Risankizumab Induction Therapy Achieves Early Symptom Improvements That Are Associated With Future Clinical and Endoscopic Outcomes in Crohn's Disease: Post Hoc Analysis of the ADVANCE, MOTIVATE, and FORTIFY Phase 3 Studies

BACKGROUND AND AIMS

Crohn's disease (CD) symptoms are a main driver for impaired quality of life and fast relief is important for patient care. Stool frequency (SF) and abdominal pain score (APS) are patient reported outcomes (PROs) measuring symptom severity, which are supported as treatment targets by the STRIDE-II consensus. This post hoc analysis examined the efficacy of risankizumab (RZB), a humanised monoclonal antibody with high specificity for interleukin-23 p19, for providing early symptom relief, along with the prognostic value of early symptom relief for achieving future clinical and endoscopic endpoints.

METHODS

Individual and combined measures of SF and AP at weeks 1, 2, and 3 were assessed in patients with moderate to severe CD who received 600 mg intravenous RZB or placebo (PBO) in the ADVANCE or MOTIVATE induction studies. Multivariate logistic regression was used to examine the predictiveness of early symptom improvement for clinical and endoscopic outcomes following RZB induction and maintenance.

RESULTS

Higher rates of SF/APS clinical remission and enhanced clinical response were observed as early as week 1 with RZB versus PBO. A larger proportion of patients achieved clinical endpoints with RZB versus PBO, irrespective of prior bio-failure status. Early PRO improvement was associated with a greater likelihood of achieving clinical and endoscopic improvement following 12-weeks induction and 52-weeks maintenance RZB dosing.

CONCLUSIONS

After the first intravenous RZB induction dose, significantly greater rates of symptom improvement versus PBO were achieved. Improvements could be observed as early as week 1 and were predictive of week 12 and 52 clinical and endoscopic improvement.

Full-scale comparison of N2O emissions from SBR N/DN operation versus one-stage deammonification MBBR treating reject water - and optimization with pH set-point

To be able to fulfill the Paris agreement regarding anthropogenic greenhouse gases, all potential emissions must be mitigated. Wastewater treatment plants should aim to eliminate emissions of the most potent greenhouse gas, nitrous oxide (N₂O). In this study, these emissions were measured at a full-scale reject water treatment tank during two different operation modes: nitrification/denitrification (N/DN) operating as a sequencing batch reactor (SBR), and deammonification (nitritation/anammox) as a moving bed biofilm reactor (MBBR). The treatment process emitted significantly less nitrous oxide in deammonification mode 0.14-0.7%, compared to 10% of total nitrogen in N/DN mode. The decrease can be linked to the changed feeding strategy, the lower concentrations of nitrite, a lower load of ammonia oxidized, a shorter aeration time, the absence of non-optimized ethanol dosage or periodic lack of oxygen as well as the introduction of biofilm. Further, evaluation was done how the operational pH set point influenced the emissions in deammonification mode. Lower concentrations of nitrous oxide were measured in water phase at higher pH (7.5-7.6) than at lower pH (6.6-7.1). This is believed to be mainly because of the lower aeration ratio and increased complete denitrification at the higher pH set point.

Anaerobic co-digestion of sludge and microalgae grown in municipal wastewater - a feasibility study

In this study a natural mix of microalgae grown in wastewater of municipal character was co-digested with sewage sludge in mesophilic conditions, in both batch and semi-continuous modes. The semi-continuous experiment was divided into two periods with OLR₁ (organic loading rate) of 2.4 kg volatile solids (VS) m^-3 d^-1 and HRT₁ (hydraulic retention time) of 15 days, and OLR₂ of 3.5 kg VS m^-3 d^-1 and HRT₂ of 10 days, respectively. Results showed stable conditions during both periods. The methane yield was reduced when adding microalgae (from 200 ± 25 NmL CH₄ g VS_in^-1, to 168 ± 22 NmL CH₄ g VS_in^-1) but VS reduction was also decreased by 51%. This low digestibility was confirmed in the anaerobic batch test. However, adding microalgae improved the dewaterability of the digested sludge. The high heavy metals content in the microalgae resulted in a high heavy metals content in the digestate, making it more difficult to reuse the digestate as fertilizer on arable land. The heavy metals are thought to originate from the flue gas used as a CO₂ source during the microalgae cultivation. Therefore the implementation of CO₂ mitigation via algal cultivation requires careful consideration regarding the source of the CO₂-rich gas.

Subcutaneous peginterferon β-1a injection-site reaction experience and mitigation: Delphi analysis of the ALLOW study

AIM

The objective of this Delphi analysis was to obtain consensus on injection-site reaction (ISR) experience and mitigation strategies for patients with relapsing-remitting multiple sclerosis switching from nonpegylated interferons (IFNs) to peginterferon β-1a in the ALLOW Phase IIIb trial using a three-step approach.

METHODS

Study investigators and coordinators from investigative sites enrolling four or more patients in ALLOW participated in three rounds of questionnaires and interviews.

RESULTS

Respondents (n = 37) agreed that the most common ISR, erythema, was not disruptive to daily activities. Patient education, as a conversation with a clinician about ISR potential, was recommended.

CONCLUSION

The consensus of Delphi respondents on ISR experience and ISR management after switching from nonpegylated IFNs to peginterferon β-1a can help inform treatment decisions and manage patient expectations.

Gastrointestinal Tolerability of Delayed-Release Dimethyl Fumarate in a Multicenter, Open-Label Study of Patients with Relapsing Forms of Multiple Sclerosis (MANAGE)

BACKGROUND

In phase 3 trials, delayed-release dimethyl fumarate (DMF; also known as gastroresistant DMF) demonstrated efficacy in relapsing-remitting multiple sclerosis (MS). Gastrointestinal (GI) events were associated with DMF treatment. The single-arm, open-label MANAGE study examined the incidence, severity, duration, and management of GI events in adults with relapsing MS initiating DMF treatment in clinical practice in the United States shortly after marketing approval.

PATIENTS AND METHODS

Patients (N = 233) took DMF for up to 12 weeks and recorded information regarding GI events using an eDiary and numerical rating scales.

RESULTS

Overall, 54.1% of patients used symptomatic therapy and had GI symptoms. The incidence of GI events was highest in the first month of treatment. The duration of GI events varied by event type, and severity was generally mild to moderate. Decreased severity was seen in patients treated with antacids, bismuth subsalicylate, acid-secretion blockers, antidiarrheals, and antiemetics. Less than 10% of patients were using symptomatic therapy for GI events by week 12 of DMF treatment. A modest reduction in severe GI events was observed in patients who regularly took DMF with food compared with patients who did not. The incidence of GI-related events was comparable in patients with or without a history of GI abnormalities and in patients who did or did not use alcohol or tobacco.

CONCLUSIONS

Gastrointestinal events associated with DMF are generally transient, mild to moderate in severity, and manageable. Symptomatic therapy and dosing with food may mitigate these events.

Steady-state analysis of activated sludge processes with a settler model including sludge compression

A reduced model of a completely stirred-tank bioreactor coupled to a settling tank with recycle is analyzed in its steady states. In the reactor, the concentrations of one dominant particulate biomass and one soluble substrate component are modelled. While the biomass decay rate is assumed to be constant, growth kinetics can depend on both substrate and biomass concentrations, and optionally model substrate inhibition. Compressive and hindered settling phenomena are included using the Bürger-Diehl settler model, which consists of a partial differential equation. Steady-state solutions of this partial differential equation are obtained from an ordinary differential equation, making steady-state analysis of the entire plant difficult. A key result showing that the ordinary differential equation can be replaced with an approximate algebraic equation simplifies model analysis. This algebraic equation takes the location of the sludge-blanket during normal operation into account, allowing for the limiting flux capacity caused by compressive settling to easily be included in the steady-state mass balance equations for the entire plant system. This novel approach grants the possibility of more realistic solutions than other previously published reduced models, comprised of yet simpler settler assumptions. The steady-state concentrations, solids residence time, and the wastage flow ratio are functions of the recycle ratio. Solutions are shown for various growth kinetics; with different values of biomass decay rate, influent volumetric flow, and substrate concentration.

BG-12 (dimethyl fumarate): a review of mechanism of action, efficacy, and safety

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory disease, affecting more than 2.5 million people worldwide with more 400,000 cases in the United States alone. There has been considerable improvement in the treatment of MS, with the introduction of disease-modifying drugs; however, new oral therapies may provide additional benefit by providing an alternative treatment modality and the potential for improved adherence by avoiding the injection-associated side effects and anxiety encountered with some first-line agents. BG-12 (dimethyl fumarate) is an oral agent approved in the United States for the treatment of relapsing forms of MS.

SCOPE

We review published literature about what is known about the mechanism of action of BG-12, and key efficacy and safety findings from three clinical studies in patients with relapsing-remitting MS (RRMS).

FINDINGS

Data from preclinical studies have demonstrated that BG-12 may promote anti-inflammatory and cytoprotective activities that are mediated, at least in part, by the nuclear factor (erythroid-derived 2)-like 2 (Nrf2) antioxidant response pathway. Studies in animals have shown a protective effect of BG-12 on neuronal, axonal and myelin integrity. Results from a phase 2 study and two randomized double-blind placebo-controlled phase 3 studies, CONFIRM and DEFINE, have shown that BG-12 provides clinical and radiologic efficacy in patients with RRMS. At 2 years, BG-12 240 mg twice and three times daily reduced annualized relapse rate (CONFIRM primary endpoint) by 44% and 51% and the risk of relapse (DEFINE primary endpoint) by 49% and 50%, respectively, compared with placebo (all p < 0.001). BG-12 was generally well tolerated and had an acceptable safety profile, with a similar incidence of adverse events across treatment groups.

CONCLUSIONS

BG-12 may have cytoprotective and anti-inflammatory properties that contribute to its efficacy among patients with RRMS. Findings from phase 2 and 3 studies further support BG-12 as an effective initial therapy. ClinicalTrials.gov ID: NCT00168701; NCT00420212: NCT00451451.

Effect of a prefabricated anterior bite stop on electromyographic activity of masticatory muscles

STATEMENT OF PROBLEM

Patients are often treated for signs and symptoms in the masticatory musculature, which may be manifested as pain and/or conditions that cause difficulty in recording jaw relation records. A quick, easy method to alleviate these signs and symptoms would be helpful.

PURPOSE

This study measured the effect of a prefabricated anterior bite stop on the electromyographic activity of the anterior temporalis, posterior temporalis, masseter and anterior digastric during clenching, and grinding tasks.

MATERIAL AND METHODS

A prefabricated anterior bite stop was fabricated for 30 randomly selected subjects. Electromyographic surface electrodes were placed on the right and left sides of these muscles. Electromyographic activity was measured during clenching and grinding both with and without the anterior bite stop.

RESULTS

The anterior bite stop had a significant effect in decreasing electromyographic activity for both clenching and grinding for all the tested muscles, except the anterior digastric.

CONCLUSIONS

For this patient population, the ready-made anterior bite stop reduced electromyographic muscle activity for the anterior and posterior temporalis and the masseter muscles during both clenching and grinding.

Bioactive annonaceous acetogenins from the bark of Xylopia aromatica

Bioactive Annonaceous acetogenins have been isolated from the EtOH extract of the bark of Xylopia aromatica by bioactivity-directed fractionation using lethality to brine shrimp. These acetogenins include xylopianin [1 , xylopiacin [2], and xylomaticin [3], which are three new mono-tetrahydrofuran ring type acetogenins, in addition to the known compounds, annomontacin, gigantetronenin, gigantetrocin A, and annonacin. Compounds 1 and 2 are unusual in having hydroxylation at C-8; 3 has the same functionalities as annonacin but with 37 carbons instead of 35 carbons. The structures were elucidated by spectral analysis of the parent compounds and/or simple chemical derivatives. These acetogenins showed cytotoxicities, comparable to adriamycin, against three human solid tumor cell lines.

Suction-assisted lipectomy for correction of 202 figure faults in 101 patients: indications, limitations, and applications

Since its introduction in the United States, suction-assisted lipectomy has proven to be a safe, effective technique for correction of figure faults. It has been greeted with considerable skepticism by many practitioners, however, owing to the poor results many have obtained in their initial attempts to apply similar techniques. Suction lipectomy using the blunt technique is a safe procedure that can yield consistently good results when appropriately applied. It is suggested that the principal reason others have had difficulty involves problems in patient selection. The technique may not be effective for the correction of generalized obesity and cannot be expected to dramatically alter overall appearance. Patients should be selected for treatment of specific "figure faults" and educated as to what may realistically be expected. The patient's emotional and psychological condition must be taken into consideration. We report a series of 101 patients treated with a total of 202 separate suction lipectomy procedures with good results and only two minor complications. A survey of patients treated by the method reveals a generally high level of satisfaction and some of the ambivalence that might be anticipated from such a technique.