Risk of Major Adverse Cardiovascular Events in Immune-Mediated Inflammatory Disorders on Biologics and Small Molecules: Network Meta-Analysis

BACKGROUND AND AIMS

Recent studies raise concern for increased risk of major adverse cardiovascular events (MACE) with Janus kinase (JAK) inhibitors used to treat immune-mediated inflammatory disorders (IMIDs). We aimed to examine MACE risk with licensed biologics and small molecules used commonly between IMIDs: inflammatory bowel disease, rheumatoid arthritis, psoriasis/psoriatic arthritis, and ankylosing spondylitis.

METHODS

Data were obtained from systematic searches (from inception to May 31, 2022) in PubMed, Embase, Ovid Medline, Scopus, Cochrane Central, and ClinicalTrials.gov. Studies that assessed a predefined MACE (myocardial infarction, cerebrovascular accident, unstable angina, cardiovascular death, or heart failure) risk in those ≥18 years of age with IMIDs treated with anti-interleukin (IL)-23 antibodies, anti-IL-12/23, anti-tumor necrosis factor α antibodies (anti-TNF-α), or JAK inhibitors were included in a network meta-analysis using a random-effects model with pooled odds ratios (ORs) reported with 95% credible intervals (CrIs) by drug class and disease state.

RESULTS

Among 3528 studies identified, 40 (36 randomized controlled trials and 4 cohort studies) were included in the systematic review, comprising 126,961 patients with IMIDs. Based on network meta-analysis of randomized controlled trials, regardless of disease state, anti-TNF-α (OR, 2.49; 95% CrI, 1.14-5.62), JAK inhibitors (OR, 2.64; 95% CrI, 1.26-5.99), and anti-IL-12/23 (OR, 3.15; 95% CrI, 1.01-13.35) were associated with increased MACE risk compared with placebo. There was no significant difference in the magnitude of the MACE risk between classes or based on IMID type.

CONCLUSIONS

Anti-IL-12/23, JAK inhibitors, and anti-TNF-α were associated with higher risk of MACE compared with placebo. The magnitude of the increased MACE risk was not different by IMID type. These results require confirmation in larger prospective studies.

The Impact of Appendectomy in Clostridium difficile Infection and Length of Hospital Stay

Introduction

We aim to investigate Clostridium difficile infection (CDI) recurrence, severity, complications, and length of hospital stay in patients with and without prior history of appendectomy who were admitted to the hospital with CDI.

Method

We analyzed retrospective data for 862 patients, 18 years and older, with C. difficile inpatients diagnosed between January 1, 2017 and December 31, 2018 and sorted into two groups, with or without prior appendicectomy, to look for outcomes such as recurrence, hospital stay, complications, and related death in each group and use statistical analysis for comparison.

Result

There were 862 patients admitted with CDI, of which 122 (14.2%) had a prior history of appendectomy and 740 (85.8%) did not. Patients with an appendectomy prior were older (median age of 75 vs. 69, p = 0.0033) and had a higher proportion of females (68.9% vs. 53.6%, p = 0.0017).

C. difficile recurrence in prior appendicectomy group vs. no appendectomy group was 12.3% and 9.3%, respectively, but no statistical difference was noted (p = 0.28). Also, there was no statistical difference in complications like ileus, colectomy, and mortality related to CDI in both groups. However, patients with appendectomies had significantly shorter hospital stays during C. difficile admission compared to patients without appendectomies (median of six days vs. seven days, p = 0.0014).

Conclusion

Our study shows that there is no statistical difference in the recurrence, severity, and complications of CDI in the presence or absence of the appendix but remarkably noted that people with prior appendicectomy had a shorter hospital stay.

Optimal sludge retention time for a bench scale MBR treating municipal sewage

Membrane bioreactors allow for higher sludge concentrations and improved degradation efficiencies with respect to conventional activated sludge. However, in the current practice these systems are often operated under sub-optimal conditions, since so far no precise indications have yet been issued on the optimal operating conditions of MBR for municipal wastewater treatment. This paper reports some results of four years of operation of a bench scale membrane bioreactor where steady state conditions were investigated under different sludge retention times. The whole experimental campaign was oriented towards the investigation of optimal process conditions in terms of COD removal and nitrification, biomass activity and growth, and sludge characteristics. The membrane bioreactor treated real municipal sewage, and four different sludge ages were tested (20, 40, 60, and 80 days) and compared with previous data on complete sludge retention. The results showed that the the biology of the system, as assessed by the oxygen uptake rate, is less affected than the sludge physical parameters. In particular, although the growth yield was observed to dramatically drop for SRT higher than 80 days, the biological activity was maintained under all the tested conditions. These considerations suggest that high SRT are convenient in terms of limited excess sludge production without losses of the treatment capacity. Physical characteristics such as the viscosity and the filterability appear to be negatively affected by prolonged sludge retention times, but their values remain within the ranges normally reported for conventional activated sludge.

Membrane bioreactor sludge rheology at different solid retention times

Rheological characterization is of crucial importance in sludge management both in terms of biomass dewatering and stabilization properties and in terms of design parameters for sludge handling operations. The sludge retention time (SRT) has a significant influence on biomass properties in biological wastewater treatment systems and in particular in membrane bioreactors (MBRs). The aim of this work is to compare the rheological behaviour of the biomass in a MBR operated under different SRTs. A bench-scale MBR was operated for 4 years under the same conditions except for the SRT, which ranged from 20 days to complete sludge retention. The rheological properties were measured over time and the apparent viscosity was correlated with the concentration of solid material when equilibrium conditions were reached and maintained. The three models most commonly adopted for rheological simulations were evaluated and compared in terms of their parameters. Then, steady-state average values of these parameters were related to the equilibrium biomass concentration (MLSS). The models were tested to select the one better fitting the experimental data in terms of mean root square error (MRSE). The relationship between the apparent viscosity and the shear rate, as a function of solid concentration, was determined and is proposed here. Statistical analysis showed that, in general, the Bingham model provided slightly better results than the Ostwald one. However, considering that a strong correlation between the two parameters of the Ostwald model was found for all the SRTs tested, both in the transient growth phases and under steady-state conditions, this model might be used more conveniently. This feature suggests that the latter model is easier to be used for the determination of the sludge apparent viscosity.

Physical characteristics of the sludge in a complete retention membrane bioreactor

Sludge physical characteristics play an important role in the operation of membrane bioreactors (MBR) due to their influence on filtration and their effects on handling of excess sludge. These systems are designed to maintain high solid concentrations, thus limiting sludge production and the related operational costs of the process. In this study, the sludge from a bench scale MBR operated for about 1 year with complete solid retention was investigated to assess its physical and rheological properties. Concentrations of mixed liquor suspended solids (MLSS) up to 24 gTSSL(-1) affected the diluted sludge volume index (DSVI), the capillary suction time (CST), the specific resistance to filtration (SRF) and the compressibility (s). The MBR sludge displayed similar dewatering properties of conventional waste activated sludge, suggesting that the upgrade of wastewater treatment plants with the MBR technology would not affect the behaviour of the dewatering equipment. The apparent viscosity was expressed as a function of the MLSS and the experimental data were interpreted by comparing different models. Ostwald model was chosen, and two equations for viscosity were proposed. The thixotropy of MBR sludge was also evaluated by measuring the reduced hysteresis area (rHa) and relating this parameter to the characteristics of the sludge. The evaluation of energy consumption for mixing evidenced that, under the tested conditions, the increase of solid concentration from 3 to 30 gTSSL(-1) resulted in a limited increase of energy requirements (25-30%).

Influence of solid retention time on the rheology of MBR sludge

The rheological characterization is of crucial importance in sludge management both for biomass dewatering and stabilization purposes and for the definition of design parameters for sludge handling operations. The sludge retention time (SRT) has a significant influence on biomass properties in biological wastewater treatment systems and in particular in membrane bioreactors (MBR). The aim of this work is to compare the rheological behaviour of the biomass in a membrane bioreactor operated under different SRT. A bench scale MBR was operated for four years under the same conditions except for the SRT, that ranged from 20 days to complete sludge retention. The rheological properties were measured over time and the apparent viscosity was correlated with the concentration of solid material under equilibrium conditions. The three models most commonly adopted for rheological simulations were evaluated and compared in terms of their parameters. Steady state average values of these parameters were related to the equilibrium biomass concentration (MLSS). The models were tested to select the one better fitting the experimental data in terms of Mean Root Square Error (MRSE). The relationship between the apparent viscosity and the shear rate, as a function of solid concentration, was determined and proposed.

Rheology of sludge in a complete retention membrane bioreactor

A rheological characterization of the sludge sampled from a complete retention membrane bioreactor was performed in order to correlate the apparent viscosity with the concentration of solids. The three most commonly adopted models were tested to select the one better fitting the experimental data. Ostwald model was choosen, and the relationship between the apparent viscosity and the shear rate was determined for mixed liquor suspended solids (MLSS) concentrations ranging between 9 and 25 g l(-1). Ostwald model parameters k and n were correlated with MLSS concentration, comparing linear, power, and exponential-power (only for k) laws in terms of R2 and Mean Root Square Error (MRSE). Both power and exponential-power functions provided good and comparable correlations for parameter k, while the linear relationship was much less accurate, especially at the highest solid concentrations. The parameter n was better modelled by a power function than by a linear one. Therefore two simulation models were proposed, both based on Ostwald's equation, where the two parameters k and n were expressed as functions of MLSS. Evaluation of energy consumption for mixing showed that the increase of solid concentration from 3 to 30 g l(-1) resulted in a limited increase in energy requirement (25-30 %). In real systems, where Reynolds numbers shift towards the turbulent regime, the increase of energy requirements for increasing solids concentration is even less pronounced. The thixotropy of membrane bioreactor sludge was also evaluated by measuring the rHa (reduced hysteresis area) and relating this parameter to the characteristics of the sludge growing within the reactor.

Zero net growth in a membrane bioreactor with complete sludge retention

A bench-scale membrane bioreactor was operated with complete sludge retention in order to evaluate biological processes and biomass characteristics over the long term. The investigation was carried out by feeding a bench-scale plant with real sewage under constant volumetric loading rate (VLR = 1.2 gCOD L(react)(-1) h(-1)). Biological processes were monitored by measuring substrate removal efficiencies and biomass-related parameters. The latter included bacterial activity as determined through respirometric tests specifically aimed at investigating long term heterotrophic and nitrifying activity. After about 180 days under the imposed operating conditions, the system reached equilibrium conditions with constant VSS concentration of 16-18gL(-1), organic loading rate (OLR) below 0.1 gCOD gVSS(-1) d(-1) and specific respiration rates of 2-3 mgO2 gVSS(-1) h(-1). These conditions were maintained for more than 150 days, confirming that an equilibrium had been achieved between biomass growth, endogenous metabolism, and solubilization of inorganic materials.