Background: Normally, regulatory T cells (also known as T regulatory cells or Tregs) migrate into inflamed tissues, dampening inflammatory responses and hastening tissue repair (1). Patients with coronavirus disease 2019 (COVID-19) and acute respiratory distress syndrome (ARDS) have protracted hospitalizations characterized by excessive systemic inflammation (cytokine storm) and delayed lung repair, which is partly due to reduced or defective Tregs (2). Objective: To describe outcomes in 2 patients with COVID-19 and ARDS who were treated with Tregs. Case Reports: The first patient was a 69-year-old man with autism who was hospitalized from his nursing home with COVID-19-induced fever and dyspnea 1 week after initial symptom onset. Despite 5 days of receiving hydroxychloroquine and broad-spectrum antimicrobial agents, he progressed to ARDS and received tocilizumab on day 7 and mechanical ventilation beginning on day 8. Renal failure and shock developed, requiring continuous, venovenous hemofiltration and vasopressors. Refractory hypoxemia required prone positioning, neuromuscular paralysis, inhaled nitric oxide, and FIO 2 greater than 70%. We administered compassionate use, cryopreserved, allogeneic Tregs derived from cord blood (CB) and expanded ex vivo (Cellenkos) at 1 × 10 8 cells per dose intravenously on days 13 and 17. By day 17, he had returned to supine positioning, paralytics were withdrawn, inhaled nitric oxide was weaned to zero, FIO 2 was decreased to 50%, vasopressors were withdrawn, and inflammatory markers were reduced (Table 1). He was extubated on day 22. On day 25, he required a tracheostomy. He is currently receiving care in a weaning facility. The second patient was a 47-year-old man who was hospitalized for COVID-19-induced fever and dyspnea 1 week after initial symptom onset. On day 2 of his hospitalization, he received tocilizumab, and hours later, he had increasing lactate levels and required mechanical ventilation and high-dose Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=L20-0681.

Ribavirin is used in the treatment of respiratory syncytial virus (RSV) in high-risk patients, including patients who have undergone hematopoietic stem cell transplantation, to reduce mortality from RSV pneumonia. It is classified as a hazardous drug with potential for carcinogenicity and teratogenicity. Very few recent studies have examined the risk of exposure, and recommendations for exposure precautions are lacking. Administration should include the use of personal protective equipment and terminal cleaning of the patient room after each administration. This article examines ribavirin use among patients who have undergone hematopoietic stem cell transplantation and have RSV-related pneumonia and explores safety considerations for staff. Nursing leaders on a hematopoietic stem cell transplantation unit addressed gaps in knowledge about ribavirin therapy, and completed a review of the hospital's ribavirin policy, which led to policy revisions, increased knowledge about the safe administration of ribavirin, and improvements in staff and patient education.

Early warning scoring systems are tools for nurses to help monitor their patients and improve how quickly a patient experiencing a sudden decline receives clinical care. Nurse leaders and frontline staff at a major academic medical center implemented a new early warning system that gives clear guidelines to nurses, nursing assistants, and other clinicians about vital-sign parameters and changes in patients' mental status. 
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There are limited data on the safety of chimeric antigen receptor (CAR) T-cells with the CD28 co-stimulatory domain (CD28 CAR T-cells), such as axicabtagene ciloleucel (Axi-cel) or brexucabtagene autoleucel (Brexu-cel), in patients with active or prior central nervous system (CNS) involvement. Due to concerns over the risk of immune effector cell-associated cytotoxicity (ICANS), patients with CNS disease were largely excluded from the pivotal ZUMA trials that led to the approval of CD28 CAR T-cells for diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma (MCL), and B-cell acute lymphoblastic leukemia (B-ALL). 1 Although anecdotal and small retrospective reports have been published, 2-6 the safety of CD28 CAR T-cell therapy in patients with CNS involvement has not been adequately evaluated. Furthermore, the safety and feasibility of outpatient administration of CAR T-cells for patients with active or prior CNS involvement remain unclear. Herein, we report on our institutional experience with outpatient CD28 CAR T-cell administration in 10 consecutive patients with CNS involvement. We performed a retrospective analysis of outcomes for all patients who received commercially available CD28 CAR T-cells at Johns Hopkins Hospital between January 2019 and November 2022 for B-cell malignancies with previously treated or active CNS involvement. The study was approved by the Institutional Review Board of Johns Hopkins. Patients were considered to have active CNS disease if they had radiographic evidence of CNS involvement or malignant B-cells detectable by flow cytometry in the cerebrospinal fluid (CSF)