Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm.This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction.This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session.P = 0.009), engagingness , and ease of use . Knowledge did not differ between the two groups .The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students’ motivation to learn.The online version contains supplementary material available at 10.1186/s12909-022-03761-5 Simulation methods are increasingly used in clinical teaching to immerse students in the delivery room before they encounter real-life situations . Among tPostpartum hemorrhage (PPH) is a frequent obstetric event, occurring in 5 to 10% of deliveries , 8; whenWe thus wondered whether a virtual simulation could be a useful pedagogical tool to help student midwives in their initial professional training to learn how to manage PPH.The aim of this study was to assess student satisfaction with virtual simulation compared to usual supervised work in learning PPH management. Our secondary objective was to compare the students’ knowledge needed to manage PPH and degree of certainty using clinical vignettes after each intervention.We conducted a two-center, two-stage, crossover, randomized controlled trial. Student midwives were randomized into 2 groups. One group underwent the virtual simulation intervention in the first period (January 2019) and the usual supervised classroom work in the second (May 2019) while the other group underwent the usual supervised classroom work in the first period and the virtual simulation intervention in the second. We followed the CONSORT statement about randomized controlled trials in reporting this trial.In Fig. The participants included in the study were student midwives in the 4th year of maieutic sciences from the Midwifery department at Versailles-Saint-Quentin University and the Midwives School in Strasbourg. The additional inclusion criterion was having received theoretical instruction in the form of courses; the exclusion criteria were prior exposure to this virtual simulation intervention or repeating the 4th year of study.In France, midwives have 5 years of specific medical education, certified by a state diploma considered equivalent to a Master’s degree. They diagnose, provide initial management of PPH, and prescribe some medications at the same time as they call the obstetrician, with whom they work closely.The Perinatsims virtual simulation (Medusims SAS) offers uThe virtual simulation session was organized for 90 min in groups of 4–5 student midwives on a virtual simulator, playing out the same 2 scenarios of an immediate PPH for each group. With the first scenario, the students learned to handle the tool, and each group managed the second scenario autonomously. This session was followed by a debriefing focused on the elements of decision-making at the beginning of the PPH management  and organization of care. The same midwife instructor conducted these games in each center .The cost of the license for this virtual simulation is $1800 for classroom use.The same midwife in each center  supervised the standard classroom work, which also took 90 min and included half the usual full group of students (n = 15 or 16 rather than 30–32). In this specific session, based on a clinical situation, students were invited to discuss the case as part of analyzing the guidelines. Part of the discussion focused on the elements of decision-making at the beginning of the PPH management  and organization of care. The classroom work did not contain hands-on components.The primary outcome was satisfaction. Satisfaction was measured by two self-administered questionnaires after each training stage (T2 and T4) with three items corresponding to: (1) global satisfaction, by a Likert scale (between 0 and 10); (2) its engagingness and appeal, and (3) its affordability and ease of use. These last two items were evaluated with multiple-choice questions with adjectives: very good, good, adequate, inadequate, with corresponding emojis. The 10-point Likert scale was chosen to offer a higher degree of measurement precision and provide a better opportunity to detect changes and more power to explain a point of view .The secondary outcome was knowledge and degree of certainty of the PPH management algorithm, evaluated during the four assessment sessions by responses to a clinical case vignette, that is, a short, pragmatic clinical case that allows participants to immerse themselves in a situation as real as possible and be questioned about the management they would perform. This method has been previously validated and used to evaluate clinical practices in the context of PPH , 22. VigThe binary secondary outcome was evaluated by a composite outcome including 4 items expected in response to the clinical vignette: alert other members of the team, administer oxytocin, manually deliver the placenta and/or examine the uterine cavity, and massage the uterus. These 4 items were selected by expert consensus in a preliminary study  and corrThese assessments took place before the beginning and after the end of each training stage. There were therefore 4 assessment sessions: T1 before the first training session, T2 after it, T3 before the second training session and T4 after it. Each test used a slightly different clinical PPH vignette but expected the same responses each time. To reduce the risk of contamination we administered out the test immediately after the training session and asked the participants not to communicate among themselves about the training sessions.Degree of certainty was measured four times, at each assessment, by a multiple-choice question after the vignette: “how sure are you?“ with the following choices: <50%, 50–70%, 70–90%, > 90%.We expected to see a 65% correct response rate to the supervised work (rate of appropriate oxytocin administration in the midwives’ survey ), and weRandomization took place after verification of the inclusion criteria and after participants had provided written informed consent. We used R software to draw up a randomization list by student class at each school. The distribution within the virtual simulation groups was random.The National Data Protection Authority  approved this study on January 21, 2017 (CNIL number DN 17 − 01).All study participants gave their written consent to take part. They were informed that they could withdraw their consent and/or their participation at any time.Categorical variables were described with numbers and percentages, and continuous variables by their means, standard deviations, and medians.The two interventions (VS and SW) were compared for the main and secondary outcomes by pooling the evaluations conducted at T2 and T4. For dichotomous variables, chi-2 and Fisher exact tests were used as appropriate to assess differences in outcomes between groups. Student’s t and nonparametric tests were used to compare continuous outcomes between the two groups.P < 0.05 was defined as statistically significant. Statistical analysis was conducted with R 3.6.2.All statistical tests were two sided, and The virtual simulation-supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47. Table  Four stuP = 0.009). These means explain why the score was dichotomized at 6.The primary outcome of satisfaction was significantly higher for the virtual simulation training Table , in partP = 0.3). The details of the results compared by test and according to the pedagogical tool are available in the appendix (supplementary file 4).At the end of the training (T2 + T4), the secondary outcome, composite knowledge, did not differ between the pooled virtual simulation group  and the pooled usual supervised work group , as shown in Fig. Similarly, degree of certainty did not differ significantly between these two modes of instruction, with T2 + T4 pooled (P = 0.009), engaging  and easy to use . Furthermore, knowledge of the algorithm for PPH management did not differ shortly after instruction by a virtual simulation or by the usual supervised work (P = 0.3).Students found the virtual simulation significantly more satisfying overall  used feedback and debriefing, helping to link the theoretical knowledge to its practical applications. Boeker et al. showed tWe observed a decrease in degree of certainty at time T3 (4 months after the first session). In their study of cardiac arrest, which included an assessment at 4 months, Drummond et al.  also sugIt has been shown that a “motivational dynamic model” increases engagement in training . MotivatOur study had several strengths. First, it was randomized. Next, in accordance with the definition by Djaouti et al. , the virNonetheless, it also had some limitations. In particular, it would have been interesting to have had a third control group without any intervention to measure the changes between T2 and T3 in both groups. During this period, the students were in internships and might have had to deal with PPH situations or reviewed some earlier instruction after the intervention, which would have affected their knowledge on the subject. We did not have the necessary power to take into account this bias related to the internships and experiences between T2 and T3 because of the number of students. Nevertheless, the results presented in the Appendix show poorer results at T3 than at T2 and T1, thus demonstrating that this bias has a moderate impact and reinforcing the importance of learning by repetition. In addition, we used clinical vignettes to show differences in knowledge. Perhaps a simulation or some other actual practice-oriented testing method might have detected smaller differences. Lastly, students performed the virtual simulation in a small group, whereas the evaluation of the primary outcome was individual. We cannot know if individual sessions would have led to better learning with more knowledge, decision-making ability, and recall. Nevertheless, the collective competition was as present in the virtual simulation group as in the supervised work group.Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. Future studies should evaluate repeat use as self-stimulation alone or in teams to continue lifelong learning. Our results indicate that further studies should focus on analyzing the cost effectiveness of virtual reality teaching compared with traditional teaching.The virtual simulation is probably useful for learning how to manage postpartum hemorrhage because of its greater student satisfaction.The virtual simulation did not produce knowledge of postpartum hemorrhage management better than that obtained with the usual supervised work.Students’ degree of certainty increases over the course of learning but decreases between 2 learning sessions.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4


We report on the comparative analysis of self-calibrating and single-slope diffuse reflectance spectroscopy in resistance to different measurement perturbations. We developed an experimental setup for diffuse reflectance spectroscopy (DRS) in a wide VIS-NIR range with a fiber-optic probe equipped with two source and two detection fibers capable of providing measurements employing both single- and dual-slope  approaches. In order to fit the dynamic range of a spectrometer in the wavelength range of 460–1030 nm, different exposure times have been applied for short (2 mm) and long (4 mm) source-detector distances. The stability of the self-calibrating and traditional single-slope approaches to instrumental perturbations were compared in phantom and in vivo studies on human palm, including attenuations in individual channels, fiber curving, and introducing optical inhomogeneities in the probe–tissue interface. The self-calibrating approach demonstrated high resistance to instrumental perturbations introduced in the source and detection channels, while the single-slope approach showed resistance only to perturbations introduced into the source channels. Diffuse reflectance spectroscopy (DRS) is an optical technique that allows the evaluation of tissue biochemistry and microstructure for a number of applications including brain hemodynamics  also calThe DRS probing spectral range is selected depending on the absorption spectra of the studied chromophores and the desired probing volume in tissue. For example, the concentrations of oxy- and deoxyhemoglobin in superficial tissues can be reconstructed using the visible  spectral range, while for deeper probing it is reasonable to use the range of 700–900 nm due to higher light penetration depth. The NIR range is also used to assess water and lipid content , while tIf tissue optical properties vary with depth, DRS in the VIS-NIR range can be applied to assess chromophore concentrations in different tissue layers using differences in sensitivity depths of the VIS and NIR spectrum regions. This approach was successfully applied to assess skin hemoglobin concentrations in the dermis and lower dermis .The results of the reconstruction of tissue chromophores in DRS have the following keys to success: (1) the applied light transport model should be realistic enough to correctly describe light attenuation from source to detector; (2) the reconstruction procedure should have a good convergence; (3) instrumental characteristics, such as source spectral brightness, detector spectral sensitivity, transient characteristics of source and detector fiber channels, and optical contact between the DRS probe and tissue should be taken into account. In the present study we concentrate mainly on the last issue because incorrect consideration of the instrumental characteristics can lead to significant errors in the reconstructed values even with an appropriate light transport model and a valid reconstruction technique. This aspect is especially essential in broadband measurements, in particular VIS-NIR, due to possible light dispersion in the instrumental part and strong differences in light attenuation in tissue in different spectral ranges, and, therefore, a need for adjusted compensation. Different strategies are applied in DRS to correctly account for the instrumental characteristics depending on the measured data type. For example, investigation of hemodynamics based on the measurement of relative changes in hemoglobin concentrations in time can be implemented using a simple single source-detector distance (SDD) approach with a single source-detector pair. The resulting equation for relative changes in hemoglobin concentrations in time allows for the exclusion of instrumental characteristics . Absoluteffµ in tissue by taking a ratio between the detected signals obtained at different SDDs. In this ratiometric approach, also called single-slope measurement, most of the instrumental characteristics are excluded in the final equation for effµ, which yields a more accurate assessment of tissue chromophore content in comparison with the single-distance approach  mm−1, f varies in the range of , volume fractions bloodC and waterC vary within , and a and b are determined according to the reported data on the range of the skin reduced scattering coefficient at a, b, and f; therefore, During the optimization procedure the following limitations were set on the extracted variables: x values ,43. SincS1 or S2 source fiber of the probe to illuminate biological tissue. Diffusively scattered light is detected by detection fibers D1 and D2, one of which is selected by a 1 × 4 switch 2  to deliver light to spectrometer Maya 2000 PRO . Switch 2 uses only two outputs for the applied optical probe which has only two detection fibers. Both switches are driven by the control unit. The Maya spectrometer has rather high sensitivity in NIR up to 1100 nm which covers water and lipid absorption bands near 980 nm and has high linearity due to the applied calibration which is essential for the application of a self-calibrating approach. The spectrometer exposure times are set individually for small and large SDDs to fit the spectrometer dynamic range. In the current in vivo and phantom studies, the exposure times were set equal to I11, I12, I21, and I22 are stored at PC for further analysis described below in An experimental DRS setup with a self-calibrating fiber-optic probe was constructed in accordance with the scheme shown in 2 area of the probe–tissue interface. Two 400 µm source fibers and two 200 µm detection fibers with 0.22 NA  were placed in line inside the probe housing at a 2 mm distance between neighboring fibers, which results in short and long SDDs of Sr = 2 mm and Lr = 4 mm, respectively.Domestically designed probe housing is made of black photopolymer resin Anycubic Basic  by 3D printing on a Phrozen Shuffle 2019  printer and has 6 × 8 mmThe fiber-optic probe is equipped with a mechanical pressure control unit. The pressure was set equal to 12.7 kPa in all studies.The DRS system is fully automated by a JAVA code operated with a source shutter, spectrometer, and fiber switches with the help of a control unit. Full acquisition time was about 6 s for the abovementioned exposure times and a heartbeat period of 1 s.The developed experimental setup was tested on a silicone-based biotissue phantom employed as a reference standard for DRS measurements in  and on aInstalling additional fibers . The measurement results are shown in The colored stickers naturally feature transmission bands corresponding to their visible colors. Note a significant difference in the transmittance coefficient for perturbations S1L and D1L consisting in the insertion of an additional fiber to the source or the detection channel, respectively, that originates from the different mismatch between the diameters of the original fibers and the inserted fiber. For each perturbation, DRS measurements were repeated 3 times; before each measurement the position of a probe was slightly changed by removing and then replacing the probe. Unperturbed measurements were repeated 6 times: 3 times before applying perturbations and 3 times after.The perturbations applied to source S2 and detector D2 are not listed in i-th wavelength, P is the perturbation index listed in m is the measurement number with the particular perturbation P, an average value over Various instrumental perturbations listed in Variations of reconstructed tissue chromophore concentrations and scattering properties obtained for in vivo measurements were calculated in the same way.Several DRS phantom measurements have been performed with and without the instrumental perturbations indicated in P results in an increase in rom μeff c,e. It ccker see  employedite ways c or posiite ways e shift iurbation . The fib to 100% . The incIn vivo DRS measurements demonstrate almost similar results to the phantom studies . High reIn contrast to the results of phantom studies, the extinction coefficient in in vivo studies calculated for unperturbed (INIT) measurements f demonst−1 for the self-calibration approach, and 0.007 and 0.011 mm−1 for the single-slope technique in two configurations, respectively. For all types of perturbations, the deviation of the extinction coefficient calculated by the self-calibration approach does not exceed 0.013 mm−1, while deviations in this value calculated using the single-slope approach exceed 0.6 mm−1 for the loss perturbations in detection channels. It also can be seen from this plot that the deviations in the extinction coefficient caused by perturbations in the source channel are smaller than those applied to the detection channel. For unperturbed measurements, deviations in the extinction coefficient are 0.003 mmExamples of fitting the extinction spectra of the in vivo human palm calculated using the self-calibrating and single-slope approaches for unperturbed DRS data with expressions given by Equations (1), (2), and (10) using Equations (11)–(13) are shown in b, and f of human palm reconstructed from fitting the experimental extinction spectra which were obtained using different measurement approaches  from DRS data measured under different instrumental perturbations listed in a, b, and f yield the orted in : the shoAs follows from the analysis of extinction coefficient deviations, skin optical parameters reconstructed from S1S2D1D2 extinction spectra demonstrate high stability for all DRS data obtained under all possible perturbations in which the deviation does not exceed 16%. In contrast, the parameters reconstructed from the single-slope data S1D1D2 and S2D1D2 demonstrate stability only for source perturbations and unperturbed data. These results are summarized in In this study we compared the capabilities of single- and dual-slope approaches in DRS to resist different perturbations that may occur during measurements. An experimental setup for wide-band DRS with a fiber-optic contact probe capable of employing a self-calibrating approach was constructed. This system contains a broadband fiber-optic source allowing for diffuse reflectance measurements in a wide VIS-NIR band (460–1030 nm). The upper wavelength range boundary is limited by the detector sensitivity curve, while detection in the short wavelength range is limited by strong probing light attenuation in biotissue. The self-calibrating scheme is based on symmetrical source-detector measurements performed through two fiber-optic switches for two source and two detection fibers of the probe . In ordeDifferent instrumental perturbations have been introduced into source and detector channels including attenuation, fiber bending, and corrupting probe–tissue interface in order to compare resistance to them of self-calibrating and single-slope approaches in phantom and in vivo studies. Both approaches have been applied to analyze the corresponding extinction spectrum deviations originating from the applied perturbation during DRS measurements. The results of phantom and in vivo studies have shown  that botReconstruction of the biotissue properties from the obtained extinction coefficient spectra demonstrated that the self-calibrating approach provides reliable values with average deviations not exceeding 16% for all the considered perturbations. In this connection, if the spectral changes induced by instrumental perturbations in clinical conditions are similar to those we employed in this study, one can expect approximately the same accuracy of the self-calibrating technique. However, it should be noted that the DRS measurements in subcutaneous tissues are sensitive to the applied pressure of a DRS probe. Excessive pressure of a DRS probe may result in a significant change in tissue optical properties, while a loose probe–tissue contact may lead to a slight probe shift during the measurement procedure. Both effects may result in errors in the reconstructed physiological parameters. To avoid these effects, in the designed system, the DRS probe was equipped with a pressure control unit allowing it to keep the optimal pressure during measurements.effµ spectrum has noticeable discrepancy with the experimental extinction spectrum obtained from the unperturbed measurements  approaches in DRS was performed using a custom-built wideband 460–1030 nm DRS setup in phantom and in vivo studies. Different instrumental perturbations have been introduced into source and detector channels in order to compare the stability of self-calibrating and single-slope approaches toward uncontrolled attenuations in individual channels, optical fiber bending, and optical inhomogeneities at the probe–tissue interface. Both single-slope and self-calibrating approaches have demonstrated high stability to perturbations introduced into the source channels. Perturbation in the detection channels may lead to significant deviations in the extinction spectra recovered from the measured back-reflectance spectra by the single-slope approach, however, the self-calibrating approach has demonstrated high stability for all types of perturbations. Reconstruction of the biotissue properties from the obtained extinction coefficient spectra demonstrated that the self-calibrating approach provides reliable values with average deviations not exceeding 16% for all the considered perturbations. Thus, we can conclude that the self-calibrating approach can be applied to DRS to provide robust measurements insensitive to instrumental perturbations in a wide VIS-NIR spectral band.


Mesenchymal stromal cells (MSCs) may be of benefit in ARDS due to immunomodulatory and reparative properties. This trial investigates a novel CD362 enriched umbilical cord derived MSC product (REALIST ORBCEL-C), produced to Good Manufacturing Practice standards, in patients with moderate to severe ARDS due to COVID-19 and ARDS due to other causes.6 cells, 200 × 106 cells or 400 × 106 cells) in a 3 + 3 design. Phase 2 is a multicentre randomised, triple blind, allocation concealed placebo-controlled trial. Two cohorts of patients, with ARDS due to COVID-19 or ARDS due to other causes, will be recruited and randomised 1:1 to receive either a single infusion of REALIST ORBCEL-C  or placebo. Planned recruitment to each cohort is 60 patients. The primary safety outcome is the incidence of serious adverse events. The primary efficacy outcome is oxygenation index at day 7. The trial will be reported according to the Consolidated Standards for Reporting Trials (CONSORT 2010) statement.Phase 1 is a multicentre open-label dose-escalation pilot trial. Patients will receive a single infusion of REALIST ORBCEL-C (100 × 10The development and manufacture of an advanced therapy medicinal product to Good Manufacturing Practice standards within NHS infrastructure are discussed, including challenges encountered during the early stages of trial set up. The rationale to include a separate cohort of patients with ARDS due to COVID-19 in phase 2 of the trial is outlined.ClinicalTrials.gov NCT03042143. Registered on 3 February 2017. EudraCT Number 2017-000584-33The online version contains supplementary material available at 10.1186/s13063-022-06220-0. The order of the items has been modified to group similar items (see Acute respiratory distress syndrome (ARDS) is characterised by acute hypoxaemia and bilateral radiographic opacities . Its morMesenchymal stromal cells  are an advanced therapy medicinal product (ATMP) proposed as a therapeutic agent in ARDS due to their immunomodulatory, reparative and antimicrobial properties . They arclinicaltrials.gov during the COVID-19 pandemic (accessed April 2021). Case series and observational studies have not identified any safety concerns [p = 0.08) from baseline to day 28 [6) or placebo control to patients with COVID-19 ARDS . UC-MSCs were found to be safe, with no infusion-associated adverse events or serious adverse events related to MSC infusions [6 MSCs/kg) or placebo control to critically ill patients with COVID-19  [p = 0.048) [There has been considerable interest in the use of MSCs for the treatment of COVID-19, with over 60 trials registered on concerns –32. Shi concerns  have repo day 28 . Improveo day 28 . Lanzoninfusions . Dilogo h group) . In this= 0.048) .As a cellular product, MSC therapeutics derived from different sources and from different manufacturing techniques are considered unique and each requires robust evaluation in clinical trials. REALIST ORBCEL-C, the investigational medicinal product (IMP) in the REALIST trial, consists of human umbilical cord (UC)-derived CD362 enriched MSCs. Umbilical cord tissue (Wharton’s Jelly) provides a cost-efficient source of MSCs, utilising a tissue source that would otherwise be disposed of as a waste product and avoiding the potential risk of bone marrow harvesting. Anti-CD362 antibody enrichment of MSCs describes a technique of isolating MSCs, which enhances the homogeneity of the cellular product and is likely to fulfil future regulations regarding the production of ATMPs. In preclinical models, CD362-enriched MSCs are as effective as traditionally manufactured MSCs in attenuating lung injury .Trials [The REALIST trial will conduct a phase 1 and phase 2 clinical trial of human umbilical cord-derived CD362-enriched MSCs (REALIST ORBCEL-C) in patients with moderate to severe ARDS, as defined by the Berlin criteria . A strucTrials .The primary objective of the study is to assess the safety of a single intravenous infusion of REALIST ORBCEL-C cells in patients with moderate to severe ARDS.Physiological indices of respiratory dysfunction reflecting severity of ARDS, as measured by oxygenation index (OI), respiratory system compliance, and P/F ratio.Sequential Organ Failure Assessment (SOFA) score.Extubation and reintubation.Ventilator-free days (VFDs) at day 28.Duration of mechanical ventilation.Length of ICU and hospital stay.Twenty-eight-day and 90-day mortality.The secondary objectives of the study are to determine, in patients with moderate to severe ARDS, the effect of a single intravenous infusion of REALIST ORBCEL-C cells on:6 cells, 200 × 106 cells and 400 × 106 cells. Patients will be assessed for dose-limiting toxicity, defined by any serious adverse event related to study drug administration, at day 7. If none of the three patients in the cohort experiences dose-limiting toxicity, then we will proceed to the next cohort. However, if one of the patients in the cohort shows dose-limiting toxicity, a further three subjects will be treated at the same dose level. The dose escalation will continue until at least two patients among a cohort of three to six patients have dose-limiting toxicity or until 400 × 106 cell dose in three patients is achieved. If dose-limiting toxicity occurs, then the lower dose  will be used in the phase 2 trial.Phase 1 is a multicentre open-label dose-escalation pilot trial in which cohorts of patients with moderate to severe ARDS will receive increasing doses of a single infusion of REALIST ORBCEL-C in a 3 + 3 design . Three c6 cells or maximum tolerated dose as determined by phase 1) or placebo  and according to the required legal framework  Regulations, 2004). Patients are likely to be incapacitated due to the nature of the condition; therefore, informed consent will be sought from a patient representative, either a Personal Legal Representative (PerLR) who is usually the patient’s next of kin, or a Professional Legal Representative (ProLR), a doctor who is not connected with the conduct of the trial. If the PerLR is not available at the clinical site due to COVID-19 restrictions, a member of the research team may contact the PerLR by telephone and seek verbal agreement to participate in the trial. Verbal agreement is recorded on a telephone agreement form and must be signed by a second member of staff who has witnessed the telephone advice. Once patients regain capacity, consent to continue will be sought. Where it is not possible to get consent to continue face to face, patients will be telephoned to ask for consent to continue. Patients may withdraw or be withdrawn (by PerLR or ProLR) from the trial at any time without prejudice.Consent for collection, use and storage of participant data and biological specimens will be sought. Consent will be sought for biological samples to be stored indefinitely for use in this trial and for future use should new scientific research or techniques become available. This includes sharing of samples with external non-NHS organisations to undertake planned and future analysis, including genetic analysis, transfer abroad and commercial research. All samples will be anonymised.The comparator, Plasma-Lyte 148, has been chosen as the placebo as it is the diluent used in the cellular product.The Investigational Medicinal Products (IMP) are:6, 200 × 106 or 400 × 106 cells in 10, 20 or 40 ml volumes respectively. The cellular product is thawed and diluted with Plasma-Lyte 148 to a total volume of 200mls for intravenous administration.Allogeneic donor anti-CD362 antibody enriched human UC-derived mesenchymal stromal cells (REALIST ORBCEL-C) supplied as a sterile, single-use cryopreserved cell suspension containing a fixed cell dose of either 100 × 10Plasma-Lyte 148 solution for infusion with an equivalent volume of 200 ml (Placebo).6, 200 × 106 or 400 × 106 cells have been chosen which equates to a range of approximately 1.4, 2.8 and 5.7 × 106 cells/kg for a predicted body weight (PBW) of 70 kg. The phase 1 trial will determine the maximum tolerated dose which will be used in the phase 2 trial.The doses chosen to assess the safety of REALIST ORBCEL-C are based on pre-clinical data and are comparable to doses used in previous human clinical trials of MSCs . To simp6 cells per ml. Cryopreserved drug product is stored at fixed cell doses of either 100 × 106, 200 × 106 or 400 × 106 cells in 10, 20 or 40 ml volumes respectively. Final drug product release testing includes appearance, morphology, sterility testing, endotoxin testing, post thaw cell count, cell viability testing (minimum threshold > 70% post thaw) and flow cytometry to confirm cell phenotype fulfils criteria of MSCs described by the international society for cellular therapy (ISCT)  and cell purity exceeding 95% ) [The cellular product (REALIST ORBCEL-C) is harvested from umbilical cord tissue (UCT) of unrelated and human leukocyte antigen (HLA) unmatched healthy donors and manufactured to Good Manufacturing Practice (GMP) standards under an MHRA MIA (IMP) authorisation by the Cellular and Molecular Therapies Division of the National Health Service Blood and Transplant (NHSBT). Donated UCT is procured by NHSBT as the starting material under licence by the Human Tissue Authority in accordance with the Human Tissues and Cells Directive 2004/23/EC. All UCT donations are made with informed consent and the donor is tested for a range of markers of infection in accordance with guidance from the Advisory Committee on the Safety of Blood, Tissues and Organs . Cells iHLA-DR)) . Cells aOn receipt of the trial prescription, the IMP (REALIST ORBCEL-C or placebo) will be prepared by the CTF. The IMP will be transported to the ICU at the clinical site for administration. To maintain blinding, care will be taken to ensure the placebo is not released earlier than the typical time needed for preparation of the cell therapy product from the frozen cellular drug substance. All patients will be administered chlorphenamine 10 mg by peripheral intravenous bolus prior to administration of the IMP. A single dose of the IMP will be administered intravenously, via a dedicated infusion line, over approximately 30 to 90 min. Patients will be monitored throughout the infusion and for 5 h following completion of the infusion by a member of the research team. The IMP will be administered through a standard blood component administration set, with a 200 micron in-line filter. The IMP will have a 6-h expiry date from the beginning of its preparation, which for the cellular product will be the beginning of the thaw process. Validation work has confirmed that a cell viability > 70% is maintained for at least 6 h following the thaw procedure. Both REALIST-ORBCEL C and Plasma-Lyte 148 placebo will be labelled with equivalent 6-h expiry dates to avoid risk of unblinding. The IMP infusion must be completed prior to this expiry.Suspected IMP related adverse eventIMP expiryDeath or discontinuation of active treatmentRequest from PerLR or ProLR to withdraw patient from the trialDecision by the treating physician on safety groundsThe IMP infusion may be terminated if one of the following occurs:Patients will be continuously monitored throughout the IMP infusion. A study drug administration guideline will provide detailed information on drug administration and guidelines will be provided for management during study drug infusion. Data will be recorded regarding the date/time of commencing and completion of the infusion. If the IMP infusion is discontinued, the reason will be recorded.Post-trial care will be according to standard critical care guidelines and at the discretion of the treating physician.Other aspects of care will be according to standard critical care guidelines and at the discretion of the treating physician. Lung protective ventilation will be the standard of care with a tidal volume of 6 ml/kg PBW .2O) x FiO2 × 100)/PaO2(kPa).The primary safety outcome is the incidence of serious adverse events (SAEs). The primary efficacy outcome is oxygenation index (OI) at day 7. OI is a physiological index of the severity of ARDS and measures both impaired oxygenation and the amount of mechanical support delivered. OI is independently predictive of mortality in patients with ARDS . Day 7 hSecondary clinical outcomes will also be assessed including OI at days 4 and 14; physiological indices of pulmonary function  on days 4, 7 and 14; organ failure as measured by the SOFA score on days 4, 7 and 14; extubation and reintubation; VFDs to day 28; duration of mechanical ventilation; length of ICU and hospital stay; and 28- and 90-day mortality.In order to determine the potential mechanisms of action of MSCs, translational outcomes will include the biological effect of MSCs on pulmonary and systemic inflammatory responses, pulmonary and systemic indices of epithelial and endothelial function and injury, indices of coagulation, anti-HLA antibodies and cardiac function.A schedule of assessments is provided in Table The phase 1 trial will recruit up to 18 participants.The sample size for the phase 2 REALIST trial is 60 patients with ARDS due to COVID-19 and 60 patients with ARDS due to other causes. Due to the clinical differences in patients with ARDS due to COVID-19 and other causes of ARDS, these will be recruited as separate cohorts.2O/kPa [t-test to detect a clinically significant difference of 39 cmH2O/kPa in OI between groups. In a previous phase 2 study of similar size, we have found that an intervention can demonstrate a change in OI of a similar magnitude confirming a treatment effect of this size can be achieved [Although the primary focus of the phase 2 trial is safety, there is, however, power to detect a difference in physiological outcomes. The primary efficacy outcome measure will be the difference in oxygenation index (OI) between the ORBCEL-C- and placebo-treated groups at day 7. Based on our data from a recently completed clinical trial in ARDS, the mean  OI at day 7 in patients with ARDS is 62 (51)  cmH2O/kPa . To alloachieved . Althougachieved . TherefoMechanically ventilated patients will be prospectively screened daily at all participating sites to identify eligible patients. Reasons for non-recruitment will be recorded in the screening log, along with an anonymised minimal dataset . Recruitment (including reasons for non-enrolment of screened patients) will be monitored by the Trial Management Group (TMG) and the Data Monitoring and Ethics Committee (DMEC).The randomisation sequence will be generated by the Northern Ireland Clinical Trials Unit (NICTU) statistician using NQuery Advisor using variable block sizes.The randomisation sequence will be saved in a restricted section of the Trial Management Folder which can only be accessed by the NICTU statistician and not those who enrol or assign interventions.6 cells of REALIST ORBCEL-C according to the dose-escalation protocol. As a safety precaution, only one patient across all sites can receive treatment at one time and no further patients should receive treatment in the 24 h following completion of REALIST ORBCEL-C infusion. This process of enrolment and confirmation of the dose allocation will be co-ordinated by the NICTU.In phase 1, participants will be allocated to receive either 100, 200 or 400 × 10In phase 2, participants will be randomised to either REALIST ORBCEL-C or placebo control in a 1:1 ratio, stratified by recruitment centre and vasopressor use. Randomisation will be via an automated centralised 24-h telephone or web-based randomisation system  by an appropriately trained and delegated member of the research team.The investigator, treating physician, other members of the site research team and participants will be blinded. Cell therapy facility, clinical trials pharmacists and designated NICTU staff will be unblinded to facilitate preparation of the IMP and distribution of the IMP supply to sites. The unblinded individuals will keep the treatment information confidential and will not discuss or release information on treatment allocation to the patient, the investigator or other members of the research team. The infusion bag containing either cell product or placebo will be masked at preparation and administered through a masked infusion set.The investigator or treating physician may unblind a participant’s treatment assignment in the case of an emergency, when knowledge of the study treatment is essential for the appropriate clinical management or welfare of the patient. Should a treating clinician require emergency unblinding, they should contact the centralised telephone randomisation system  and follow the trial specific unblinding guidelines.Data will be collected according to the schedule of assessments outlined in Table Baseline data (day 0) will be collected in the 24 h prior to IMP administration and will include patient demographics, height, weight, PBW, date and time of ICU admission, date and time of onset of mechanical ventilation, date and time of consent and enrolment (phase 1) or randomisation (phase 2), aetiology of ARDS, APACHE II score, first qualifying PF ratio, worst PF ratio, Murray Lung injury score, determinants of the SOFA score, temperature, ventilation parameters, arterial blood gas parameters, oxygenation index (OI), use of adjunctive therapies and clinical laboratory assessments.Physiological and ventilatory parameters, along with temperature and vasopressor doses, will be recorded immediately prior to IMP administration, every 15 min during infusion of the IMP and every hour for the 5 h following IMP administration. Daily data will be collected until day 14 (or death or ICU discharge if sooner). It will include determinants of the SOFA score, temperature, ventilation and arterial blood gas parameters, use of adjunctive therapies and renal replacement therapy, clinical laboratory assessments and fluid balance. Additionally, arterial blood gas parameters will be recorded every 12 h on days 2 and 3. During phase 2, echocardiography parameters including but not limited to ventricular size and function and tricuspid annular plane systolic excursion (TAPSE) will be collected where possible on day 4.Additional clinical data collected will include extubation, re-intubation, duration of ventilation and duration of critical care and hospital stay. VFDs to day 28 are defined as the number of days from the time of initiating unassisted breathing to day 28 after study drug administration, assuming survival for at least 48 h after initiating unassisted breathing and continued unassisted breathing to day 28. Adverse events will be collected until day 90. After discharge from hospital, participant survival and significant medical events at 1 and 2 years post IMP administration will be determined by review of medical records or telephone contact with the patient or their GP.Blood and urine samples will be collected and processed by trained members of the research team according to sample processing guidelines. Bronchoscopy and broncheoalveolar lavage (BAL) will be undertaken where possible, in accordance with previous descriptions , 47. SamPatients will be informed of their participation in the trial by the responsible clinician or a member of the research team once they regain capacity to understand the details of the trial. After discharge, participants will be sent a note thanking them for their participation in the study and reminding them we will be back in contact for follow-up.In the event of a request to withdraw from the study, the researcher will determine which elements of the trial are to be withdrawn from. In the event that the request is to withdraw from all elements of the study, only anonymised data recorded up to the point of withdrawal will be included in the study analysis. Consent will also be requested to use the samples collected to that point.Data for individual patients will be collected by the site team and recorded in an electronic case report form (CRF). For routinely collected clinical data, the patient’s medical record will be the source document. Data will be processed by the NICTU Standard Operating Procedures (SOPs) and trial-specific Data Management Plan. Data queries will be generated electronically for site staff to clarify data or provide missing information. Trial monitoring procedures will check the accuracy of entries on the electronic CRF against the source documents, the adherence to the protocol, procedures and Good Clinical Practice. Quality control will be implemented by the NICTU in the form of SOPs, which are defined to encompass aspects of the clinical data management process and to ensure standardisation and adherence to International Conference of Harmonisation Good Clinical Practice (ICH-GCP) guidelines and regulatory requirements.Each patient enrolled in the study will be allocated a unique Participant Study Number, which will be used throughout the study for participant identification. In order to maintain confidentiality, all CRFs, questionnaires, study reports and communication regarding the study will identify the patients by their unique participant study number and initials only. Patient confidentiality will be maintained at every stage and will not be made publicly available to the extent permitted by the applicable laws and regulations.As detailed above consent will be sought for storage and use of biological samples, including for genetic analysis.For the phase 1 trial, no formal statistical analysis will be performed on safety data. The primary analysis will be descriptive and will focus on adverse events. The number of pre-specified cell infusion associated events will also be reported. Descriptive analysis of pulmonary and non-pulmonary organ function will also be undertaken. A final analysis and report of the phase 1 study is planned following the last patient’s 90 day follow-up. The 2 year follow-up data will be reported thereafter.t-tests and analysis of covariance with transformations of variables to normality if appropriate, or non- parametric equivalents. Chi-square tests (or Fisher’s exact tests) will be used for categorical variables. All statistical tests will be 2-sided and a p-value of 0.05 will be considered as statistically significant.For the phase 2 trial, adverse events and prespecified cell infusion-associated events will be reported as for the phase 1 study in a descriptive analysis. For continuously distributed outcomes, differences between groups will be tested using independent samples Correlations between changes in the biological markers measured and physiological and clinical outcomes will be assessed by appropriate graphical and statistical methods including Pearson’s (or Spearman’s) correlation coefficient.A final analysis and report of each cohort in the phase 2 study is planned following the last patient’s 90-day follow-up in each cohort. The 2-year follow-up data will be reported thereafter.No interim analysis is planned.In phase 2, the primary analysis will be conducted on outcome data obtained from randomised participants who receive at least some of their randomly allocated treatment. Adjusted  analysis will be carried out to determine if there is a statistically significant difference between the ORBCEL-C and placebo groups. It is possible that some subjects may not receive the full treatment dose. Therefore, a secondary analysis will be undertaken on the population who receive the complete treatment dose. An additional analysis in the COVID-19 cohort will also be conducted on patients who have a confirmed PCR diagnosis of COVID-19. Even if an additional risk factor for ARDS co-exists, these patients will be included in the COVID-19 cohort. A patient will be analysed according to the cohort to which they were randomised. A priori defined subgroup analyses will be undertaken for the primary efficacy outcome and selected secondary outcomes  based on severity of inflammation (as measured by plasma CRP and ferritin) and PF ratio.Every effort will be made to minimise missing baseline and outcome data in this trial. The level and pattern of the missing data in the baseline variables and outcomes will be established by forming appropriate tables and the likely causes of any missing data will be investigated. This information will be used to determine whether the level and type of missing data has the potential to introduce bias into the analysis results for the proposed statistical methods, or substantially reduce the precision of estimates related to treatment effects. If necessary, these issues will be dealt with using multiple imputation or Bayesian methods for missing data as appropriate.http://www.nictu.hscni.net/realist-trial-documents/ (last accessed 20 April 2020) and are available as supplemental document  will be responsible for the day-to-day operational management of the trial. It will be chaired by the Chief Investigator and have representatives from the NICTU and other co-investigators/collaborators who provide trial specific expertise. The conduct of the trial will be overseen by a Trial Steering Committee (TSC) on behalf of the Sponsor/Funder. The majority of the TSC are independent members. It will include the Chief Investigator, 2 of the co-investigators and a group of experienced critical care clinicians and trialists, as well as a lay representative.An independent data monitoring and ethics committee (DMEC) will provide oversight of data monitoring, safety and ethical conduct during trial conduct. The DMEC will provide recommendations for dose escalation during phase 1 and review the maximum tolerated dose prior to proceeding to phase 2. During phase 2, the DMEC will be convened monthly initially, and frequency of meetings will be kept under review. No interim analysis is planned but the DMEC will be provided with interim information on recruitment, AE reporting and deaths from all causes at 28 days.2 ≥ 0.2 and an increase in PEEP ≥5 to maintain SpO2 in target range; and clinical scenario consistent with transfusion incompatibility or transfusion-related infection. Additionally, the following pre-specified adverse events occurring within 24 h of the start of infusion will be collected: any death, any cardiac arrest and temperatures > 38.5 °C or an increase of ≥1 °C when temperature was > 38.5 °C prior to IMP administration.Patients recruited to the REALIST trial are already critically ill and as such many patients will experience events that are expected in this population . These will not be reported as an adverse event unless considered to be related to the IMP or unexpectedly severe or frequent. The following prespecified adverse events occurring within 6 h of the start of the infusion will be collected: increase in vasopressor dose ; new ventricular tachycardia, ventricular fibrillation or asystole; new cardiac arrhythmia requiring cardioversion; hypoxaemia requiring an increase in FiOSeriousness and causality of the adverse event will be determined by the investigator. As REALIST ORBCEL-C has not been administered to patients with ARDS, all adverse events related to IMP will be considered unexpected. Therefore, all serious adverse events (SAEs) related to the IMP  will be a suspected unexpected serious adverse reaction (SUSAR). All SAEs, SAR/SUSARs should be reported to the NICTU within 24 h of the research team becoming aware of the event.Trial monitoring will be conducted regularly throughout the trial by the NICTU. The frequency and type of monitoring will be detailed in the monitoring plan and agreed by the sponsor. Audit activities will be completed during the trial as agreed by the sponsor.All protocol amendments will be undertaken in accordance with the regulatory requirements. Substantial changes to the protocol will require REC and MHRA approval prior to implementation, except when modification is needed to institute an urgent safety measure to maintain patient safety.Publications will be reported according to the CONSORT 2010 statement . The phaPatients and public involvement (PPI) in the development of the trial proposal and protocol development has been sought. Mr Barry Williams, the PPI representative, is a member of the Trial Steering Committee and has provided guidance throughout the trial development as well as provided input in the development of patient facing materials prior to their approved use. On completion of the study, we will seek advice on dissemination of the results.REALIST ORBCEL-C CD362 is an advanced therapy medicinal product (ATMP), consisting of UC derived CD362 enriched human MSCs. MSCs are a heterogenous cell population, traditionally isolated by plastic adherence, with minimal defining criteria . In prevThe REALIST trial aimed to manufacture this novel therapeutic product within existing NHS infrastructure, namely the NHSBT. It is hoped that establishing manufacture within existing NHS infrastructure lends itself to large-scale production and distribution for future clinical trials and clinical use if effective. The NHSBT have considerable experience in the handling and manipulation of cell therapies for bone marrow and haematopoietic stem cell transplant patients. Their experience of cellular products has been advantageous throughout the development and manufacturing process of this cellular product and in the implementation of infrastructure required to facilitate the trial. The benefits of using existing infrastructure have been evident during the expansion of the phase 2 trial at the outset of the COVID-19 pandemic. Existing cell therapy facilities were utilised to increase the network of clinical sites involved in the trial, supporting expediated recruitment of the COVID-19 ARDS cohort. Furthermore, NHSBT were able to support increased cell manufacture for an additional cohort of patients through use of their facilities at a second manufacturing site.In March 2020, phase 2 of the trial was ready to commence, with appropriate approvals and resources in place. However, COVID-19 was declared a pandemic on the 11th of March, and on the 19th of March 2020, the National Institute for Health Research (NIHR) issued guidance to pause any new or ongoing studies at NHS sites that were not nationally prioritised COVID-19 studies , 55. As Phase 1 was commenced in January 2019 and completed recruitment in January 2020. The findings of the 90-day analysis and follow-up to 1 year have been published . Follow-Additional file 1: Supplemental file 1. List of participating hospital sitesAdditional file 2: Supplemental file 2. REALIST Protocol v6.0 30.09.2020Additional file 3: Supplemental file 3. REALIST SAP Phase 1Additional file 4: Supplemental file 4. REALIST SAP Phase 2


Prostate cancer is a rising health concern and accounts for 3.8% of all cancer deaths globally. Uganda has one of the highest incidence rates of the disease in Africa at 5.2% with the majority of diagnosed patients found to have advanced disease. This study aimed to use the STEAP2 protein (prostate cancer–specific biomarker) for the discovery of new targeted therapy. To determine the most likely compound that can bind to the STEAP2 protein, we docked the modeled STEAP2 3D structure against 2466 FDA (Food and Drug Administration)-approved drug candidates using AutoDock Vina. Protein basic local alignment search tool (BLASTp) search, multiple sequence alignment (MSA), and phylogenetics were further carried out to analyze the diversity of this marker and determine its conserved domains as suitable target regions. Six promising drug candidates (ligands) were identified. Triptorelin had the highest binding energy  followed by leuprolide . All the top two drug candidates interacted with residues Ser-372 and Gly-369 in close proximity with the iron-binding domain . The two drugs had earlier been approved for the treatment of advanced prostate cancer with an elusive mode of action. Through this study, further insight into figuring out their interaction with STEAP2 might be important during treatment. Cancer is a disease in which abnormal cells divide uncontrollably and progressively destroy body tissue. It is the second leading cause of death before 70 years in 91 of 172 countries according to the World Health Organization in 2015 and responsible for an estimated 9.6 million deaths in 2018 . One in Prostate cancer is the second most frequently diagnosed cancer in men globally and accounts for 3.8% of all deaths caused by cancer in men as of 2018 . In UganIn vitro and in vivo studies show that STEAP2 plays a key role in prostate cancer progression (Six transmembrane antigen of prostate 2 (STEAP2) also known as the six transmembrane protein of prostate 1 (STAMP1) is a member of the metalloreductase family important in the metal reduction of copper and iron. gression . STEAP2 gression . Its knogression . Immunohgression . It is dgression . STEAP2 gression . Their lgression . STEAP2 gression ,  process and phoshpatidyinositol-3-kinase protein kinase B mammalian target of rapamycin (PI3K/Akt/mTOR) signaling pathways seem to be implicated .in silico methods and promising results were achieved. STEAP2 targeting may be studied in the future in the context of developing anti-prostate cancer therapies.Although there has been great improvement in therapeutic options for prostate cancer over the last decade, the drugs currently used are still limited and not 100% effective making the cure elusive . This isThe study involved retrieval of STEAP2-related protein sequences from the protein data bank from a protein BLAST search. The selected sequences were used for multiple sequence alignment (MSA) and phylogenetics to determine the most related species to the human STEAP2 protein. For molecular docking, a set of FDA-approved drugs were retrieved from the drug bank and used as ligands for protein–ligand docking. The protein (STEAP2) 3-D structure was first modeled and evaluated prior to the docking exercise. The protein–ligand interactions were characterized using ligplots .https://www.proteinatlas.org/ENSG00000157214-STEAP2)  . The seaH. sapiens STEAP2 (Uniprot accession number: Q8NFT2) was obtained in a FASTA format from UniProt  search of the reference proteins in the PDB. In the BLASTp search, the algorithm parameter of maximum target sequences to return was adjusted to 5,000 and the rest of the parameters were left as default. A total of 30 sequences of the 5,000 returned were selected for MSA based on the percentage similarity in bins of 0–40, 41–60, 61–80, and 81%–100%. A number of sequences were selected from each range .From the table, the 0–40 and 41–60 similarity ranges took an extra hit to ensure that more distant hits from the query sequence were considered for confidence purposes.via the align tab in MEGAX  was created in MEGAX . The seqH. sapiens STEAP2 (Uniprot accession number: Q8NFT2) FASTA sequence was used as a query sequence in the different modeling engines that were best-ranked using the Continuous Automated Model Evaluation (CAMEO) website and one other from the critical assessment of protein structure prediction (CASP) website (I-TASSER) to search for similar sequences for homology modeling (modeling . The simmodeling . The besmodeling . The hommodeling https://zlab.umassmed.edu/bu/rama/index.pl). Using PyMol, the stoichiometry of the homology model was determined by chain coloration and critically looking at structures to identify any non-conformity such as long loops or knots  and define atom types (T) in the ligand and receptor files (in a PDB format), respectively, to generate their PDBQT files. The search box in the configuration file was set to dimensions x, y, and z . These were determined using MGL tool graphical user interface with cross-sectional measurements along each axis. The median point of the line between the two furthest points of the molecule on that axis guided toward the center point to center the search box so as to cover the entire protein in all 3 dimensions.The results of molecular docking were characterized by 3D proximity to a central residue termed as “Euclidian distance”— which is the length of a line between two points in geometrical space which can be 2 or 3D and binding energy of the ligand to the receptor molecule. All results were screened and a binding energy threshold of less than or equal to −7 and Euclidian distance of 50 Å were set. The complexes that met the selection criteria were then considered for further analysis.The entire protein was covered by the search box during molecular docking, a method also known as blind docking to mitigate bias to any region of the receptor.To determine the nature of the bonds formed between STEAP2 and the different ligands, Ligplot which is a program used to generate 2D representations of the nature of bonds formed between protein receptor residues and ligand atoms was used for this task . The proet al. was followed  expression analysis of the FANTOM5 dataset showed that STEAP2 was most abundantly expressed in prostate tissue followed by ovarian and vaginal tissue . ProstatA dendrogram generated using Molecular Evolution Genetic Analysis (MEGA) showed that STEAP2 was conserved mostly in species under phylum Chordata . The valH. sapiens falls together with its most similar species G. gorilla  closely associated with the NADP domain and six other trans-membrane (TM) domains  associated with iron binding (The MSA image depicts the conserved residues across 15 selected sequences of STEAP2 baring species and  binding . An MSA Template 6HCY/6HDY (human STEAP4) was the most common top hit for five of the six modeling engines with a better coverage than 2VNS identified using PRIMO .The homology model from SWISS-MODEL was a homo-3-mer. Homology models from the different engines (images generated in cartoon format using PyMol) .The homology model from SWISS-MODEL  was a hoThe rest of the results are summarized in From Some of the receptor residues interacting with the drug ligands from the ligplots were found to be within highly conserved motifs of the STEAP2 protein with some forming hydrogen bonds in addition to other hydrophobic interactions. The 2D interactions are shown in panel A and the respective 3D in panel B of the images. The images of the top 3 complexes, In the protein–ligand complex with Drugbank 1543 (triptorelin), Ser-372 with the hydrogen bond lies in the 6th TM domain which is part of the iron-binding domain and this is shown to be highly conserved from the MSA of only STEAP2 containing species . It togeIn the protein–ligand complex with Drugbank 2 (leuprolide), the interacting protein amino acids such as Ser-372 with leuprolide lie within the TM domains that are highly conserved as shown in the MSA. These are associated with the iron-binding domain and bind to the ligand leuprolide which is also approved for the treatment of advanced prostate cancer .In the protein–ligand complex with Drugbank 2328 , some of the listed residues such as Thr-210 are conserved under the NADP domain, the 5th TM domain having residues Glu-390 and Lys-303. The residues together with others form bonds with ligand Drugbank 2328 which is 1,2 icosapentoyl-sn-glycero-3-phosphoserine, an approved experimental drug for Corona virus-19 disease treatment .Residues from The mentioned residues of From the images, the protein–ligand complex of ligand 1,543 had the least number of hydrogen bonds between the ligand and protein but had the most number of hydrophobic contacts within the receptor. The summation of these bonds was, therefore, responsible for the observed high-binding energy associated with the complex . The ligThe complex, 01_SWISS-MODEL and Drugbank 1543 had the least binding energy.The docking validation by PatchDock produced the same order in terms of scores based on the geometric shape complementarity of solutions. The scores were ranked in the same order as the binding energy measured using AutoDock Vina. The complex of STEAP2 and Drugbank 1543 ligand had the highest score of 11,346 followed by the complex with Drugbank 2 and Drugbank 2328 with scores 11,274 and 11,224, respectively. The least ranked complex was that with Drugbank 3300 .The exact docking poses from AutoDock Vina could not be reproduced by PatchDock despite maintaining the same ranking order. Another docking engine, AutoDock4, could not reproduce the exact docking poses.results from the ProBiS analysis of STEAP2 for potential binding sites found STEAP4 as the most locally and structurally similar protein as it was also the used template for homology modeling. The most structurally conserved residues in binding site one, for small molecules, appeared red and were in the NADP-binding domain. All six identified binding ligands were NADP’s with confidences of 4.21–3.58. Binding site two, for proteins, had all amino acids unconserved as they appeared blue and confidence from 2.42 to 2.29. No binding sites were found for nucleic acids and ions (The and ions .Consistent with these findings were those from PrankWeb whose pocket 1 was HEM binding (pocket score 24.48), 2 (pocket score 10.48) was NADP binding with the most conserved residues, pockets 3 and 6 with pocket scores 6.26 and 3.09, respectively, were also within the NADP-binding domain. Pockets 4 and 5 were all within the FAD-binding domain with scores 5.86 and 3.75, respectively. Surface pockets 4 and 5 and pocket 3 were shown to be in close proximity with docked ligands, triptorelin and leuprolide .The results from CAVIAR analysis for binding sites found 7 cavities, cavity 5 with ligandability score 0.8 lays in the most conserved residues of the chain that also bind NADP, 1 and 6 lay in the HEM-binding domain that is not very conserved with ligandability scores of 0.6 and 0.8, respectively, and 2 with ligandability score 0.8 lays in the FAD-binding domain. Cavity 2/pocket 2 was close to bound ligands triptorelin and leuprolide. Cavities with ligandability score of 0.8–1 are considered easy to the ligand and of these, cavity 5 had the best score, size (109 A), and degree of conserved residues in comparison with conservation residue score results from PrankWeb. These results are detailed in a text file of cavity identification and Our study aimed to identify potential compounds that could be used in the development of anti-prostate cancer drugs that target STEAP2 using molecular docking. To our knowledge at the time, there are no studies in the literature that have used this approach with the aim of treating prostate cancer. Findings from our study showed that drugs such as triptorelin and leuprolide earlier prescribed for advanced prostate cancer could be effective in early-stage diseases with a more defined mode of action.With a modeled homolog and docking process of a pool of approved candidates from the drug bank, a number of drug compounds that formed significant interactions with the homology model gave insight to some of the current drugs that could be repurposed for the treatment of prostate cancer.The best homology model of STEAP2 was generated by the SWISS-MODEL as shown by the results from assessment by the 5 evaluation tools used . SWISS-MOn model analysis, a lower score below 100% in the favored region on a Ramachandran plot shows that there are residues whose phi and psi angles are not sterically possible when modeled . A lowerFrom the docking results, ligand Drugbank 1543 had the least binding energy and highest affinity from a selected set of 2,466 ligands. Having the least binding energy means the complex is more naturally stable due to affinity between the two constituent molecules with no or less external energy applied. The ligand formed its hydrogen bond with a residue Ser372 in the transmembrane domain of the receptor molecule as most of its other non-hydrogen bond interactions. From a key of the Drugbank, Drugbank 1543, accession number DB06825, generic name triptorelin is a synthetic decapeptide gonadotrophin releasing hormone (GnRH) agonist. The drug is proven for the palliative treatment of advanced stage prostate cancer . With thThe study by Drugbank 2 accession number DB00007 generic name leuprolide is a synthetic 9 residue peptide analog of GnRH shown to have a quicker onset of action in achieving serum testosterone levels equivalent to medically castrated men compared to triptorelin . The finData from the protein atlas places brain tissue  third with the STEAP2 content after the ovary and vagina  In men,Drugbank 2328, accession number DB14096, 1,2 icosapentoyl-sn-glycero-3-phosphoserineis an approved experimental drug for the treatment of Corona Virus Disease-19 (COVID-19) . DrugbanWe presume the exact docking poses could not be reproduced by AutoDock4 because the engine requires the use of a single chain of the homo-3-mer for the protein ligand docking vis-à-vis the 3 identical chains used in the docking by AutoDock Vina. The coherence in ranking order of the protein–ligand complex stability between AutoDock Vina and PatchDock, however, suggests the complexes are rightfully ordered.The metalloreductase activity of STEAP2 occurs across its transmembrane domains but these are neither binding sites nor druggable regions of the protein from binding site analysis using ProBiS, PrankWeb, and CAVIAR . These rThe production of the STEAP2 should, therefore, be both suppressed in the prostate and where possible, a potent ligand should bind to it to block its role in prostate cancer progression.Its role in metal Fe3+ and Cu2+ reduction for transmembrane transfer into cells can be carried on by STEAP3 metalloreductase associated with prostate cancer tumor suppression through induced apoptosis . Other SThe findings from this study give conjecture on the mechanistic role of triptorelin and leuprolide among others if STEAP2 was a target in the treatment of prostate cancer right from the early-stage disease. Targeting STEAP2 may, therefore, lead to the development of new anti-prostate cancer therapies in the future with further studies.Due to time and cost limitations we were unable to successfully validate the docking poses but the binding energy rankings of the top ligands using different and independent docking engines.in vitro assays to validate the results from this in silico study on growth and viability changes in the presence of these drugs and whether there are genes, gene products, and or enzymes that could potentially upregulate STEAP2 in its signaling pathway leading to its role in the development and progression of prostate cancer.We recommend that future work should include reproducing the docking poses using other commercial and/or free docking engines in addition to molecular dynamics simulations. The docking engine used (AutoDock Vina) is, however, documented to be one of the best at the time as shown in the study by


Rotator cuff tears are commonly associated with pain at rest and at night particularly if lying on the affected shoulder. This case describes a 54-year-old man who reported concerns of severe night pain in his left shoulder and had to undergo arthroscopic rotator cuff repair. The severity of night pain and blood flow velocity in the anterior humeral circumflex artery (AHCA) were measured over time. The patient reported his night pain as 10/10 on the numerical rating scale in the first week after surgery. In the fourth week, he rated his night pain as 6/10, and in the fifth week, his pain was <2/10. We measured blood flow velocity in the AHCA using a 3-11MHz color Doppler and power Doppler ultrasound , and we calculated peak systolic velocity. The course of peak systolic velocity in the AHCA ranged from 27.7 to 62.4 cm/s until four weeks after surgery when his night pain was severe; AHCA flow velocity ranged from 16.7 to 19.3 cm/s five weeks after surgery when his night pain had reduced. The initially high blood flow velocity in the AHCA decreased almost simultaneously with the improvement in night pain. Our case highlights that blood flow velocity in the AHCA synchronized with the severity of night pain, which may contribute to the understanding of sleep disturbances in patients after arthroscopic rotator cuff repair. Rotator cuff tears (RCTs) typically cause shoulder pain at night . The cauTerabayashi et al. conducted a recent cross-sectional study using power Doppler ultrasonography . They foWe report a case of a 54-year-old man with severe night pain in his left shoulder who underwent ARCR whose blood flow velocity in the AHCA correlated with the severity of his night pain. As this case highlights, the previous findings that AHCA blood flow velocity is associated with night pain  may be gA 54-year-old man reported concerns of pain in his left shoulder after a fall. He had no resting pain during the day but had to sleep sitting up because of pain at night. Despite four months of conservative treatment , his night pain did not improve. Magnetic resonance imaging showed an RCT with a Goutallier Grade 0, and he had to undergo ARCR. Preoperatively, his night pain was 8/10 on the 11-point numerical rating scale , and his sleep disturbance was a Pittsburgh Sleep Quality Index (PSQI) score of 6 (PSQI of 5.5 or higher indicates poor sleep) [The ARCR was performed in the beach chair position. The tear was a moderate crescent-shaped tear repaired according to the double anchor footprint fixation technique. Arthroscopy showed severe synovitis of the lateral portion of the glenohumeral joint capsule with a Davis score of 5 , paracetamol, and tramadol hydrochloride were prescribed Table .We measured his blood flow velocity in the AHCA with a 3-11MHz color Doppler and powered Doppler ultrasound , and we calculated his peak systolic velocity (PSV) according to the method reported by Terabayashi et al. . BrieflyThe patient's night pain was NRS 10/10 in the first week after ARCR and NRS 6/10 in the fourth week. At this stage, he had no pain in the daytime, and his night pain interfered with sleep and made him want to sit up. Five weeks after ARCR, he could finally sleep soundly in the supine position and reported the night pain had reduced to NRS 2/10. The course of PSVs in the AHCA ranged from 27.7 to 62.4 cm/s four weeks after the ARCR when his night pain was severe and from 16.7 to 19.3 cm/s five weeks after the ARCR when night pain was reduced. The night pain and sleep disturbances during this period are shown in Table Our patient's blood flow velocity in the AHCA was elevated in the preoperative and early postoperative periods when the patient was in severe pain. Tada et al. calculated a PSV cutoff value of 20.5 cm/s to determine the presence of night pain . Although the severity of synovitis during this period could not be confirmed by arthroscopy, the decrease in blood flow velocity may reflect a decrease in inflammation [Several authors have reported on other mechanisms of night pain in patients with RCT -6. ModulThe blood flow velocity and sleep disturbances improved synchronously with night pain. However, sleep disturbances can be caused by multiple factors and night pain in the shoulder, such as poor mental health, psychiatric disorders, and depression . FurtherOur findings that night pain was synchronous with blood flow velocity, which may reflect synovitis, suggest that NSAIDs are candidates for night pain management. Although NSAIDs have been reported to increase rotator cuff retear , their iOur patient's pain interfered with his sleep and made him want to sit up, the same inclusion criteria for Terabayashi et al.'s study . TherefoThe initially high blood flow velocity in the AHCA decreased almost simultaneously with the improvement in night pain and sleep disturbance. Therefore, blood flow velocity in the AHCA can be a parameter reflecting the presence of night pain. Future studies focusing on the blood flow velocity in the AHCA with a larger sample size, including randomized controlled trials, will help form a better understanding and management of patients with night pain.


The NHS response to COVID-19 altered provision and access to primary care.To examine the impact of COVID-19 on GP contacts with children and young people (CYP) in England.A longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database.All CYP aged <25 years registered with a GP in the CPRD Aurum database were included. The number of total, remote, and face-to-face contacts during the first UK lockdown (March to June 2020) were compared with the mean contacts for comparable weeks from 2015 to 2019.In total, 47 607 765 GP contacts with 4 307 120 CYP were included. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1–14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1–14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%).During the COVID-19 pandemic, CYP’s contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts and changing health-seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions. Face-to-face appointments were drastically reduced, while telephone appointments more than doubled.5 Reports of difficulty accessing GP appointments during the COVID-19 lockdowns led to concerns about patients’ unmet needs, which led to NHS England cautioning GPs to offer face-to-face appointments.6 However, GP leaders responded that general practice had complied with official guidance to offer predominantly remote services. GP surgeries remained open throughout the pandemic despite a dramatic increase in workload to adapt to the pandemic and manage COVID-19 infection.7During the COVID-19 pandemic, health systems globally shifted towards treating COVID-19 infection in adults and minimising use of health services for other patients, including children and young people (CYP), who were less susceptible to severe COVID-19.8–11 It became apparent early in the pandemic that CYP were less likely to become seriously unwell from COVID-19 infection.1 During the initial lockdowns, children aged <15 years, who are usually among the highest users of health services,11,12 had fewer emergency department visits compared with previous years.13 There was little evidence that these falls led to serious harms, an increase in mortality, or more severe illness presentations in CYP.13 However, it is not known how CYP’s consultation patterns changed in primary care, and whether the falls and changes in type of consulting reported for adults were similar for CYP.Children’s access to primary care is highly sensitive to health system shocks. The literature on primary care sensitive conditions has shown how rising pressures to manage a growing burden of adult chronic disease in primary care have squeezed children out of primary care and been associated with increases in children’s emergency department visits and hospital admissions for common non-transmissible conditions such as urinary tract infections, diabetes, epilepsy, and appendicitis.This study therefore aimed to examine the impact of the COVID-19 pandemic on total, face-to-face, and remote GP contacts with CYP in England.14 It is generally representative both of the population in England and across its geographic regions in terms of age, sex, and deprivation status.14A cross-sectional descriptive study was conducted using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database. CPRD Aurum contains electronic health record data routinely collected from GP practices using EMIS clinical systems in England and Northern Ireland, covering over 13% of the population.14 Electronic health record data was included from 3 months before the formal registration start date with that practice. Any health records collected after de-registration and with young people aged ≥25 years were excluded. All GP contacts were assigned to one of six developmental age groups according to their age in years on the date of the health contact: <1 years, 1–4 years, 5–9 years, 10–14 years, 15–19 years, and 20–24 years.The study population included all CYP aged <25 years who were registered with a GP practice in the CPRD Aurum database anytime during the study period (3 January 2015 to 30 October 2020). CYP were included if they had an ‘acceptable’ flag recorded in the database, indicating that their data met certain quality standards for key variables.The main outcome was the total number of weekly contacts with a GP using codes for staff identity. Contacts with practice nurses and allied health practitioners, such as healthcare assistants, were excluded. Contacts included both ‘remote’  and ‘face-to-face’ consultations, and were defined in the CPRD Aurum database using administrative and clinical codes. This process is described in detail in Supplementary Box S1 and Supplementary Figure S1, and relevant code lists can be found in Supplementary Tables S1 and S2.To describe the total healthcare activity, all face-to-face and remote contacts with GPs were included, even if there were multiple contacts with the same child or young person within a single day.15–25The secondary outcomes were weekly number of contacts with GPs for respiratory illnesses  and primary care sensitive conditions . The authors convened a clinician–researcher panel to develop and build code lists for each of these conditions using the CPRD Aurum code browser and existing lists from prior publications and code list repositories (see Supplementary Table S3).26The first lockdown period in the UK was defined as 21 March to 5 June 2020, which corresponds to weeks 13 to 23 (inclusive) set by the Office for National Statistics. This time period was selected because of the timing of government restrictions and social distancing measures in place.The number of contacts with GPs in each week from January 2015 to October 2020 was plotted. The percentage change in all outcomes was calculated by comparing the number of contacts during weeks 13 to 23 of 2020 with the mean number of contacts for weeks 13 to 23 from 2015 to 2019 to ensure more robust estimates of secular trends. All analyses were completed using Stata (version 17).There were 47 607 765 GP contacts included in this study from January 2015 to October 2020. There were 3 927 298 CYP included at the start of the study, rising to 4 307 120 by the end of the study period. Total contacts with GPs for CYP fell by 40.7%  during the first lockdown weeks in the UK (21 March to 5 June 2020) from an average of 1 752 874 over the same weeks (March to June) in 2015–2019 to 1 038 832 in March to June 2020 . There wFace-to-face contacts fell by 1 201 340  for all ages , from anFrom March 2015 to June 2019, an average of 22% of the total weekly contacts with GPs were remote, compared with 85% of all GP contacts held remotely in March to June 2020 . Remote Changes in GP contacts were similar in males and females . Remote Contact patterns for respiratory illnesses and primary care sensitive conditions followed similar trends to the overall patterns, with a large drop in face-to-face contacts and a switch to remote contacts. Remote contacts for CYP for respiratory illnesses (respiratory tract infections and asthma) spiked initially at the start of the first lockdown, followed by another spike in remote contacts in September 2020 coinciding with schools reopening . Face-toGP contacts for primary care sensitive conditions  shifted from face-to-face contacts to remote contacts during the lockdown period, but the drop in total contacts was only 30.9% (95% CI = 23.2 to 33.6) during the lockdown weeks compared with a fall of 74.0% (95% CI = 66.7 to 79.5) in total contacts for respiratory tract infections and asthma. Patterns for selected primary care sensitive conditions are shown in CYP’s GP contacts fell 41% during the first lockdown of the COVID-19 pandemic. Face-to-face contacts fell 88% overall, with the greatest falls among children aged 1–14 years (>90%) and a slightly smaller drop for infants (77%). There was a shift to remote contacts in all age groups, but large increases in remote contacts for infants and young people aged 15–24 years mitigated total falls. Contacts for respiratory illnesses fell dramatically (74%) whereas contacts for primary care sensitive conditions had less of a drop overall (31%) because of the shift from face-to-face to remote.To the authors’ knowledge, this is the first national report of children’s GP consulting patterns in the COVID-19 era. Its strengths include the large study population that is broadly representative of CYP in England and allows comparison with data from the previous 5 years. Therefore, it is highly unlikely the differences found in this study occurred by chance or sample selection effects, or could be explained by longer-term trends in healthcare activity.Another strength of this study is that the baseline comparison averaged 5 years of data from 2015 to 2019. The mean from 2015 to 2019 is consistent and therefore a good comparator. In a sensitivity analysis comparing GP contacts from 2020 to the year 2019 only had a small impact on the main findings. However, there are some limitations to note in interpreting the findings of this study. In common with other large observational studies, data accuracy and completeness are variable. For example, administrative and clinical codes were used to differentiate face-to-face from remote contacts (see Supplementary Box S1). This may have resulted in some misclassification. In line with the specific aims of this study only contacts with GPs were looked at, and contacts with other providers such as practice nurses, pharmacists, or physician assistants whose roles have expanded in recent years were not examined.27,28 Unlike a study primarily in adults that suggested primary care contacts returned to pre-pandemic levels,29 this study found that by October 2020 CYP’s contacts had recovered but remained at around 18% below pre-pandemic levels.This study’s findings of falls in GP contacts with CYP are consistent with other reports of a drop in face-to-face contacts in adults and switch to remote contacts during the pandemic lockdowns of 2020.30 Social distancing measures and lockdown restrictions intended to reduce transmission of COVID-19 will also reduce other circulating viruses. Hence, infectious illnesses, which are among the most common reasons for children’s attendance in primary care, fell during the lockdowns,31 and an increase in incidence of infectious illness may also explain the spikes noted in this study in remote contacts at the start of the first wave of the pandemic in March 2020 and coinciding with schools reopening/restrictions easing in September 2020.32Possible explanations for these findings include changing disease incidence, altered health-seeking behaviour, and changes to physician-consulting behaviour and services, all of which appear to have been affected by the pandemic.33 Some parents expressed fear of exposure to COVID-19 from health settings34 whereas others reported incorrectly that GP practices were closed to face-to-face consultations.35,36 Misinformation about the availability of GP appointments and face-to-face consulting has been widely disseminated by social and news media.37Strong public messaging to ‘Stay at home, protect the NHS and save lives’ during lockdowns will inevitably have kept some patients away from health settings. Adherence to lockdown measures may have led to more management of minor childhood illnesses at home, and there is evidence from other countries that adults consulted GPs less frequently during the initial lockdown in 2020 for some minor conditions.10,11 Thus pandemic disruptions have had a significant impact against a backdrop of existing pressures to provide GP contacts. The authors estimate that the falls of 41% resulted in 2 785 611 fewer GP contacts with CYP in England from March to June 2020 compared with previous years. However, the finding that GP contacts for respiratory illnesses fell drove a significant part of this decline, which was likely because of reduced transmission from containment measures. Emergency department attendances and child mortality for seasonal respiratory and gastrointestinal infection has reportedly fallen during lockdowns38 but is unlikely to be sustained as schools and educational settings reopen.Children’s access to primary care has been falling in the UK and other countries for decades, accompanied by concomitant rises in use of urgent care including emergency department visits and hospital admissions.39 However, there may have also been difficulties in accessing remote care because of lack of space to speak privately and insufficient phone data or internet connectivity to take video calls.40 Access and utilisation challenges disproportionately affect CYP living in more deprived areas.41 Reassuringly, this study found that the total contacts for primary care sensitive conditions such as urinary tract infections, appendicitis, and epilepsy remained relatively high, and international reports confirm the incidence of these conditions changed little during this time.42 There is little evidence of a rise in serious illness in children during the lockdowns,13,38,43 suggesting that relatively few CYP experienced significant harm because of delays in seeking care.The findings of this study that remote contacts with young people more than doubled may indicate the shift to remote consulting by phone or video may have facilitated access to GPs for some younger people who often have excellent digital literacy and access.44 Underinvestment in primary care to meet this rising workload has had an adverse impact on morale, with record numbers of GP principals leaving the profession, and has led to a declining workforce.The system-wide reorganisations of 2020 came after several years of primary care reforms. GPs have faced rising patient demand for appointments, an increasing workload because of a shift from hospital specialists to community care, and the demands of an ageing population with complex needs.45 Although the current study has reported the health system was able to adapt and respond to short-term pandemic disruptions, further work is needed to understand the long-term impact of preventive primary care on CYP’s health.46It is important to consider key lessons from the recent health system response.. Particularly at the start of the COVID-19 pandemic remote consultations offered opportunities for triage and provided practical solutions for GP contact with those shielding or self-isolating.47,48 As lockdown eased and consultation rates increased from July 2020, some GPs reported remote consulting became more time consuming, challenging, and fragmented.48 As the UK emerges from the winter of 2021–2022 with schools fully open, acute infection rates are rising and demand for acute appointments remains high. During the future anticipated peaks in infectious illnesses, such as respiratory syncytial virus, there may be a shortfall in primary care capacity for increased demand and need for face-to-face assessments to ensure safety and quality of children’s primary care.49 A picture is emerging whereby a hybrid model designed around patient preference is likely to replace traditional primary care.50 More work is needed to understand the optimal combination.51,52 The rebuild offers great opportunities to codesign primary care with CYP’s preferences.Remote and face-to-face consultations both have distinct advantages 53 published before the pandemic, has encouraged a shift towards integrated care systems to bring together NHS services, local authorities, and the voluntary sector for public health improvement.54 In addition to integration, the plan promises better prevention, workforce support, investment in digital infrastructure, and a better start to life for all CYP. It is essential that in this reorganisation, CYP are included in the plans for primary care reform.The NHS Long Term Plan,27 A major part of this shift may be ascribed to the change in prevalence of seasonal viral infections. Most contacts were held remotely but face-to-face consulting for infants was less disrupted and there was a major shift to remote contacts for primary care sensitive conditions mitigating overall falls. In reforming primary care services, the priority must be to consult stakeholders, including GPs and children and families, build safe digital and physical infrastructure, and support the primary care workforce to meet demand and to deliver better health outcomes for the whole population.In conclusion, during the first phases of the pandemic, CYP’s contact with GPs, particularly for face-to-face assessment, was lower than observed in adult populations.