Anti-GM-CSF otilimab versus sarilumab or placebo in patients with rheumatoid arthritis and inadequate response to targeted therapies: a phase III randomised trial (contRAst 3)

OBJECTIVES

To investigate the efficacy and safety of otilimab, an anti-granulocyte-macrophage colony-stimulating factor antibody, in patients with active rheumatoid arthritis and an inadequate response to conventional synthetic (cs) and biologic disease-modifying antirheumatic drugs (DMARDs) and/or Janus kinase inhibitors.

METHODS

ContRAst 3 was a 24-week, phase III, multicentre, randomised controlled trial. Patients received subcutaneous otilimab (90/150 mg once weekly), subcutaneous sarilumab (200 mg every 2 weeks) or placebo for 12 weeks, in addition to csDMARDs. Patients receiving placebo were switched to active interventions at week 12 and treatment continued to week 24. The primary end point was the proportion of patients achieving an American College of Rheumatology ≥20% response (ACR20) at week 12.

RESULTS

Overall, 549 patients received treatment. At week 12, there was no significant difference in the proportion of ACR20 responders with otilimab 90 mg and 150 mg versus placebo (45% (p=0.2868) and 51% (p=0.0596) vs 38%, respectively). There were no significant differences in Clinical Disease Activity Index, Health Assessment Questionnaire-Disability Index, pain Visual Analogue Scale or Functional Assessment of Chronic Illness Therapy-Fatigue scores with otilimab versus placebo at week 12. Sarilumab demonstrated superiority to otilimab in ACR20 response and secondary end points. The incidence of adverse or serious adverse events was similar across treatment groups.

CONCLUSIONS

Otilimab demonstrated an acceptable safety profile but failed to achieve the primary end point of ACR20 and improve secondary end points versus placebo or demonstrate non-inferiority to sarilumab in this patient population.

TRIAL REGISTRATION NUMBER

NCT04134728.

Anti-GM-CSF otilimab versus tofacitinib or placebo in patients with active rheumatoid arthritis and an inadequate response to conventional or biologic DMARDs: two phase 3 randomised trials (contRAst 1 and contRAst 2)

OBJECTIVES

To investigate the efficacy and safety of otilimab, an antigranulocyte-macrophage colony-stimulating factor antibody, in patients with active rheumatoid arthritis.

METHODS

Two phase 3, double-blind randomised controlled trials including patients with inadequate responses to methotrexate (contRAst 1) or conventional synthetic/biologic disease-modifying antirheumatic drugs (cs/bDMARDs; contRAst 2). Patients received background csDMARDs. Through a testing hierarchy, subcutaneous otilimab (90/150 mg once weekly) was compared with placebo for week 12 endpoints (after which, patients receiving placebo switched to active interventions) or oral tofacitinib (5 mg two times per day) for week 24 endpoints.

PRIMARY ENDPOINT

proportion of patients achieving an American College of Rheumatology response ≥20% (ACR20) at week 12.

RESULTS

The intention-to-treat populations comprised 1537 (contRAst 1) and 1625 (contRAst 2) patients.

PRIMARY ENDPOINT

proportions of ACR20 responders were statistically significantly greater with otilimab 90 mg and 150 mg vs placebo in contRAst 1 (54.7% (p=0.0023) and 50.9% (p=0.0362) vs 41.7%) and contRAst 2 (54.9% (p<0.0001) and 54.5% (p<0.0001) vs 32.5%). Secondary endpoints: in both trials, compared with placebo, otilimab increased the proportion of Clinical Disease Activity Index (CDAI) low disease activity (LDA) responders (not significant for otilimab 150 mg in contRAst 1), and reduced Health Assessment Questionnaire-Disability Index (HAQ-DI) scores. Benefits with tofacitinib were consistently greater than with otilimab across multiple endpoints. Safety outcomes were similar across treatment groups.

CONCLUSIONS

Although otilimab demonstrated superiority to placebo in ACR20, CDAI LDA and HAQ-DI, improved symptoms, and had an acceptable safety profile, it was inferior to tofacitinib.

TRIAL REGISTRATION NUMBERS

NCT03980483, NCT03970837.

A Retrospective Application of the Arbon and Hartman Models to the Union Cycliste International Mountain Bike World Cup

INTRODUCTION

Outdoor activities have accelerated in the past several years. The authors were tasked with providing medical care for the Union Cycliste International (UCI) mountain biking World Cup in Snowshoe, West Virginia (USA) in September 2021. The Hartman and Arbon models were designed to predict patient presentation and hospital transport rates as well as needed medical resources at urban mass-gathering events. However, there is a lack of standardized methods to predict injury, illness, and insult severity at rural mass gatherings.

STUDY OBJECTIVE

This study aimed to determine whether the Arbon model would predict, within 10%, the number of patient presentations to be expected and to determine if the event classification provided by the Hartman model would adequately predict resources needed during the event.

METHODS

Race data were collected from UCI event officials and injury data were collected from participants at time of presentation for medical care. Predicted presentation and transport rates were calculated using the Arbon model, which was then compared to the actual observed presentation rates. Furthermore, the event classification provided by the Hartman model was compared to the resources utilized during the event.

RESULTS

During the event, 34 patients presented for medical care and eight patients required some level of transport to a medical facility. The Arbon predictive model for the 2021 event yielded 30.3 expected patient presentations. There were 34 total patient presentations during the 2021 race, approximately 11% more than predicted. The Hartman model yielded a score of four. Based on this score, this race would be classified as an "intermediate" event, requiring multiple Advanced Life Support (ALS) and Basic Life Support (BLS) personnel and transport units.

CONCLUSION

The Arbon model provided a predicted patient presentation rate within reasonable error to allow for effective pre-event planning and resource allocation with only a four patient presentation difference from the actual data. While the Arbon model under-predicted patient presentations, the Hartman model under-estimated resources needed due to the high-risk nature of downhill cycling. The events staffed required physician skills and air medical services to safely care for patients. Further evaluation of rural events will be needed to determine if there is a generalized need for physician presence at smaller events with inherently risky activities, or if this recurring cycling event is an outlier.

Do patients prefer face-to-face or telephone consultations in an outpatient cardiology department?

Introduction

There has been a significant rise in the telephone clinic consultations in preference to face-to-face (FTF) clinics in the UK during the COVID 19 pandemic. The cardiology department in a district general hospital has also seen increased use of telephone clinics. We wanted a greater understanding of the impact of telephone consultations on patient satisfaction.

Methods

A patient satisfaction survey was designed based on the joint Royal College of Physicians training board (JRCPTB) patient satisfaction survey. The survey (Image 1) was sent via post to 300 patients reviewed by the cardiology outpatient department during November 2021. 150 who had telephone appointments and to 150 patients who had FTF appointments. Descriptive statistics and student T test were used to compare differences between the two groups with a p value of <0.05.

Results

There were 171 responses returned over a four-week period giving a 57% response rate. Of these, 75 respondents had a telephone appointment and 96 who had FTF appointments. 49% of the FTF patients were male compared to 55% of the telephone clinic respondents. The majority of patients were aged 70–89 in both groups and most patients were retired (79.2% for FTF and 65.3% on the telephone consultation group).

More patients felt the doctor was polite and considerate in FTF clinics compared to telephone consultation (97% compared to 92% positive responses, p value – 0.02). There was no significant difference in patients feeling listened too, being allowed time to ask questions, understanding their condition and being involved in decision making between the two groups (Table 1).

Of the FTF group, 81% preferred FTF clinics with only 3% preferring telephone clinics and 16% with no preference. Of the telephone group 53% stated a preference for FTF clinics, with 11% having a preference for phone clinics and 36% having no preference.

Patients rated overall experience more positively with FTF appointments (95%) compared to telephone clinics (85%, p value 0.02).

Conclusion

Telephone consultations performed at a comparable level to FTF clinics although patients demonstrate an overall preference for FTF clinics.

Funding Acknowledgement

Type of funding sources: None.

Effect of calcium on moving-bed biofilm reactor biofilms

The effect of calcium concentration on the biofilm structure, microbiology, and treatment performance was evaluated in a moving-bed biofilm reactor. Three experiments were conducted in replicate laboratory-scale reactors to determine if wastewater calcium is an important variable for the design and optimization of these reactors. Biofilm structural properties, such as thickness, oxygen microprofiles, and the composition of extracellular polymeric substances (EPS) were affected by increasing calcium concentrations. Above a threshold concentration of calcium between 1 and 50 mg/L, biofilms became thicker and denser, with a shift toward increasingly proteinaceous EPS at higher calcium concentrations up to 200 mgCa2+/L. At 300 mgCa2+/L, biofilms were found to become primarily composed of inorganic calcium precipitates. Microbiology was assessed through microscopy, denaturing grade gel electrophoresis, and enumeration of higher organisms. Higher calcium concentrations were found to change the bacterial community and promote the abundant growth of filamentous organisms and various protazoa and metazoan populations. The chemical oxygen demand removal efficiency was improved for reactors at calcium concentrations of 50 mg/L and above. Reactor effluents for the lowest calcium concentration (1 mgCa2+/L) were found to be turbid (>50 NTU), as a result of the detachment of small and poorly settling planktonic biomass, whereas higher concentrations promoted settling of the suspended phase. In general, calcium was found to be an important variable causing significant changes in biofilm structure and reactor function.

The clinical needs of patients with chronic gastrointestinal symptoms after pelvic radiotherapy

BACKGROUND

After radiotherapy for pelvic cancer, gastrointestinal symptoms affecting quality of life are common. How they affect daily living is unknown.

AIM

To investigate the day-to-day impact of gastrointestinal symptoms in patients after pelvic radiotherapy.

METHODS

New patients referred for gastroenterological evaluation of radiotherapy-induced symptoms were sent a questionnaire.

RESULTS

Over 15 months, 75 of 100 questionnaires were completed before the gastroenterology appointment by 45 men (median age 70) and 30 women (median age 57) treated for urological (n = 44), gynaecological (n = 27) and gastrointestinal (n = 4) cancers. Time since radiotherapy was 3 years (median) for women and 1.5 years (men). Women experienced 6 (median) symptoms whilst men experienced 4. Having someone listen to problems was often as important as treatment. Urgency, diarrhoea, pain, rectal bleeding, flatulence and bloating were particularly troublesome. 57% women and 33% men were 'very affected'. Symptoms rarely improved with time and in 33% had been present for more than 2 years. Gastrointestinal symptoms affected quality of life through change of routine (F 37%, M 22%), social limitation (F 17%, M 33%), physical limitations (F 33%, M 16%), emotional difficulties (F 47%, M 18%) and sexual problems (F 30%, M 51%).

CONCLUSIONS

Patients experience a high number of physical symptoms for long periods before referral. Clinicians must focus systematically on physical, emotional and psychosexual issues.

Multivariate statistical analysis of a high rate biofilm process treating kraft mill bleach plant effluent

This study reports on a multivariate analysis of the moving bed biofilm reactor (MBBR) wastewater treatment system at a Canadian pulp mill. The modelling approach involved a data overview by principal component analysis (PCA) followed by partial least squares (PLS) modelling with the objective of explaining and predicting changes in the BOD output of the reactor. Over two years of data with 87 process measurements were used to build the models. Variables were collected from the MBBR control scheme as well as upstream in the bleach plant and in digestion. To account for process dynamics, a variable lagging approach was used for variables with significant temporal correlations. It was found that wood type pulped at the mill was a significant variable governing reactor performance. Other important variables included flow parameters, faults in the temperature or pH control of the reactor, and some potential indirect indicators of biomass activity (residual nitrogen and pH out). The most predictive model was found to have an RMSEP value of 606 kgBOD/d, representing a 14.5% average error. This was a good fit, given the measurement error of the BOD test. Overall, the statistical approach was effective in describing and predicting MBBR treatment performance.

Amaranth decoloration by Trametes versicolor in a rotating biological contacting reactor

Sequential batch and continuous operation of a rotating biological contacting (RBC) reactor and the effects of dissolved oxygen on the decoloration of amaranth by Trametes versicolor were evaluated. Amaranth belongs to the group of azo dyes which are potential carcinogens and/or mutagens that can be transformed into toxic aryl amines under anaerobic conditions. Cultivation of T. versicolor in a stirred tank reactor was found to be unsuitable for amaranth decoloration due to significant biomass fouling and increase in medium viscosity. Assuming that decoloration follows first-order kinetics, amaranth was decolorized more rapidly when T. versicolor was immobilized on jute twine in a RBC reactor operated either in a sequential batch (k=0.25 h(-1)) or in a continuous (0.051 h(-1)) mode compared to a stirred tank reactor (0.015 h(-1)). Oxygen was found to be essential for decoloration with the highest decoloration rates occurring at oxygen saturation. Although longer retention times resulted in more decoloration when the RBC was operated in the continuous mode (about 33% amaranth decoloration), sequential batch operation gave better results (>95%) under similar nutrient conditions. Our data indicate that the fastest decoloration should occur in the RBC using nitrogen-free Kirk's medium with 1 g/l glucose in sequential batch operation at rotational speeds and/or aeration rates which maintain oxygen saturation in the liquid phase.

Interactive process of conducting and utilizing research in nursing service administration

The authors report on a project that evolved from a single-purpose project--research use in nursing service administration--to a multipurpose process. The project team initially intended to conduct a classic research use project to develop management interventions to improve job satisfaction. The team eventually conducted three basic research projects and systematically applied this knowledge to the practice of nursing service administration. The members of the team, who came from academic and service settings, collaborated in a dynamic and interactive process of generating and applying knowledge. The products of this work were immediately useful in the setting and can be used more broadly in organizing and managing the care of hospital patients.

Infusing research into practice to promote quality care

This article describes the Iowa Model of Research in Practice, a heuristic model used at the University of Iowa Hospitals and Clinics for infusing research into practice to improve the quality of care. The components of the model are presented with examples. The impact of the model on patient, staff, and fiscal outcomes is delineated.

Nasogastric and nasointestinal feeding tube placement: an integrative review of research

The authors present a review of the research on various methods for determining placement of nasogastric and nasointestinal feeding tubes. They also discuss research on associated risk factors, complications specific to critical care patient populations, and techniques for postpyloric placement. They present research consensus, recommendations for practice, and implementation strategies.

Preferences for decision-making autonomy

Nurses' lack of autonomy has been identified as a leading cause of job dissatisfaction, but attempts to increase satisfaction by increasing autonomy have not always been successful. This survey of 356 randomly selected staff nurses and 130 head nurses from 16 hospitals extends previous work by identifying the preferred level of involvement in 21 patient care and 21 unit operation decisions. Staff nurses agreed on 60 percent of the decisions and, in general, preferred independent decision-making for patient care decisions and shared decision-making for unit operation. Head nurses indicated that staff nurses should have a higher level of autonomy than the staff nurses indicated for themselves.

Aluminium in bone from patients with renal failure

Some samples of bone from patients with renal failure contained more aluminium than others, and the concentration tended to be highest in patients who had been uraemic or on dialysis longest. The significance of the association of raised concentrations of aluminium in bone with renal failure is discussed.