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Approximately one-third of patients on biologic therapy for rheumatoid arthritis (RA) receive them as monotherapy. There are few head-to-head randomised control trials comparing biologics as monotherapy. Our aim was to compare the efficacy and persistence of multimodal biologic agents as monotherapy in biologic naïve patients with RA in the real-world setting. A multicentre retrospective observational study was carried out comparing TNF inhibitors (TNFi), IL6 receptor inhibitor (IL6Ri) and CTLA-4 inhibitor (CTLA-4i) monotherapy in biologic naïve RA patients. The primary study outcome was DAS28 score at 6, 12, and 18 months. 126 patients were enrolled; 98 patients (78%) were taking TNFi, 19 patients (15%) IL6Ri and 10 (8%) CTLA-4i with similar baseline characteristics of sex and age across groups. Patients in the CTLA-4i group were more often seropositive and had greater numbers of comorbidities. At 6 and 12 months, patients in the IL6Ri group had a lower DAS28 score compared to TNFi monotherapy. Those on CTLA-4i monotherapy also had a lower DAS28 score at 6 months than the TNFi group, although differences were lost by 12 months. Drug retention at 18 months was highest in the IL6Ri arm (68%) and CTLA-4i arm (80%) compared with only 55% in the TNFi group. Our findings support current guidance that IL6Ri should be considered in biologic naïve patients requiring biologic monotherapy, but also indicated that CTLA-4i could be an option. Patients and methodsWe conducted a retrospective observational study across four UK Rheumatology units. Ethical approval for the study protocol was sought and gained with the UK Health Research Authority following research ethics committee Rheumatology INTERNATIONAL * SizhengPublisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

has been re-written to reflect the structure and format of the paper. 2. Methods have been expanded upon to provide more detail regarding the project overall, the companies/software utilised and example scenarios used in the programme. Questionnaires have also been added as supplementary files. 3. Results have been expanded upon to include more detail regarding both quantitative and qualitative data. 4. Discussion has been amended to include limitations of the study and the implications during the COVID-19 pandemic. 5. References have been amended to reflect the above changes. Referencing errors have also been addressed.

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Teaching non-technical skills (NTS) is an important part of the undergraduate medical curriculum. Resource intensive high-fidelity simulation has an established role in this. We developed an innovative series of immersive virtual reality simulation videos for medical students. We found they demonstrated efficacy in teaching NTS and after viewing students felt better prepared for clinical placements.