicle solution. Both groups received best standard of care. Primary endpoint was safety (adverse events [AEs]) within 6 hours; cardiac arrest or death within 24 hours postinfusion). Secondary endpoints included patient survival at 31 days after the first infusion and time to recovery. No difference was observed between groups in infusion‐associated AEs. No serious adverse events (SAEs) were observed related to UC‐MSC infusions. UC‐MSC infusions in COVID‐19 ARDS were found to be safe. Inflammatory cytokines were significantly decreased in UC‐MSC‐treated subjects at day 6. Treatment was associated with significantly improved patient survival (91% vs 42%, P = .015), SAE‐free survival (P = .008), and time to recovery (P = .03). UC‐MSC infusions are safe and could be beneficial in treating subjects with COVID‐19 ARDS.

Lessons learned

  • Two intravenous infusions of umbilical cord mesenchymal stem cells (UC‐MSCs), at a dose of 100 million cells per infusion, given 72 hours apart, are safe in COVID‐19 patients with acute respiratory distress syndrome.
  • This double blind randomized controlled trial in 24 subjects demonstrated fewer serious adverse events in the UC‐MSC treatment group compared with the control group.
  • UC‐MSC treatment was associated with a significant decrease in a set of inflammatory cytokines involved in the COVID‐19 “cytokine storm.”
  • UC‐MSC treatment was associated with significantly improved patient survival and time to recovery.
  • The observed findings strongly support further investigation in a larger trial designed to estimate and establish efficacy.

Significance statement

This study was a double‐blind, randomized, controlled, early phase clinical trial of umbilical cord mesenchymal stem cell treatment in 24 subjects with COVID‐19 acute respiratory distress syndrome. This study demonstrated fewer serious adverse events in the treatment group compared with control. Exploratory efficacy analyses provide evidence of significantly improved patient survival and time to recovery. The observed findings strongly support further investigation in a larger trial designed to estimate and establish efficacy. These observations will inform physicians influencing clinical practice and future research in the fields of acute respiratory distress syndrome, COVID‐19, and other immune‐related disorders.

1 INTRODUCTION

Coronavirus disease 2019 (COVID‐19), a pneumonia‐like disease caused by the virus severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), reached pandemic proportions in early 2020.1, 2 A subset of subjects infected by SARS‐CoV‐2 develop severe COVID‐19 requiring hospitalization.3, 4 Severe COVID‐19 is believed to result from hyperinflammation, overactive immune response triggering cytokine storm, and a prothrombotic state, collectively determined as immunothrombosis, all elicited by SARS‐CoV‐2 infection.58 Subjects progressing to acute respiratory distress syndrome (ARDS) require high‐flow oxygen therapy, intensive care, and frequently, mechanical ventilation.3, 4, 912 Mortality in patients with COVID‐19 and ARDS was reported to be 52.4%.10 There is an urgent need for novel therapies that can attenuate the excessive inflammatory response associated with the immunopathological cytokine storm and immunothrombosis, that can accelerate the recovery of functional lung tissue, and that can abate mortality in patients with severe COVID‐19.

Mesenchymal stem cells, also known as mesenchymal stromal cells or medicinal signaling cells (MSCs),13 have been shown to modulate overactive immune and hyperinflammatory processes, promote tissue repair, and secrete antimicrobial molecules.1416 These cells, with established safety profile when administered intravenously,17 have been studied for treatment of autoimmune diseases (eg, type 1 diabetes [T1D]),18, 19 systemic lupus erythematous,20 inflammatory disorders,21 and steroid‐refractory graft‐vs‐host‐disease (GvHD).22 MSCs have been reported to limit inflammation and fibrosis in the lungs,23, 24 and have generated variable yet promising results in ARDS of viral25 and nonviral etiology.2629 Multiple ongoing trials are now testing MSCs in patients with severe COVID‐19, and pilot uncontrolled trials have reported promising results.16, 3034 MSCs can be isolated and expanded from multiple tissues, including the umbilical cord (UC). UC‐MSCs constitute a cell type of choice in cell therapy trials, including for COVID‐19.15, 3035 The experience accumulated thus far indicates that allogeneic UC‐MSC administration is safe in a multitude of diseases.36 These cells can be derived from umbilical cords discarded after delivery and quickly expanded to clinically relevant numbers.37 They express low levels of class I and class II human leukocyte antigen, which may reduce alloreactivity.37 Our Current Good Manufacturing Practice (cGMP) manufacturing facility is now scaling up UC‐MSC manufacturing to support upcoming multisite clinical trials, where large numbers of cell doses will be required.

The objective of this study was to establish safety and explore efficacy of allogenic UC‐MSC infusions in hospitalized patients with ARDS secondary to COVID‐19. Here we report the results at 1 month of follow‐up of a double‐blind randomized controlled trial (RCT) testing this cell‐based therapy approach.

2 MATERIALS AND METHODS

2.1 Trial design

This double‐blind, phase 1/2a randomized controlled trial was an academic, investigator‐initiated trial performed at UHealth System/Jackson Health System (UHS/JHS), in Miami, Florida. This trial was designed to evaluate safety and explore efficacy endpoints of allogeneic UC‐MSCs in patients with COVID‐19 and ARDS.

Regulatory, ethical, and institutional review board approvals were obtained by the Western Institutional Review Board and UHS/JHS Human Subject Research Office/Institutional Review Board in accordance with local institutional requirements.

Additional details are provided in the supplemental online Methods.

2.2 Participants

The trial was conducted in accordance with the principles of the Declaration of Helsinki and consistent with the Good Clinical Practice guidelines of the International Conference on Harmonisation.

Subjects diagnosed with COVID‐19 ARDS were eligible for inclusion if they met the eligibility criteria listed in Table S1 within 24 hours of enrollment. The investigations were performed with informed consent.

2.3 Randomization

Twenty‐four subjects hospitalized for COVID‐19 were randomized 1:1 to either UC‐MSC treatment (n = 12) or to the control group (n = 12). Patients were assigned to treatment group using a stratified, blocked randomized design.

Additional details are provided in the supplemental online Methods.

2.4 Blinding

The study was double‐blinded: neither the patient nor the assessing physician was aware of treatment assignment, and the staff responsible for product administration were blinded to group assignment.

2.5 UC‐MSC investigational product

UC‐MSCs were manufactured as previously described.38 UC‐MSCs were culture‐expanded from a previously established and characterized master cell bank (MCB) derived from the subepithelial lining of a UC, collected from a healthy term delivery (kindly provided by Jadi Cell and Amit Patel, M.D.).37, 39 The MCB and its source tissue were tested according to the applicable U.S. Food and Drug Administration (FDA) regulations and American Association of Blood Banks (AABB) and Foundation for the Accreditation for Cellular Therapy (FACT) standards for cellular therapies.

In preparation for infusion, frozen UC‐MSCs were quickly thawed and slowly diluted in Plasma‐LyteA supplemented with human serum albumin and heparin (vehicle solution). The final volume of UC‐MSC suspension or vehicle solution (control) for infusion was 50 mL. Cell dose (100 ± 20 × 106), cell viability by trypan blue (>80%), cell surface marker expression by flow cytometric analysis (CD90/CD105 > 95%, CD34/CD45 < 5%), endotoxin (<1.65 EU/mL), Gram stain (negative), and 14‐day sterility (negative) were used as product release criteria. The vehicle solution was tested for 14‐day sterility, Gram stain, and endotoxin. The UC‐MSC suspension or vehicle solution was infused within 3 hours of preparation for infusion.

Additional details are provided in the supplemental online Methods.

2.6 Interventions

Subjects in the UC‐MSC treatment group received two intravenous infusions of 100 ± 20 × 106 UC‐MSCs each, in 50 mL vehicle solution containing human serum albumin and heparin, infused over 10 ± 5 minutes, at days 0 and 3. Subjects in the control group (n = 12) received two infusions of 50 mL vehicle solution, at day 0 and day 3. Best standard of care was provided in both groups following the current institutional COVID‐19 guidelines.

Additional details are provided in the supplemental online Methods.

2.7 Outcomes

2.7.1 Primary endpoints

Primary endpoints were the following: (a) safety, defined by the occurrence of prespecified infusion‐associated adverse events (AEs) within 6 hours from each infusion; (b) cardiac arrest or death within 24 hours postinfusion; and (c) incidence of AEs.

2.7.2 Secondary endpoints

Secondary endpoints included exploratory efficacy defined by clinical outcomes and laboratory testing and mechanistic analyses.

Clinical outcomes included the following: (a) survival at day 28 after treatment; (b) time to recovery, defined as time to discharge or, if the subject was hospitalized, no longer requiring supplemental oxygen and no longer requiring COVID‐19‐related medical care; and (c) AEs, serious AEs (SAEs), and clinical outcomes assessed for 31 days after the first infusion, corresponding to 28 days after the last infusion.

Laboratory testing and mechanistic analyses included the following: (a) viral load by SARS‐CoV‐2 real‐time polymerase chain reaction (RT‐PCR) in peripheral blood plasma samples and (b) inflammatory cytokines, chemokines, and growth factors in peripheral blood plasma.

Primary and secondary endpoints are presented in detail in the supplemental online Methods.

2.8 Plasma preparation from peripheral blood

Whole blood was collected from randomized subjects at day 0 (immediately pretreatment) and at day 6 after treatment initiation. Whole blood was collected into EDTA‐treated tubes, transferred on ice, and processed for plasma separation within 4 hours. Whole blood was centrifuged at 2000g for 15 minutes at 4°C. The plasma (top fraction) was collected, aliquoted into cryogenic tubes, and stored at −80°C until processing.

2.9 Analysis of viral load by SARS‐CoV‐2 RT‐PCR

The RealStar SARS‐COV‐2 RT‐PCR kit (Altona Diagnostics GmbH, Hamburg, Germany) was used to detect the SARS‐CoV‐2‐specific S gene and quantify the number of copies per mL of plasma. The assay was performed following the manufacturer’s instruction, using plasma samples collected from the randomized subjects on day 0 and day 6.

2.10 Analysis of inflammatory cytokines, chemokines, and growth factors in peripheral blood plasma

A protein array (RayBio Q‐Series, RayBiotech, Peachtree Corners, Georgia) was used to determine plasma levels of a set of inflammatory cytokines, chemokines, and growth factors (granulocyte‐macrophage colony‐stimulating factor [GM‐CSF], interferon [IFN]g, interleukin [IL]‐2, IL‐5, IL‐6, IL‐7, tumor necrosis factor [TNF]a, TNFb, platelet‐derived growth factor [PDGF]‐BB, regulated on activation, normal T cell expressed and secreted, RANTES). The assay was performed using plasma samples collected from the randomized subjects on day 0 and day 6. On the processing day, 1 mL of plasma per sample was thawed in a 37°C water bath and supplemented with 10 μL of 100× Halt Protease and Phosphatase inhibitor cocktail (Thermo Fisher Scientific, Waltham, Massachusetts). Each plasma sample was diluted 1:2 with sample diluent and assayed following the manufacturer’s instructions. The fluorescent signals were visualized via a laser scanner equipped with a Cy3 wavelength (green channel) and converted to concentrations (pg/mL) using the standard curve generated per array.

2.11 Statistical methods

Comparisons of AEs, SAEs, demographics, clinical characteristics, comorbidities, and concomitant treatments between the two groups were performed using Fisher’s exact test and Wilcoxon two‐sample tests for categorical and continuous variables, respectively. Survival, survival in absence of SAE (SAE‐free survival), and time to recovery were estimated in each group with Kaplan‐Meier survival estimates. Log‐rank tests were used to compare hazards between groups. For the analyses of viral load, P values were calculated using the Wilcoxon rank‐sum test on SAS 9.4. The data were nonnormally distributed. For the analyses of inflammatory cytokines, chemokines, and growth factors, group data at a specific day were analyzed via nonparametric unpaired Mann‐Whitney t test; for the analyses on longitudinal changes in each group, data at day 0 and day 6 were analyzed via nonparametric paired Wilcoxon t test.

2.12 Registration

This trial was registered with ClinicalTrials.gov identifier NCT04355728 (https://clinicaltrials.gov/ct2/show/NCT04355728?term=NCT04355728&draw=2&rank=1).

2.13 Clinical trial protocol

The clinical trial protocol is included in the Data S1.

3 RESULTS

3.1 Participant flow

Participant flow is shown in Figure 1.

image
Enrollment and randomization. UC‐MSC, umbilical cord mesenchymal stem cell

3.2 Recruitment

From 25 April 2020, to 21 July 2020, a total of 28 subjects were enrolled. Four subjects were subsequently determined to be ineligible because of screen failure. Twenty‐four subjects were randomized (Figure 1). At enrollment, 11 subjects (46%) were receiving invasive mechanical ventilation, and 13 (54%) were on high flow oxygen therapy via noninvasive ventilation (including high flow nasal cannula, continuous positive airways pressure, or bilevel positive airways pressure) prior to initiation of treatment.

Demographics and baseline characteristics for enrolled subjects, along with stratification, randomization, and concomitant treatment information are presented in Table 1 and Table S2.

TABLE 1. Baseline characteristics and concomitant treatments during index of hospitalization by treatment group
Characteristics and treatments UC‐MSC (n = 12) Control (n = 12) P value
Sex, n (%) .41
Male 5 (41.7) 8 (66.7)
Female 7 (58.3) 4 (33.3)
Age, mean ± SD, years 58.58 ± 15.93 58.83 ± 11.61 .97
Race, n (%) 0.99
White 11 (91.7) 10 (83.3)
African American 1 (8.3) 2 (16.7)
Ethnicity, n (%) 0.99
Hispanic or Latino 11 (91.7) 11 (91.7)
Non‐Hispanic 1 (8.3) 1 (8.3)
PaO2/FiO2 ratio at enrollment, median (IQR) 124 (68‐164) 108.5 (68.5‐165.5) .67
ARDS severity stratification, n (%) 0.99
Mild‐to‐moderate 3 (25) 3 (25)
Moderate‐to‐severe 9 (75) 9 (75)
BMI, mean ± SD, kg/m2 34.5 ± 4.5 29.6 ± 3.5 .01
Smoker (former), n (%) 0 2 (16.7) .48
Comorbidities, n (%)
Diabetes 5 (41.7) 6 (50) 0.99
Hypertension 7 (58.3) 9 (75) .67
Obesity (BMI >30) 11 (91.7) 5 (41.7) .03
Cancer 0 1 (8.3) 0.99
Heart disease 1 (8.3) 3 (25) .59
Concomitant treatments, n (%)
Heparin 12 (100) 12 (100) 0.99
Only prophylactic dose heparina 9 (75) 7 (58.3) .67
Therapeutic dose heparinb 3 (25) 5 (41.7) .67
Remdesivir 9 (75) 7 (58.3) .67
Convalescent plasma 3 (25) 4 (33.3) 0.99
Corticosteroids 10 (83.3) 9 (75) 0.99
Tocilizumab 1 (8.3) 4 (33.3) .32
Hydroxychloroquine 1 (8.3) 2 (18.2) .59
Alteplase 0 2 (16.7) .48
  • Note: Age and BMI are normally distributed. PaO2/FiO2 ratio at enrollment is non‐normally distributed. t test, Wilcoxon two‐sample test, and Fisher’s exact test were used for continuous normal, continuous non‐normal and categorical variables, respectively.
  • Abbreviations: ARDS, acute respiratory distress syndrome; BMI, body mass index; FiO2, fraction of inspired oxygen; IQR, interquartile range; PaO2, partial pressure of oxygen; UC‐MSC, umbilical cord mesenchymal stem cell.
  • a Prophylactic dose heparin: either prophylactic unfractionated heparin, subcutaneous injection, 5000 units two to three times daily (up to 15 000 units) or prophylactic enoxaparin 40 to 60 mg daily.
  • b Therapeutic dose heparin: either full dose unfractionated heparin, intravenous, titrated to a goal of activated partial thromboplastin time, or full dose enoxaparin 1 mg/kg twice daily.

Two cases required special considerations. Subject #11 died for reasons unrelated to COVID‐19 after failed endotracheal intubation. Therefore, this subject was considered as censored in the data analysis for time to COVID‐19‐related death and time to recovery outcomes. Subject #24 left the hospital against medical advice 11 days after second infusion and was thus considered as censored in the time to recovery analysis. This patient eventually recovered at home and was confirmed alive at 31 days after the first infusion.

A Data Safety Monitoring Board reviewed all safety data.

At the time of this writing, all subjects have been followed for 31 days after the first infusion, corresponding to 28 days after the second infusion.

3.3 Baseline data

Twelve subjects were randomized to the UC‐MSC treatment group (age 59 ± 16 years; 7 women [58%]) and 12 to the control group (age 59 ± 12 years; 4 women [33%]) (Table 1; Table S2). The age of enrolled subjects was 59 ± 14 years (mean ± SD).

Three subjects in each group were stratified to the mild‐to‐moderate ARDS severity stratum, and nine subjects in each group into the moderate‐to‐severe stratum. There were no significant differences in concomitant treatments between the groups (Table 1; Table S2). The only differences observed in baseline characteristics and comorbidities were in body mass index and obesity, which were higher in the UC‐MSC treatment group (Table 1; Table S2). The analysis was by original assigned groups.

3.4 Investigational product

An average of 98.7 × 106 UC‐MSCs were administered per infusion. The viability of UC‐MSCs (investigational product) at the time of product release for administration was found to be 96.2% ± 1.8% by trypan blue and 88.4% ± 7.6% by flow cytometry using fixable viability stain. Apoptosis, assessed by activated caspase‐3, was found to be 2.4% ± 3.7%, by flow cytometry (Figure S1). No differences in cell dose, cell viability, or degree of apoptosis were observed between UC‐MSCs (investigational product) prepared for the first or second infusion. Stability studies demonstrated stability of the UC‐MSC investigational product for up to 8 hours after thawing and preparation, as assessed by cell count, viability by trypan blue and flow cytometry, and apoptosis assessed by flow cytometry. Cell surface marker analysis demonstrated a typical surface marker profile characteristic of MSCs: CD90 of 97.9% ± 2.6%, CD105 of 98.1% ± 1.4%, and CD34/CD45 of 2.2% ± 4.9% (Figure S1).

3.5 Outcomes and estimations

A total of nine deaths were documented by day 28 after the second infusion. Two deaths occurred in the UC‐MSC treatment group and seven deaths in the control group. One subject (Subject #11) in the UC‐MSC treatment group died as a result of a failed endotracheal intubation. This outcome was deemed to be unrelated to the patient’s COVID‐19 disease. Therefore, data analyses for this subject were censored at the time of failed endotracheal intubation.

The details of all deaths are presented in Table S3.

3.6 Adverse events

Two serious adverse events (SAEs) were observed in the UC‐MSC group and 16 SAEs in the control group, affecting 2 of 12 and 8 of 12 subjects, respectively (P = .04; Fisher’s exact test). There were significantly more subjects experiencing SAEs in the control group than in the UC‐MSC treatment group. The adverse events in all subjects are summarized in Table 2.

TABLE 2. Summary of all adverse events for randomized subjects
Topics UC‐MSC treatment, n (%) Controls, n (%) Total (n = 24; 12 per group), n (%) Fisher’s exact test
Number of AEs reported 35 53 88
Number of subjects with AEsa 8 11 19 NS
Number of SAEs reported 2 16 18
Number of subjects with SAEsa 2 8 10 P = .04
Number of AEs by severityb
Mild 13 (37) 13 (24) 26 (30)
Moderate 18 (51) 21 (40) 39 (44)
Severe 4 (12) 19 (36) 23 (26)
Subjects with AEs by severityc,d
Mild 7 (44) 5 (25) 12 (33) NS
Moderate 7 (44) 8 (40) 15 (42) NS
Severe 2 (12) 7 (35) 9 (25) NS
Number of AEs by relatedness to treatmentb
Unrelated 31 (89) 45 (85) 76 (86)
Unlikely 3 (9) 7 (13) 10 (11)
Possible 1 (3) 1 (2) 2 (3)
Probable 0 (0) 0 (0) 0 (0)
Definite 0 (0) 0 (0) 0 (0)
Subjects with AEs by relatedness to treatmentc,d
Unrelated 8 (80) 10 (67) 18 (72) NS
Unlikely 1 (10) 4 (26) 5 (20) NS
Possible 1 (10) 1 (7) 2 (8) NS
Probable 0 (0.0) 0 (0.0) 0 (0.0) NS
Definite 0 (0.0) 0 (0.0) 0 (0.0) NS
  • Abbreviations: AE, adverse event; SAE, serious adverse event; NS, not significant; UC‐MSC, umbilical cord mesenchymal stem cell.
  • a Subjects who experience one or more AEs or SAEs are counted only once.
  • b Percentages are based on number of AEs reported for each treatment group.
  • c Subjects are counted only once within a particular severity grade or relatedness category.
  • d Percentages are based on n for each treatment group.

3.7 Primary endpoint

The primary endpoint was safety, defined as the occurrence of prespecified infusion‐associated AEs within 6 hours after infusion in addition to cardiac arrest or death within 24 hours after infusion. Prespecified infusion‐associated AEs are outlined in Table 3. One subject in each group developed infusion‐associated AEs. UC‐MSC treatment was found to be safe, as it did not lead to an increase in prespecified infusion‐associated AEs. In the UC‐MSC treatment group, the only reported adverse event occurred in a subject with bradycardia, who experienced worsening of bradycardia and required transient vasopressor treatment. In the control group, all prespecified infusion‐associated AEs occurred in the same subject, who experienced cardiac arrest 2 hours after infusion of vehicle solution. In each group, one subject developed infusion‐associated AEs.

TABLE 3. Primary endpoint: Safety
Adverse event Adverse events
UC‐MSC treatment (n = 12), n (%) Control (n = 12), n (%)
1a. An increase in vasopressor dose 1a 1
1b. In patients receiving mechanical ventilation: worsening hypoxemia 0 0
1c. In patients receiving high flow oxygen therapy: worsening hypoxemia, as indicated by requirement of intubation and mechanical ventilation 0 0
1d. New cardiac arrhythmia requiring cardioversion 0 1
1e. New ventricular tachycardia, ventricular fibrillation, or asystole 0 1
1f. A clinical scenario consistent with transfusion incompatibility or transfusion‐related infection 0 0
2. Cardiac arrest or death within 24 h postinfusion 0 0
  • Note: Safety: as defined by the occurrence of prespecified infusion‐associated adverse events within 6 hours (1a‐1f) and occurrence of cardiac arrest or death within 24 hours postinfusion (2).
  • a The vasopressor dose increase was ordered by the primary treating physician before the infusion started, but it was not given until hours later, after the infusion.

3.8 Secondary endpoints

At 31 days after the first infusion (corresponding to 28 days after the last infusion), patient survival was significantly improved in the UC‐MSC vs the control group: 10 of 11 (91%) vs 5 of 12 (42%), respectively (P = .015). The hazard ratio for death comparing the control group with UC‐MSC treatment group was 8.76 (95% confidence interval [CI]: 1.07‐71.4), indicating that the control group had a higher risk of death. Kaplan‐Meier estimates are presented in Figure 2A (survival).

image
Kaplan‐Meier curves. A, Survival. At 31 days after the first infusion (corresponding to 28 days after the last infusion), patient survival was 91% vs 42% in the UC‐MSC and control group, respectively (P = .015). The difference between the groups was statistically significant. B, SAE‐free survival. SAE‐free survival was significantly improved in the UC‐MSC treatment group compared with the control group (P = .008). SAEs affected two vs eight patients in the UC‐MSC and control group, respectively. C, Time to recovery. Time to recovery was significantly shorter in the UC‐MSC treatment group compared with the control group (P = .031). Censoring was limited to dropout from study, and the event of interest was recovery. In the case of death, the patient’s time to recovery was considered censored at the end of study observation; thus the patient conservatively remained in the risk set for all Kaplan‐Meier estimation throughout the study period. CI, confidence interval; HR, hazard ratio; SAE, serious adverse event; UC‐MSC, umbilical cord mesenchymal stem cell

SAE‐free survival was significantly improved in the UC‐MSC treatment group (P = .0081). The hazard ratio for SAE, comparing the control group with the UC‐MSC treatment group, was 6.22 (95% CI: 1.33‐28.96), indicating that the control group experienced an increased risk of SAEs. Kaplan‐Meier estimates are presented in Figure 2B (SAE‐free survival).

Time to recovery was significantly shorter in the UC‐MSC treatment group (P = .0307). The hazard ratio for recovery comparing the control group with the UC‐MSC treatment group was 0.29 (95% CI: 0.09‐0.95); this is evidence of a lower rate of recovery for the control group. Kaplan‐Meier estimates are presented in Figure 2C (time to recovery).

3.9 Analysis of viral load in peripheral blood plasma

The median viral load at day 0 or day 6 did not differ significantly between the UC‐MSC treatment and control group. The P values were .196 and .136 for day 0 and day 6, respectively (Figure S2).

3.10 Analysis of inflammatory cytokines and chemokines levels in peripheral blood plasma

The blood plasma levels of 10 inflammation‐related proteins were assessed by quantitative enzyme‐linked immunosorbent assay in both UC‐MSC treatment and control groups on days 0 and 6. Baseline levels of proteins tested were comparable in both UC‐MSC and control groups (Figure 3; day 0 column, unpaired t tests), with the exception of IL‐6, which showed higher baseline levels in the control group (P < .05, an imbalance between groups possibly resulting from the small sample size). At 6 days after treatment initiation, we observed significant differences between the groups, and a consistent decrease in inflammatory markers only in the UC‐MSC treatment group. In a comparison between groups at day 6, we observed significant differences in the concentration of GM‐CSF, IFNg, IL‐5, IL‐6, IL‐7, TNFa, TNFb, PDGF‐BB, and RANTES (P < .05); median values of these molecules were lower in the UC‐MSC group (Figure 3; day 6 column, unpaired t tests). The difference in IL‐2 resulted very close to statistical significance (P = .051) (Figure 3; day 6 column, IL‐2). In the longitudinal analysis, inflammatory cytokine concentrations showed marked and statistically significant decreases from day 0 to day 6 only in the UC‐MSC treatment group (Figure 3; UC‐MSC treatment and control columns, paired t tests).

image
Analysis of inflammatory cytokines, chemokines, and growth factors in plasma of randomized subjects. In the comparison between groups at day 6 and in the longitudinal analysis from day 0 to day 6, inflammatory cytokine concentrations showed marked and statistically significant decreases from day 0 to day 6 only in the UC‐MSC treatment group. The overall “signature” of the response in the UC‐MSC treatment group is characterized by a reduction of the levels of key inflammatory molecules involved in the COVID‐19 “cytokine storm,” including IFNg, IL‐6, and TNFa cytokines and RANTES chemokine. GM‐CSF and PDGF‐BB also decreased significantly only in the UC‐MSC treatment group. ns, not significant; UC‐MSC, umbilical cord mesenchymal stem cell

4 DISCUSSION

Severe COVID‐19 is believed to result from a hyperinflammatory state and overactive immune response with cytokine storm and immunothrombosis elicited by SARS‐CoV‐2 infection.5, 40, 41 Patients with severe COVID‐19 frequently develop ARDS, which is associated with poor prognosis.4, 40 Mortality in COVID‐19 is associated with ARDS and multiple organ failure.42 Mortality in patients with COVID‐19 and ARDS was reported to be 52.4%.10 Various treatment modalities have been investigated and recently reported, including dexamethasone11 and convalescent plasma.43 Yet, there remains a need for therapies that can modulate the inflammatory response, shorten the course of disease, and further improve survival.

UC‐MSCs may have beneficial effects in patients with severe COVID‐19 by modulating immune responses and altering the immunopathogenic cytokine storm.3032 The cells used in this trial were derived from the subepithelial lining of the umbilical cord and can be rapidly expanded for clinical applications under strict Good Manufacturing Practice conditions.37 UC‐MSCs were reported to be safe in clinical trials in other disease states and have been safely administered across histocompatibility barriers.4446 Because of their immunomodulatory functions, UC‐MSCs have already been tested in the treatment of autoimmune and inflammatory disorders. Clinical applications using UC‐MSCs processed at our cGMP facility have been authorized by the FDA in subjects with T1D (IND#018302) and Alzheimer’s disease (IND#18200).

Several clinical trials have been conducted to test MSCs as treatment of ARDS, mainly focused on determining safety.2529 Variable results have been reported, possibly because of differences in trial design and quality of the cell product used. Improved outcomes were recently reported in patients with COVID‐19 pneumonia treated with angiotensin converting enzyme ‐ 2 (ACE‐2)‐negative MSCs.30 Additional pilot studies of UC‐MSCs for COVID‐19 also reported promising results.3133

Based on previous encouraging results by other groups,3033 our experience with cell therapy clinical protocols, and the urgent need to develop effective therapeutic strategies, the purpose of this RCT was to determine safety and explore efficacy of UC‐MSCs for treatment of subjects with ARDS secondary to COVID‐19 (ClinicalTrials.gov identifier: NCT04355728).

The current report presents, for the first time, the results of a double‐blind, phase 1/2a RCT testing UC‐MSCs in 24 subjects with COVID‐19 and ARDS. There was overall balance in the distribution of baseline characteristics, comorbidities, or concomitant treatments between the groups. No serious adverse events related to UC‐MSC infusion were observed. There was no observed difference in number of subjects experiencing infusion‐associated adverse events. At 28 days after the last infusion, patient survival was 91% in the UC‐MSC group and 42% in the control group (P = .015). Two SAEs were reported in the UC‐MSC group and 16 in the control group, affecting two and eight patients, respectively (P = .04). SAE‐free survival (P = .008) and time to recovery (P = .03) were significantly improved in the UC‐MSC treatment group.

This study was not intended as an efficacy trial, but instead as an early phase study to establish safety. We relied on randomization to protect against imbalance in biasing preliminary estimates of efficacy. Stratified, blocked randomization was employed to evenly represent ARDS severity and changing standard of care over time between groups. Even with blocked randomization, confounding may exist because, with small numbers, there is still potential for imbalance. Table 1 and Table S2 illustrate overall balance in the distribution of demographic and clinical factors thought to be associated with COVID‐19 trajectory. The only differences observed at baseline, in body mass index and obesity, would be expected to worsen COVID‐19 outcomes in the UC‐MSC treatment group.47, 48 The viral load at baseline did not differ significantly between the UC‐MSC treatment and the control group. An important change in inclusion criteria is worthy of discussion. The study was initially designed to enroll patients receiving invasive mechanical ventilation. At the time of study inception, there were concerns regarding the potential for high flow oxygen therapy and noninvasive mechanical ventilation to increase aerosolization and infection risk in health care workers. Such concerns led practitioners to avoid these therapies and prompted infection control leadership to restrict them in our study sites. Subsequent studies called these concerns into question,49 and high flow oxygen became broadly used. At that time, it appeared appropriate to include in our trial patients of similar disease severity but who were being treated with a different modality, and on 22 June 2020, we made a change in our inclusion criteria to reflect this. Subsequent studies have shown that high flow oxygen therapy is associated with a reduction in the proportion of patients who receive invasive mechanical ventilation, but no difference in mortality.12 This supports the idea that the change of inclusion criteria did not necessarily alter the severity of patients enrolled but rather just reflects the secular trends and treatment patterns in the care of patients with a novel disease.

The inferences we make from the efficacy results observed in this phase 1/2a trial in 24 subjects, including the outcome of survival, are still subject to limitations of sample size and potential bias because of factors we were not yet aware of. However, results do provide preliminary evidence of a remarkable effect, which substantiates the need for further investigation in a larger, stratified, and adjusted clinical trial. In addition, based on our results and those from previously reported clinical trials, synergistic combination strategies could be explored, with agents that have shown a beneficial effect at similar stages of COVID‐19 disease progression, such as dexamethasone11 and convalescent plasma.43

The overall “signature” of the response in the UC‐MSC treatment group is characterized by a reduction of the levels of key inflammatory molecules involved in the COVID‐19 “cytokine storm,” including IFNg, IL‐6, and TNFa cytokines and RANTES chemokine.50 In parallel, a reduction in GM‐CSF was observed. GM‐CSF is the main activator of the proinflammatory M1 macrophage phenotype; hence, its reduction could lead to macrophage polarization toward alternatively activated M2 macrophages.51 The levels of PDGF‐BB also resulted significantly reduced in the UC‐MSC treatment group. Notably, PDGF‐BB stimulates mesenchymal cell activation, airway smooth muscle cell proliferation and migration, lung fibroblast cytokine production, and activation of nociceptive neurons.5254 Hence, it is possible that the administration of allogeneic MSCs could accelerate the steps of tissue repair in the lungs, decreasing the need for further mesenchymal cell activation.

The positive response in subjects receiving UC‐MSC treatment seems to be more closely associated to a decrease in inflammatory cytokines, rather than a change in viral load.

The observations made in this study could be of assistance for future studies in the field of COVID‐19, ARDS, hyperinflammatory states, overactive immune responses, and autoimmunity. In addition, the preferential targeting of lung tissue after intravenous infusion could make UC‐MSCs particularly appealing for ARDS secondary to trauma, microbial infection, and pulmonary GvHD.

5 CONCLUSION

The results of this trial indicate that UC‐MSC infusions in COVID‐19 with ARDS are safe. Moreover, UC‐MSC treatment was associated with a significant reduction in SAEs, mortality, and time to recovery, compared with controls.

ACKNOWLEDGMENTS

The authors wish to thank the North America’s Building Trades Unions (NABTU), The Cure Alliance, the Diabetes Research Institute Foundation (DRIF), the Barilla Group and Family, the Fondazione Silvio Tronchetti Provera, the Simkins Family Foundation, and Ugo Colombo for funding this clinical trial; Dr. Amit N Patel for the invaluable contributions to UC‐MSC manufacturing and infusion protocols over the years; Jadi Cell for providing the initial UC‐MSC master cell bank (cells provided at no cost by JadiCell ‐ US Patent # 9,803,176 B2) used in this trial, further expanded at the Diabetes Research Institute (DRI) cGMP Facility to generate the Investigational Product; Drs. George Burke and Ronald Goldberg for serving as Medical Monitor and DSMB Chair; the DRI‐Cell Transplant Center cGMP Staff; Joana R.N. Lemos for the help with data analysis; Melissa Willman for the help in experimental design; and the Clinical Translational Research Site at the Miami Clinical and Translational Science Institute (UL1TR000460) from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. The trial was supported by unrestricted donations from the North America’s Building Trades Unions (NABTU), The Cure Alliance, the Diabetes Research Institute Foundation (DRIF), the Barilla Group and Family, the Fondazione Silvio Tronchetti Provera, the Simkins Family Foundation, and Ugo Colombo. This publication was supported by the Clinical Translational Research Site Grants Number UL1TR000460 and UL1TR002736 from the National Center for Advancing Translational Sciences (NCATS). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The funding sources had no roles in study design, patient recruitment, data collection, data analysis, data interpretation, or writing the report. None of the authors has been paid to write this article by a pharmaceutical company or other agency. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit this manuscript for publication.

CONFLICT OF INTEREST

The authors declared no potential conflicts of interest.

AUTHOR CONTRIBUTIONS

G.L.: conception/design, collection and/or assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript; E.L.: conception/design, manuscript writing, final approval of manuscript, other (UC‐MSC manufacture); D.C.: collection and/or assembly of data, manuscript writing, final approval of manuscript; S.M.C.: conception/design, data analysis and interpretation, manuscript writing, final approval of manuscript; R.A.A.: conception/design, manuscript writing, final approval of manuscript, other (implementation of the study); D.K.: collection and/or assembly of data, manuscript writing, final approval of manuscript; A.A.G.: collection and/or assembly of data, manuscript writing, final approval of manuscript, other (implementation of the study), other (clinical monitoring); R.P.: collection and/or assembly of data, manuscript writing, final approval of manuscript, other (implementation of the study), other (clinical monitoring); P.R.: conception/design, collection and/or assembly of data, manuscript writing, final approval of manuscript; A.C.M.: manuscript writing, final approval of manuscript, other (implementation of the study); K.H.: manuscript writing, final approval of manuscript, other (protocol preparation), other (regulatory compliance and coordination); C.A.B.: collection and/or assembly of data, manuscript writing, final approval of manuscript, other (implementation of the study); H.K.: collection and/or assembly of data, manuscript writing, final approval of manuscript, other (implementation of the study); L. Rafkin: manuscript writing, final approval of manuscript, other (protocol preparation), other (regulatory compliance and coordination); D.B.: conception/design, manuscript writing, final approval of manuscript, other (clinical monitoring); A.P. and K.G.: manuscript writing, final approval of manuscript, other (implementation of the study); C.L. and X.W.: manuscript writing, final approval of manuscript, other (UC‐MSC manufacture); A.M.A.M. and S.W.M.: data analysis and interpretation, manuscript writing, final approval of manuscript; L. Roque: manuscript writing, final approval of manuscript, other (protocol preparation), other (regulatory compliance and coordination); B.M.: manuscript writing, final approval of manuscript, other (regulatory compliance and coordination); N.S.K., E.G., X.X., J.T., A.I.C., and M.K.G.: conception/design, manuscript writing, final approval of manuscript; R.A.: conception/design, manuscript writing, final approval of manuscript, other (clinical monitoring); C.R.: conception/design, manuscript writing, final approval of manuscript, other (principal investigator), other (clinical monitoring).

Open Research

Supporting Information
REFERENCES

#10…”Chronic Viral Infections”

New post on The Stem Cellar

A look back: CIRM funded trial aims to help patients suffering from chronic viral infections

by Yimy Villa

Dr. Michael Pulsipher

All this month we are using our blog and social media to highlight a new chapter in CIRM’s life, thanks to the voters approving Proposition 14. We are looking back at what we have done since we were created in 2004, and also looking forward to the future. Today we look at a way of making blood stem cell transplants safer and more readily available

Blood stem cell transplants have provided lifechanging treatments to individuals.  This statement is observed firsthand in several patients in CIRM funded trials for X-linked Chronic Granulomatous Disease (X-CGD), Sickle Cell Disease (SCD), and Severe Combined Immunodeficiency (SCID).  The personal journeys of Evangelina Padilla-Vaccaro, Evie Junior, and Brenden Whittaker speak volumes for the potential this treatment holds.  In these trials, defective blood stem cells from the patient are corrected outside the body and then returned to the patient in a transplant procedure.

Unfortunately, there is still a certain degree of risk that accompanies this procedure.  Before a blood stem cell transplant can be performed,  diseased or defective blood stem cells in the patient’s bone marrow need to be removed using chemotherapy or radiation to make room for the transplant.  This leaves the patient temporarily without an immune system and at risk for a life-threatening viral infection.  Additionally, viral infections pose a serious risk to patients with immune deficiency disorders, with viruses accounting upwards of 40% of deaths in these patients.

That’s why in October 2017, the CIRM ICOC Board awarded $4.8M to fund a clinical trial conducted by Dr. Michael Pulsipher at the Children’s Hospital of Los Angeles.  Dr. Pulsipher and his team are using virus-specific T cells (VSTs), a special type of cell that plays an important role in the immune response, to treat immunosuppressed or immune deficient patients battling life-threatening viral infections.  This trial includes patients with persistent viral infections after having received a blood stem cell transplant as well as those with immune deficiency disorders that have not yet received a blood stem cell transplant.  The VSTs used in this trial specifically treat cytomegalovirus (CMV), Epstein-Barr virus (EBV), and adenovirus infections.  They are manufactured using cells from healthy donors and are banked so as to be readily available when needed.

One challenge of receiving a stem cell transplant can be finding a patient and donor that are a close or identical match.  This is done by looking at specific human leukocyte antigens (HLA), which are protein molecules we inherit from our parents.  To give you an idea of how challenging this can be, you only have a 25% chance of being an HLA identical match with your sibling.

Because VSTs are temporary soldiers that are administered to fight the viral infection and then disappear, Dr. Pulsipher and his team are using partially HLA-matched VSTs to treat patients in their trial.  Previous studies have indicated that partially HLA-matched T-cells can be effective in treating patients.  The availability of partially HLA-matched VST banks that can be used “off the shelf” improves accessibility and shortens the time for patients to receive VST therapy, which will save lives.

To learn more about Dr. Pulsipher’s work, please view the video below:

#12….Sickle Cell Disease

New post on The Stem Cellar

Progress in the fight against Sickle Cell Disease

by Kevin McCormack

Last November Marissa Cors, a patient advocate in the fight against Sickle Cell Disease (SCD), told the Stem Cellar “A stem cell cure will end generations of guilt, suffering, pain and early death. It will give SCD families relief from the financial, emotional and spiritual burden of caring someone living with SCD. It will give all of us an opportunity to have a normal life. Go to school, go to work, live with confidence.” With each passing month it seems we are getting closer to that day.

CIRM is funding four clinical trials targeting SCD and another project we are supporting has just been given the green light by the Food and Drug Administration to start a clinical trial. Clearly progress is being made.

Yesterday we got a chance to see that progress. We held a Zoom event featuring Marissa Cors and other key figures in the fight against SCD, CIRM Science Officer Dr. Ingrid Caras and Evie Junior. Evie is a pioneer in this struggle, having lived with sickle cell all his life but now hoping to live his life free of the disease. He is five months past a treatment that holds out the hope of eradicating the distorted blood cells that cause such devastation to people with the disease.

You can listen to his story, and hear about the other progress being made. Here’s a recording of the Zoom event.

#11….”Proposition 14″

New post on The Stem Cellar

Month of CIRM – Our Therapeutics Team Goes Hunting

by Kevin McCormack

All this month we are using our blog and social media to highlight a new chapter in CIRM’s life, thanks to the voters approving Proposition 14. We are looking back at what we have done since we were created in 2004, and also looking forward to the future. Today we have a guest blog by CIRM Senior Science Officer Lisa Kadyk, outlining how she and her colleagues actively search for the best science to fund.

Lisa Kadyk, Ph.D.

Hi everyone,

This is Lisa Kadyk, a Science Officer from the CIRM Therapeutics team, here to tell you about some of the work our team does to support the CIRM mission of accelerating stem cell treatments to patients with unmet medical needs.  Our job involves seeking out and recruiting great scientists to apply to CIRM and supporting those we fund.

Therapeutics team members manage both the awards that fund the final preclinical studies required before testing a therapeutic in a clinical trial (CLIN1), and the awards that fund the clinical trials themselves (CLIN2).

I mentioned above that we actively recruit new applicants for our CLIN1 and CLIN2 awards – which is not an activity that is typical of most funding agencies – so why and how do we do this?

It all comes down to our mission of accelerating the development of therapies to help patients with unmet medical needs.  It turns out that there are many potential applicants developing cutting edge therapies who don’t know much or anything about CIRM, and the ways we can help them with getting those therapies to the clinic and through clinical trials.    So, to bridge this gap, we Science Officers attend scientific conferences, read the scientific literature and meet regularly with each other to stay abreast of new therapeutic approaches being developed in both academia and industry, with the goal of identifying and reaching out to potential applicants about what CIRM has to offer.

What are some of the things we tell potential applicants about how partnering with CIRM can help accelerate their programs?   First of all, due to the efforts of a very efficient Review team, CIRM is probably the fastest in the business for the time between application and potential funding.  It can be as short as three months for a CLIN1 or CLIN2 application to be reviewed by the external Grants Working Group and approved by the CIRM Board, whereas the NIH (for example) estimates it takes seven to ten months to fund an application.   Second, we have frequent application deadlines (monthly for CLIN1 and CLIN2), so we are always available when the applicant is ready to apply.  Third, we have other accelerating mechanisms in place to help grantees once they’ve received funding, such as the CIRM Alpha Stem Cell Clinics network of six clinical sites throughout California (more efficient clinical trial processes and patient recruitment) and Clinical Advisory Panels (CAPs) – that provide technical, clinical or regulatory expertise as well as patient advocate guidance to the grantee.  Finally, we Science Officers do our best to help every step of the way, from application through grant closeout.

We now feel confident that our recruitment efforts, combined with CIRM’s more efficient funding pipeline and review processes, are accelerating development of new therapies.  Back in 2016, a new CIRM Strategic Plan included the goal of recruiting 50 successful (i.e., funded) clinical trial applicants within five years.  This goal seemed like quite a stretch, since CIRM had funded fewer than 20 clinical trials in the previous ten years.  Fast-forward to the end of 2020, and CIRM had funded 51 new trials in those five years, for a grand total of 68 trials.

Now, with the passage of Proposition 14 this past November, we are looking forward to bringing more cell and gene therapeutic candidates into clinical trials.   If you are developing one yourself, feel free to let us know… or don’t be surprised if you hear from us!