POS0939 BIMEKIZUMAB IN PATIENTS WITH ACTIVE NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: 24-WEEK EFFICACY & SAFETY FROM BE MOBILE 1, A PHASE 3, MULTICENTRE, RANDOMISED, PLACEBO‑CONTROLLED STUDY

Background

Bimekizumab (BKZ) is a monoclonal IgG1 antibody that selectively inhibits IL-17F in addition to IL-17A. BKZ has shown rapid and sustained efficacy and was well tolerated up to 156 weeks (wks) in a phase 2b study in patients (pts) with active ankylosing spondylitis.1,2

Objectives

To assess efficacy and safety of BKZ vs placebo (PBO) in pts with active non-radiographic axial spondyloarthritis (nr-axSpA) up to Wk 24 in the ongoing pivotal phase 3 study, BE MOBILE 1.

Methods

BE MOBILE 1 (NCT03928704) comprises a 16-wk double-blind, PBO-controlled period and 36-wk maintenance period. Pts were aged ≥18 yrs, had BASDAI ≥4 and spinal pain ≥4 at BL, and sacroiliitis on MRI and/or elevated CRP at screening. Pts were randomised 1:1, BKZ 160 mg Q4W:PBO. From Wk 16, all pts received BKZ 160 mg Q4W. Primary and secondary efficacy endpoints were assessed at Wk 16.

Results

Of 254 randomised pts (BKZ: 128; PBO: 126), 244 (96.1%) completed Wk 16, 240 (94.5%) Wk 24. BL characteristics were comparable between groups: mean age 39.4 yrs, symptom duration 9.0 yrs; 54.3% pts male, 77.6% HLA-B27+, 10.6% TNFi-experienced. At Wk 16, the primary (ASAS40: 47.7% BKZ vs 21.4% PBO; p<0.001) and all ranked secondary endpoints were met (Table 1). Responses were rapid with BKZ, including in PBO pts who switched to BKZ at Wk 16, and increased to Wk 24 (Figure 1; Table 1). Substantial reductions of hs-CRP by Wk 2 and MRI SIJ inflammation by Wk 16 were achieved with BKZ vs PBO (Table 1). At Wk 24, >50% of pts initially randomised to BKZ had achieved ASDAS <2.1 (Figure 1).

Table 1.

Efficacy at Wks 16 and 24

BLWk 16Wk 24PBO N=126BKZ 160 mg Q4W N=128PBO N=126BKZ 160 mg Q4W N=128p valuePBO→BKZ 160 mg Q4W N=126BKZ 160 mg Q4W N=128Ranked endpoints in hierarchical orderASAS40* [NRI] n (%)--27 (21.4)61 (47.7)<0.00159 (46.8)67 (52.3)BASDAI CfB† [MI] mean (SE)6.7 (0.1)6.9 (0.1)–1.5 (0.2)–3.1 (0.2)<0.001–3.2 (0.2)–3.4 (0.2)ASAS20† [NRI] n (%)--48 (38.1)88 (68.8)<0.00187 (69.0)96 (75.0)ASAS PR† [NRI] n (%)--9 (7.1)33 (25.8)<0.00135 (27.8)37 (28.9)ASDAS-MI† [NRI] n (%)--9 (7.1)35 (27.3)<0.00137 (29.4)41 (32.0)ASAS 5/6† [NRI] n (%)--21 (16.7)49 (38.3)<0.00151 (40.5)57 (44.5)BASFI CfB† [MI] mean (SE)5.3 (0.2)5.5 (0.2)–1.0 (0.2)–2.5 (0.2)<0.001–2.3 (0.2)–2.8 (0.2)Nocturnal spinal pain CfB† [MI] mean (SE)6.7 (0.2)6.9 (0.2)–1.7 (0.2)–3.6 (0.3)<0.001–3.5 (0.2)–4.0 (0.3)ASQoL CfB† [MI] mean (SE)9.4 (0.4)9.5 (0.4)–2.5 (0.4)–5.2 (0.4)<0.001–4.8 (0.4)–5.7 (0.4)SF-36 PCS CfB† [MI] mean (SE)33.6 (0.8)33.3 (0.7)5.5 (0.7)9.5 (0.7)<0.00110.1 (0.8)10.6 (0.8)Other endpointsdEnthesitis-free state†a [NRI] n (%)--22 (23.9)b48 (51.1)c-40 (43.5)b45 (47.9)cASAS40 in TNFi-experienced [NRI] n (%)--2 (11.8)e6 (60.0)f---ASDAS-CRP CfB [MI] mean (SE)3.7 (0.1)3.8 (0.1)–0.6 (0.1)–1.5 (0.1)-–1.5 (0.1)–1.6 (0.1)hs-CRP, mg/L [MI] geometric mean (median)5.0 (6.5)4.6 (6.1)3.8 (4.1)2.0 (1.8)-2.3 (2.6)1.9 (1.8)MRI spine Berlin CfBg [OC] mean (SD)1.9 (3.2)h1.6 (2.9)i–0.1 (1.7)j–0.7 (2.2)k---SPARCC MRI SIJ score CfBg [OC] mean (SD)10.5 (13.8)l8.5 (10.3)m–1.5 (9.2)n–6.3 (10.0)o---

Randomised set. *Primary endpoint; †Secondary endpoint; aMASES=0 in pts with BL MASES >0; bn=92; cn=94; dNominal p values not shown; en=17; fn=10; gIn pts in MRI sub-study; hn=65; in=75; jn=58; kn=73; ln=68; mn=79; nn=60; on=77.

Over 16 wks, 80/128 (62.5%) pts had ≥1 TEAE on BKZ vs 71/126 (56.3%) on PBO; most frequent were nasopharyngitis (BKZ: 9.4%; PBO: 4.8%), upper respiratory tract infection (BKZ: 7.0%; PBO: 7.1%) and oral candidiasis (BKZ: 3.1%; PBO: 0%). No systemic candidiasis was observed. Up to 16 wks, incidence of SAEs was low (BKZ: 0.0%; PBO: 0.8%); no MACE or deaths were reported; 0 IBD cases occurred in pts on BKZ vs 1 (0.8%) in a pt on PBO.

Conclusion

Dual inhibition of IL-17A and IL-17F with BKZ in pts with active nr-axSpA resulted in rapid, clinically relevant improvements in efficacy outcomes vs PBO. No new safety signals were observed.1,2

References

[1]van der Heijde D. Ann Rheum Dis 2020;79:595–604;

[2]Gensler L. Arthritis Rheumatol 2021;73(suppl 10):0491.

Acknowledgements

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests

Atul Deodhar Speakers bureau: Janssen, Novartis, and Pfizer, Consultant of: AbbVie, Amgen, Aurinia, BMS, Celgene, Eli Lilly, GSK, Janssen, MoonLake, Novartis, Pfizer, and UCB Pharma, Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, and UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, and UCB Pharma, Employee of: Imaging Rheumatology BV (Director), Lianne S. Gensler Consultant of: AbbVie, Eli Lilly, GSK, Janssen, Novartis, Pfizer, and UCB Pharma, Grant/research support from: Novartis, Pfizer and UCB Pharma, Huji Xu: None declared, Karl Gaffney Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Eli Lilly, Novartis, and UCB Pharma, Grant/research support from: AbbVie, Gilead, Eli Lilly, Novartis, and UCB Pharma, Hiroaki Dobashi Speakers bureau: BMS, Chugai, Eli Lilly, GSK, MSD, Novartis, Pfizer, UCB Pharma, Walter P Maksymowych Consultant of: AbbVie, Boehringer-Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Janssen, Novartis and Pfizer, Employee of: Chief Medical Officer for CARE Arthritis, Martin Rudwaleit Speakers bureau: AbbVie, BMS, Boehringer Ingelheim, Chugai, Eli Lilly, Janssen, Novartis, Pfizer, and UCB Pharma, Paid instructor for: Janssen, Novartis, and UCB Pharma, Consultant of: AbbVie, Novartis, and UCB Pharma, Marina Magrey Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie and UCB Pharma, Dirk Elewaut Speakers bureau: AbbVie, Eli Lilly, Galapagos, Novartis and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Galapagos, Novartis and UCB Pharma, Marga Oortgiesen Employee of: Employee of UCB Pharma, Carmen Fleurinck Employee of: Employee of UCB Pharma, Alicia Ellis Employee of: Employee of UCB Pharma, Thomas Vaux Employee of: Employee of UCB Pharma, julie smith Employee of: Employee of UCB Pharma, Xenofon Baraliakos Speakers bureau: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, and UCB Pharma, Paid instructor for: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, and UCB Pharma

Collocated burn and fracture injuries in major trauma: a 10 year experience

INTRODUCTION

Collocated burn and fracture injuries, defined as a burn overlying the site of a fracture, represent a serious subset of major burns and trauma. The literature pertaining to these rare injuries is inconclusive. Recent studies cast doubt on the safety of operative fixation in this population. No study to date has examined outcomes of collocated burn and fracture injuries compared with control. The aim of this study was to compare characteristics, injury patterns and complication rates in major burns and fracture patients with a collocated injury to those without.

METHODS

A retrospective chart review of all consecutive patients with dermal burns and major fractures were undertaken between January 2005 and December 2015 at a tertiary referral trauma hospital. Outcomes assessed included demographics, injury characteristics and complications, including infection. Orthopaedic infection was defined as orthopaedic surgical site infection or osteomyelitis.

RESULTS

Of the 40 patients identified, 21 subjects sustained collocated injuries. Patients with collocated injuries demonstrated a trend towards higher injury severity, higher percentage of total body surface area affected, longer length of stay and greater overall and orthopaedic complication rate. Significant predictors of orthopaedic infection were related to injury severity rather than collocation or operative management.

CONCLUSION

There are differences in the characteristics and complication rates between collocated and non-collocated burn and fracture injuries. Collocated injuries tend to result from greater energy mechanisms, undergo longer inpatient stays and demonstrate increased morbidity. Injury severity appears to be the most important factor in determining postoperative orthopaedic infection. These characteristics must be considered when managing these rare but significant injuries.

86-GBaud subcarrier multiplexed 16QAM signal generation using an electrical 90 degree hybrid and IQ mixers

We experimentally demonstrate an aggregate 86-GBaud (over three sub-bands and one polarization) signal generation based on subcarrier multiplexing technique using IQ mixers, an electrical 90 degree hybrid, and diplexers. The electrical hybrid allows transmitter-side digital signal processing to be simplified to pulse shaping and digital pre-emphasis. We verified the configuration by testing the performance of an 86-GBaud Nyquist-shaped 16 quadrature amplitude modulation signal with differential bit encoding. The implementation penalty assuming 7% hard-decision forward error correction is reduced to 2 dB by utilizing a 31-tap decision-directed least mean square based multiple-input multiple-output equalizer for sideband crosstalk mitigation.

First report of Comamonas kerstersii causing urinary tract infection

The association of Comamonas kerstersii with peritonitis resulting from perforated appendix and its isolation from a psoas abscess and pelvic peritonitis have previously been described by us. We present the first case of C. kerstersii urinary tract infection, broadening the spectrum of infections caused by this species.

All bereaved parents are entitled to good care after stillbirth: a mixed-methods multicentre study (INSIGHT)

OBJECTIVE

To understand challenges in care after stillbirth and provide tailored solutions.

DESIGN

Multi-centre case study.

SETTING

Three maternity hospitals.

POPULATION

Parents with a stillborn baby, maternity staff.

METHODS

Thematic analysis of parent interviews and staff focus groups and service provision investigation.

OUTCOMES

1 Themes; 2 Triangulation matrix; 3 Recommendations.

RESULTS

Twenty-one women, 14 partners, and 22 staff participated. Service Provision: Care for parents after stillbirth varies excessively; there are misconceptions; post-mortem does not delay follow-up.

PRESENTATION

Women 'do not feel right' before stillbirth; their management is haphazard and should be standardised.

DIAGNOSIS

Stillbirth is an emergency for parents but not always for staff; communication can seem cold; well-designed bereavement space is critical. Birth: Staff shift priorities to mother and future, but for parents their baby is still a baby; parents are not comfortable with staff recommending vaginal birth as the norm; there are several reasons why parents ask for a caesarean; better care involves clear communication, normal behaviour, and discussion of coping strategies. Post-mortem: Parents are influenced by discussions with staff. Staff should 'sow seeds', clarify its respectful nature, delineate its purpose, and explain the timescale.

FOLLOW-UP

It is not standardised; parents wish to see their multi-professional team.

CONCLUSIONS

There is unacceptable variation in care after stillbirth, and insensitive interactions between staff and bereaved parents. Understanding parents' needs, including why they ask for caesarean birth, will facilitate joint decision-making. Every bereaved parent is entitled to good, respectful care.

TWEETABLE ABSTRACT

Care too varied & interactions often insensitive after stillbirth; national pathway & training urgently needed PLAIN LANGUAGE SUMMARY: Why and how was the study carried out? Previous studies have shown that improving care after stillbirth is important for families. We investigated the opinions of bereaved parents and maternity staff to find ways to improve care. At three hospitals in 2013, all women who experienced a stillbirth were invited to an interview along with their partners. Thirty-five parents of 21 babies agreed to participate. Twenty-two obstetricians and midwives took part in focus group discussions. What were the main findings? Care was often not as good as it should and could be. Communication with parents was not always as sensitive as they would have liked because staff did not have appropriate training. Some women reported they did not 'feel right' before going to hospital. Once they arrived, there was no standard approach to how care was given. Sometimes there were long delays before the death of the baby was confirmed and action was taken. After it had been confirmed that the baby had died, staff focussed on the mothers' needs, but the parents' priorities were still with their baby. There were several reasons why parents asked for a caesarean birth that staff had not considered. Staff influenced parents' decisions about post-mortem examinations. Parents found it helpful when staff explained the respectful nature and purpose of the examination. After discharge from hospital, there was no consistent plan for how follow-up care would be given. Parents would have liked more information about their next hospital appointment. What are the limitations of the work? The parents interviewed depended on their memories of the details of the care, which happened some time ago. In staff group discussions, junior doctors may not have spoken openly because there were senior doctors present. Further research is necessary to understand and improve care globally. What is the implication for parents? Every bereaved parent is entitled to the best possible care after stillbirth, but some do not get good care. Parents and staff made suggestions that can help to develop processes for how care is given after stillbirth. These suggestions can also inform staff training, so that every single parent is treated respectfully and participates in decision making.

Neuroinflammation and the generation of neuropathic pain

Inflammation is the process by which an organism responds to tissue injury involving both immune cell recruitment and mediator release. Diverse causes of neuropathic pain are associated with excessive inflammation in both the peripheral and central nervous system which may contribute to the initiation and maintenance of persistent pain. Chemical mediators, such as cytokines, chemokines, and lipid mediators, released during an inflammatory response have the undesired effect of sensitizing and stimulating nociceptors, their central synaptic targets or both. These changes can promote long-term maladaptive plasticity resulting in persistent neuropathic pain. This review aims to provide an overview of inflammatory mechanisms at differing levels of the sensory neuroaxis with a focus on neuropathic pain. We will compare and contrast neuropathic pain states such as traumatic nerve injury which is associated with a vigorous inflammatory response and chemotherapy induced pain in which the inflammatory response is much more modest. Targeting excessive inflammation in neuropathic pain provides potential therapeutic opportunities and we will discuss some of the opportunities but also the clinical challenges in such an approach.

Contamination and current practice in decontamination pof nebulisers in ventilated patients

To examine the incidence of contamination and current practice of decontamination of nebulisers after use within a ventilator circuit, in public- and private sector intensive care units (ICUs) in Johannesburg; to assess the presence of and adherence to a decontamination protocol in these ICUs and to identify which practices were associated with lower or no bacterial growth. Methods: A cross-sectional study design was used which included a semi-structured interview with the ICU manager and an audit of current nebuliser practice. Nebulisers that were identified in the interview were swabbed and streaked on blood agar plates (BAPs). BAPs were incubated and assessed for bacterial colonisation, number of colony forming units (CFUs) and number of different species of CFUs present. Results: Two hundred and sixty-nine ICU beds were surveyed over a two-month period resulting in 45 nebulisers used within a ventilator circuit that could be tested. The majority (93%) were single-use jet nebulisers, all were being re-used and 52% presented with contamination. None of the ICUs had a nebuliser decontamination protocol in place. Contaminated nebulisers that were stored in a sterile drape had significantly higher concentrations of bacterial growth (p=0.03). Conclusion: The rate of colonisation of re-used jet nebulisers is high. Nebuliser decontamination protocols are urgently needed.

Defining the endoscopic appearances of tylosis using conventional and narrow-band imaging: a case series

Tylosis is an autosomal dominant skin disorder strongly associated with esophageal squamous cell cancer. We present a single-operator experience of utilizing conventional endoscopy and narrow-band imaging with magnification to characterize esophageal appearances in tylosis. Nineteen consecutive patients with tylosis attending for surveillance endoscopy were studied. White-light imaging (WLI) and narrow-band imaging (NBI) were undertaken, with magnification being performed as necessary. On WLI, we classified 12 patients as having mild change, 5 moderate change, and 2 severe change. WLI can define changes to the esophageal mucosa of variable hyperkeratosis and identify more significant focal abnormalities. NBI enhances these mucosal changes, and NBI with magnification can demonstrate intrapapillary capillary loop changes compatible with dysplasia, prompting consideration of surgery. This report is the first to characterize the endoscopic appearances in tylosis.

40 Gbit/s asynchronous digital optical regenerator

We present the first experimental demonstration of an asynchronous digital optical regenerator at 42.67 Gbit/s. The system effectively retimes incoming asynchronous data bursts to a local clock without burst mode clock recovery and converts the signal to a desired wavelength and duty cycle.

Inherited predisposition to colorectal adenomas caused by multiple rare alleles of MUTYH but not OGG1, NUDT1, NTH1 or NEIL 1, 2 or 3

BACKGROUND

MUTYH-associated polyposis (MAP) is a recessive trait characterised by multiple colorectal adenomas and a high risk of colorectal cancer. MUTYH functions in the DNA base excision repair pathway and has a key role in the repair of oxidative DNA damage.

OBJECTIVES

To assess the contribution of inherited variants in genes involved in base excision repair and oxidative DNA damage including MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 to the multiple colorectal adenoma phenotype.

METHODS

Inherited variants of MUTYH, OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 were sought in 167 unrelated patients with multiple colorectal adenomas whose family histories were consistent with recessive inheritance. These variants were also characterised in approximately 300 population controls.

RESULTS

Thirty-three patients (20%) and no controls were MUTYH homozygotes or compound heterozygotes (ie, carried two mutations) and therefore had MAP. Eight different pathogenic MUTYH mutations were identified, of which four were novel. MAP cases had significantly more adenomas than non-MAP cases (p = 0.0009; exact test for trends in proportions) and presented earlier (p = 0.013; analysis of variance). Twenty-four protein-altering variants were identified upon screening of OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1. However, all combinations of two (or more) variants that were identified at an individual locus in patients were also seen in controls, and no variants were significantly over-represented (or under-represented) in cases.

CONCLUSION

Multiple rare alleles of MUTYH are associated with autosomal recessive MAP, while OGG1, NEIL1, NEIL2, NEIL3, NUDT1 and NTH1 do not contribute significantly to autosomal recessive polyposis.

Clinical trial: randomized study of clarithromycin versus placebo in active Crohn's disease

BACKGROUND

Crohn's disease is characterized by defective innate immune responses to intestinal bacteria. Clarithromycin is a broad-spectrum antibiotic that has good penetration into macrophages.

AIM

To assess the efficacy of clarithromycin in active Crohn's disease.

METHODS

Patients with Crohn's disease activity index > 200 and serum C-reactive protein > or = 10 mg/L were randomized to receive clarithromycin 1 g o.d. or placebo for 3 months. Patients taking more than 10 mg/day prednisolone or 3 mg/day budesonide were excluded. Primary outcome was remission (CDAI < or = 150) or response (fall in CDAI > or = 70 from pre-treatment level) at 3 months.

RESULTS

The trial was stopped after 41 patients had been recruited because of poor overall efficacy. There was no difference in combined remission or response rates at 3 months between clarithromycin: 26% (five of 19) and placebo: 27% (six of 22) (P = 1.00). The mean (s.d.) fall in Crohn's disease activity index was 35 (80) clarithromycin and -2 (114) placebo (P = 0.24). However, post hoc analysis showed a significant difference in response/remission determined by Crohn's disease activity index after 1 month: 53% (10 of 19) clarithromycin vs. 14% (three of 22) placebo (P = 0.01).

CONCLUSION

Clarithromycin 1 g for 3 months is ineffective in active Crohn's disease but possible benefit was observed at 1 month, suggesting that an initial effect may be attenuated by subsequent bacterial resistance.