Patient subjective assessment of drug side effects in inflammatory bowel disease

DSE-HNGCN: Predicting the frequencies of drug-side effects based on heterogeneous networks with mining interactions between drugs and side effects

Evaluating the frequencies of drug-side effects is crucial in drug development and risk-benefit analysis. While existing deep learning methods show promise, they have yet to explore using heterogeneous networks to simultaneously model the various relationship between drugs and side effects, highlighting areas for potential enhancement. In this study, we propose DSE-HNGCN, a novel method that leverages heterogeneous networks to simultaneously model the various relationships between drugs and side effects. By employing multi-layer graph convolutional networks, we aim to mine the interactions between drugs and side effects to predict the frequencies of drug-side effects. To address the over-smoothing problem in graph convolutional networks and capture diverse semantic information from different layers, we introduce a layer importance combination strategy. Additionally, we have developed an integrated prediction module that effectively utilizes drug and side effect features from different networks. Our experimental results, using benchmark datasets in a range of scenarios, show that our model outperforms existing methods in predicting the frequencies of drug-side effects. Comparative experiments and visual analysis highlight the substantial benefits of incorporating heterogeneous networks and other pertinent modules, thus improving the accuracy of DSE-HNGCN predictions. We also provide interpretability for DSE-HNGCN, indicating that the extracted features are potentially biologically significant. Case studies validate our model's capability to identify potential side effects of drugs, offering valuable insights for subsequent biological validation experiments.

Network pharmacology and experimental verification in vivo reveal the mechanism of Zhushao Granules against ulcerative colitis

BACKGROUND

Zhushao Granules (ZSG) had exhibited beneficial effects in the treatment of ulcerative colitis (UC) as an effective herbal prescription in Traditional Chinese Medicine. However, the underlying anti-inflammatory mechanism of ZSG remains unclear. This study aimed to decipher the mechanism of ZSG against UC combining network pharmacology and animal-based experiments.

METHODS

Network pharmacology was employed to identify active components and therapeutic targets of ZSG against UC. The protein-protein interaction (PPI) network was constructed among the therapeutic targets using the STRING database, and GO and pathway analyses were carried out using DAVID. Then, the "herb-component-target-pathway" network based on therapeutic targets was established and the topological parameters were subsequently calculated to identify hub active components, targets and pathways by Cytoscape. Finally, the therapeutic function and the special pathway of ZSG against UC were validated using a TNBS-induced UC model in BABL/c mice.

RESULTS

Ninety-four active components of ZSG and 460 potential targets were acquired from the Encyclopedia of Traditional Chinese Medicine and Tradition Chinese Medicine Systems Pharmacology Database and Analysis Platform. 884 potential targets of UC were obtained from OMIM and HINT. Sixty-two overlapping potential targets were identified as therapeutic targets of ZSG against UC. PPI network filtered out 61 therapeutic targets. GO and pathway analyses extracted 48, 25, and 98 terms corresponding to biological processes, molecular functions and Reactome pathways, respectively. Enrichment analysis suggested that the therapeutic targets were mainly involved in immune regulation, especially RIP-mediated NF-κB activation via ZBP1. Topological analysis of the "herb-component-target-pathway" network recognized 9 hub components, 20 hub targets and 18 hub pathways. The animal-based experiments revealed that ZSG ameliorated symptoms and histological changes in TNBS-induced colitis by significantly inhibiting the ZBP1/RIP/NF-κB pathway.

CONCLUSIONS

ZSG might alleviate the mucosal damage and ameliorate colitis via targeting ZBP1/RIP/NF-κB pathway, which laid the theoretical foundation for the clinical application and further study of ZSG and provided new insights into UC treatment.

Exploring gut microbiota as a novel therapeutic target in Crohn's disease: Insights and emerging strategies

Extensive research has investigated the etiology of Crohn's disease (CD), encompassing genetic predisposition, lifestyle factors, and environmental triggers. Recently, the gut microbiome, recognized as the human body's second-largest gene pool, has garnered significant attention for its crucial role in the pathogenesis of CD. This paper investigates the mechanisms underlying CD, focusing on the role of 'creeping fat' in disease progression and exploring emerging therapeutic strategies, including fecal microbiota transplantation, enteral nutrition, and therapeutic diets. Creeping fat has been identified as a unique pathological feature of CD and has recently been found to be associated with dysbiosis of the gut microbiome. We characterize this dysbiotic state by identifying key microbiome-bacteria, fungi, viruses, and archaea, and their contributions to CD pathogenesis. Additionally, this paper reviews contemporary therapies, emphasizing the potential of biological therapies like fecal microbiota transplantation and dietary interventions. By elucidating the complex interactions between host-microbiome dynamics and CD pathology, this article aims to advance our understanding of the disease and guide the development of more effective therapeutic strategies for managing CD.

Exploring the mechanism of Suxin Hugan Fang in treating ulcerative colitis based on network pharmacology

As a traditional Chinese medicine formula used in clinical practice for an extended period, Suxin-Hugan-Fang (SXHGF) exhibits excellent anti-inflammatory properties. However, the efficacy of SXHGF in treating ulcerative colitis (UC) and its mechanism of action are still unclear. In this study, the therapeutic effects of SXHGF on UC were evaluated using network pharmacology and experimental validation, while also investigating its mechanism of action. By administering DSS to C57BL/6 mice to construct a mouse model of ulcerative colitis, the therapeutic effect of SXHGF on ulcerative colitis was evaluated based on weight loss percentage, disease activity index, colon length changes, and pathological conditions as indicators. The main chemical components of SXHGF were determined by LC-MS-QTOF method. The potential targets and mechanisms of action of SXHGF in the treatment of UC were inferred using bioinformatics methods, and further validated through ELISA, IHC, and Western blotting assays. The experimental results demonstrate that SXHGF can suppress oxidative stress and oxidative damage in the colon tissue of UC mice, and alleviate DSS-induced ulcerative colitis by inhibiting the JAK2/STAT3 and NFκB pathways.

Side Streams of Vegetable Processing and Its Bioactive Compounds Support Microbiota, Intestine Milieu, and Immune System

The industry of vegetable processing generates large amounts of by-products, which often emerge seasonally and are susceptible to microbial degradation. Inadequate management of this biomass results in the loss of valuable compounds that are found in vegetable by-products that can be recovered. Considering the possibility of using waste, scientists are trying to reuse discarded biomass and residues to create a product of higher value than those processed. The by-products from the vegetable industry can provide an added source of fibre, essential oils, proteins, lipids, carbohydrates, and bioactive compounds, such as phenolics. Many of these compounds have bioactive properties, such as antioxidative, antimicrobial, and anti-inflammatory activity, which could be used, especially in the prevention or treatment of lifestyle diseases connected with the intestinal milieu, including dysbiosis and immune-mediated diseases resulting in inflammation. This review summarises the key aspects of the health-promoting value of by-products and their bioactive compounds derived from fresh or processed biomass and extracts. In this paper, the relevance of side streams as a source of beneficial compounds with the potential for promoting health is considered, particularly their impact on the microbiota, immune system, and gut milieu because all of these fields interact closely to affect host nutrition, prevent chronic inflammation, and provide resistance to some pathogens.

Modulating the Microbiome for Crohn's Disease Treatment

The central role of the gut microbiota in the regulation of health and disease has been convincingly demonstrated. Polymicrobial interkingdom interactions between bacterial (the bacteriome) and fungal (the mycobiome) communities of the gut have become a prominent focus for development of potential therapeutic approaches. In addition to polymicrobial interactions, the complex gut ecosystem also mediates interactions between the host and the microbiota. These interactions are complex and bidirectional; microbiota composition can be influenced by host immune response, disease-specific therapeutics, antimicrobial drugs, and overall ecosystems. However, the gut microbiota also influences host immune response to a drug or therapy by potentially transforming the drug's structure and altering bioavailability, activity, or toxicity. This is especially true in cases where the gut microbiota has produced a biofilm. The negative ramifications of biofilm formation include alteration of gut permeability, enhanced antimicrobial resistance, and alteration of host immune response effectiveness. Natural modulation of the gut microbiota, using probiotic and prebiotic approaches, may also be used to affect the host microbiome, a type of "natural" modulation of the host microbiota composition. In this review, we discuss potential bidirectional interactions between microbes and host, and we describe the changes in gut microbiota induced by probiotic and prebiotic approaches as well as their potential clinical consequences, including biofilm formation. We outline a systematic approach to designing probiotics capable of altering the host microbiota in disease states, using Crohn's disease as a model chronic disease. Understanding how the effective changes in the microbiome may enhance treatment efficacy may unlock the possibility of modulating the gut microbiome to improve treatment using a natural approach.

Inflammatory bowel disease addressed by Caco-2 and monocyte-derived macrophages: an opportunity for an in vitro drug screening assay

Inflammatory bowel disease (IBD) is a widespread disease, affecting a growing demographic. The treatment of chronic inflammation located in the GI-tract is dependent on the severity; therefore, the IBD treatment pyramid is commonly applied. Animal experimentation plays a key role for novel IBD drug development; nevertheless, it is ethically questionable and limited in its throughput. Reliable and valid in vitro assays offer the opportunity to overcome these limitations. We combined Caco-2 with monocyte-derived macrophages and exposed them to known drugs, targeting an in vitro-in vivo correlation (IVIVC) with a focus on the severity level and its related drug candidate. This co-culture assay addresses namely the intestinal barrier and the immune response in IBD. The drug efficacy was analyzed by an LPS-inflammation of the co-culture and drug exposure according to the IBD treatment pyramid. Efficacy was defined as the range between LPS control (0%) and untreated co-culture (100%) independent of the investigated read-out (TEER, Papp, cytokine release: IL-6, IL-8, IL-10, TNF-α). The release of IL-6, IL-8, and TNF-α was identified as an appropriate readout for a fast drug screening ("yes-no response"). TEER showed a remarkable IVIVC correlation to the human treatment pyramid (5-ASA, Prednisolone, 6-mercaptopurine, and infliximab) with an R2 of 0.68. Similar to the description of an adverse outcome pathway (AOP) framework, we advocate establishing an "Efficacy Outcome Pathways (EOPs)" framework for drug efficacy assays. The in vitro assay offers an easy and scalable method for IBD drug screening with a focus on human data, which requires further validation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44164-022-00035-8.

Current Applications of Telemedicine in Gastroenterology

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.

Inflammatory Bowel Disease Self-Management: Exploring Adolescent Use of an Online Instagram Support Community

The purpose of this qualitative study was to explore the challenges adolescents with inflammatory bowel disease (IBD) experience with disease self-management as expressed in an online Instagram social support community. Public Instagram posts between January and December 2019 were manually collected from an online IBD support community. To focus on adolescent self-management needs, only posts from Instagram users who (1) indicated they had inflammatory bowel disease, (2) were 13-24 years old, or were in middle school, high school, or college were collected. Using thematic analysis, authors independently coded and identified emerging themes about self-management. Of 2,700 Instagram posts assessed for eligibility, 83 posts met inclusion criteria. Six major themes about inflammatory bowel disease self-management emerged: Desire for Normalcy, Dietary Changes, Education and Career, Healthcare System, Relationships With Others, and Symptoms and Complications. As the first thematic analysis of Instagram posts in an online inflammatory bowel disease community, results provide a crucial perspective of the concerns of adolescents with inflammatory bowel disease. Self-management challenges were wide-ranging and complex, underscoring the importance of IBD self-management in the adolescent population. Nurses should take a holistic approach to assess self-management challenges and tailor care to the specific needs of adolescents living with inflammatory bowel disease.

Ficus pandurata Hance Inhibits Ulcerative Colitis and Colitis-Associated Secondary Liver Damage of Mice by Enhancing Antioxidation Activity

Inflammatory bowel disease (IBD), a global disease threatening human health, is commonly accompanied by secondary liver damage (SLD) mediated by the gut-liver axis. Oxidative stress acts a critical role in the onset of IBD, during which excessive oxidation would destroy the tight junctions between intestinal cells, promote proinflammatory factors to penetrate, and thereby damage the intestinal mucosa. Ficus pandurata Hance (FPH) is widely used for daily health care in South China. Our previous study showed that FPH protected acute liver damage induced by alcohol. However, there is no study reporting FPH treating ulcerative colitis (UC). This study is designed to investigate whether FPH could inhibit UC and reveal its potential mechanism. The results showed that FPH significantly alleviated the UC disease symptoms including the body weight loss, disease activity index (DAI), stool consistency changing, rectal bleeding, and colon length loss of UC mice induced by dextran sulfate sodium (DSS) and reversed the influences of DSS on myeloperoxidase (MPO) and diamine oxidase activity (DAO). FPH suppressed UC via inhibiting the TLR4/MyD88/NF-κB pathway and strengthened the gut barrier of mice via increasing the expressions of ZO-1 and occludin and enhancing the colonic antioxidative stress property by increasing the levels of T-SOD and GSH-Px and the expressions of NRF2, HO-1, and NQO1 and reducing MDA level and Keap1, p22-phox, and NOX2 expressions. Furthermore, FPH significantly inhibited SLD related to colitis by reducing the abnormal levels of the liver index, ALT, AST, and cytokines including TNFα, LPS, LBP, sCD14, and IL-18 in the livers, as well as decreasing the protein expressions of NLRP3, TNFα, LBP, CD14, TLR4, MyD88, NF-κB, and p-NF-κB, suggesting that FPH alleviated UC-related SLD via suppressing inflammation mediated by inhibiting the TLR4/MyD88/NF-κB pathway. Our study firstly investigates the anticolitis pharmacological efficacy of FPH, suggesting that it can be enlarged to treat colitis and colitis-associated liver diseases in humans.

Discrepancy between patient- and healthcare provider-reported adverse drug reactions in inflammatory bowel disease patients on biological therapy

BACKGROUND

Only limited data is available on the extent and burden of adverse drug reactions (ADRs) to biological therapy in inflammatory bowel disease (IBD) patients in daily practice, especially from a patient's perspective.

OBJECTIVE

The aim of this study was to systematically assess patient-reported ADRs during biological therapy in IBD patients and compare these with healthcare provider (HCP)-reported ADRs.

METHODS

This multicentre, prospective, event monitoring study enrolled IBD patients on biological therapy. Patients completed bimonthly comprehensive web-based questionnaires regarding description of biological induced ADRs, follow-up of previous ADRs and experienced burden of the ADR using a five-point Likert scale. The relationship between patient-reported ADRs and biological therapy was assessed. HCP-reported ADRs were extracted from the electronic healthcare records.

RESULTS

In total, 182 patients (female 51%, mean age 42.2 [standard deviation 14.2] years, Crohn's disease 77%) were included and completed 728 questionnaires. At baseline, 60% of patients used infliximab, 30% adalimumab, 9% vedolizumab and 1% ustekinumab. Fifty percent of participants reported at least one ADR with a total of 239 unique ADRs. Fatigue (n = 26) and headache (n = 20) resulted in the highest burden and a correlation in time with the administration of the biological was described in 56% and 85% respectively. Out of 239 ADRs, 115 were considered biological-related. HCPs reported 119 ADRs. Agreement between patient-reported ADRs and HCP-reported ADRs was only 13%.

CONCLUSION

IBD patients often report ADRs during biological therapy. We observed an important significant difference between the type and frequency of patient-reported ADRs versus HCP-reported ADRs, leading to an underestimation of more subjective ADRs and patients' ADR-related burden.

Impact of surgery on quality of life in Crohn's disease: short- and mid-term follow-up

Active Crohn's disease has a substantial impact on Quality of Life (QoL). Medical management could be associated to side effects, hospitalization, long treatment period and requires patient's compliance, impacting QoL. Ileocecal resection (ICR) is often required, open or laparoscopic. Aim of the study was to assess Health-Related (HR) QoL changes following ICR, and to identify factors impacting on QoL in the short and mid-term. From a single institution, we created a prospective database of patients undergoing ICR from 01/2009 to 12/2015. HRQoL was analysed with Cleveland Global Quality of Life (CGQL) score, Overall Quality of Happiness (OQH), and asking patients if they would have surgery again. QoL scores were recorded at 30 days, 6, 12 and 36 months postoperatively and compared according to follow-up timing, technique, medical treatment and demographics. Statistical analysis included 187 patients. Mean follow-up was 3.8 ± 2.9 years. Both at 30 days and 6 months postoperatively, CGQL, its items and OQH increased significantly (p < 0.001). Increased values were also recorded at 1 and 3 years; 88% of patients would undergo surgery again. Laparoscopy was associated with improved CGQL scores, while preoperative steroids with worsen data. Young female patients, with penetrating pattern, experienced greater HRQoL improvements. Surgery is associated with improvements of HRQoL and patients' happiness in the short and mid-term. Laparoscopy, steroid-free and young patients showed the best results. ICR should be considered a reasonable alternative to non-operative strategies in selected cases.

Effect of TELEmedicine for Inflammatory Bowel Disease on Patient Activation and Self-Efficacy

INTRODUCTION

Limitations in inflammatory bowel disease (IBD) care necessitate greater patient activation and self-efficacy, measures associated with positive health outcomes.

METHODS

We assessed change in patient activation and general self-efficacy from baseline to 12 months through our TELEmedicine for IBD trial, a multicenter, randomized controlled trial consisting of a web-based monitoring system that interacts with participants via text messaging. A total of 222 adults with IBD who had experienced an IBD flare within 2 years prior to the trial were randomized into either a control arm that received standard care (SC) or an intervention arm that completed self-testing through the TELE-IBD system every other week (EOW) or weekly (W).

RESULTS

Changes in self-efficacy scores were not significantly different between control and experimental groups. Patient activation scores were significantly different between standard care and the TELE-IBD EOW group only (p = 0.03).

CONCLUSIONS

Use of remote monitoring did not improve self-efficacy or patient activation compared to routine care.

The Telemedicine for Patients With Inflammatory Bowel Disease (TELE-IBD) Clinical Trial: Qualitative Assessment of Participants' Perceptions

BACKGROUND

Inflammatory bowel disease (IBD), comprising Crohn disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of this study, telemedicine for patients with IBD (TELE-IBD), was to compare disease activity and quality of life (QoL) in a 1-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL, but there were no significant differences between groups. Study adherence to the text-based intervention was less than 80%, the targeted goal.

OBJECTIVE

To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants' perceptions, including their recommendations for future monitoring.

METHODS

In this study, patients attending 3 tertiary referral centers with worsening IBD symptoms in the previous 2 years were eligible for randomization to remote monitoring via SMS text messages (short message service, SMS) every other week, weekly, or standard care. Participants (n=348) were evenly enrolled in the treatment groups, and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and nonadherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% (278/348) or more of the weekly or every other week self-assessments. Semistructured interviews conducted by phone surveyed (1) the strengths and benefits of TELE-IBD, (2) challenges associated with using TELE-IBD, and (3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on a priori concepts and emergent themes with the aid of ATLAS.ti, version.7 qualitative data analysis software.

RESULTS

Participants' discussions centered on 3 elements of the intervention: (1) self-assessment questions, (2) action plans, and (3) educational messages. Participants also commented on text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and nonadherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive the intervention as effective in facilitating IBD self-management.

CONCLUSIONS

Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants' perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD.

A Randomized Controlled Trial of TELEmedicine for Patients with Inflammatory Bowel Disease (TELE-IBD)

INTRODUCTION

Telemedicine has shown promise in inflammatory bowel disease (IBD). The objective of this study was to compare disease activity and quality of life (QoL) in a 1-year randomized trial of IBD patients receiving telemedicine vs. standard care.

METHODS

Patients with worsening symptoms in the prior 2 years were eligible for randomization to telemedicine (monitoring via texts EOW or weekly) or standard care. The primary outcomes were the differences in change in disease activity and QoL between the groups; change in healthcare utilization among groups was a secondary aim.

RESULTS

348 participants were enrolled (117 control group, 115 TELE-IBD EOW, and 116 TELE-IBD weekly). 259 (74.4%) completed the study. Age was 38.9 ± 12.3 years, 56.6% were women, 91.9% were Caucasian, 67.9% had Crohn's disease (CD) and 42.5% had active disease at baseline. In CD, all groups experienced a decrease in disease activity (control -5.2 ± 5.0 to 3.7 ± 3.6, TELE-IBD EOW 4.7 ± 4.1 to 4.2 ± 3.9, and TELE-IBD weekly 4.2 ± 4.2 to 3.2 ± 3.4, p < 0.0001 for each of the groups) In UC, only controls had a significant decrease in disease activity (control 2.9 ± 3.1 to 1.4 ± 1.4, p = 0.01, TELE-IBD EOW 2.7 ± 3.1 to 1.7 ± 1.9, p = 0.35, and TELE-IBD Weekly 2.5 ± 2.5 to 2.0 ± 1.8, p = 0.31). QoL increased in all groups; the increase was significant only in TELE-IBD EOW (control 168.1 ± 34.0 to 179.3 ± 28.2, p = 0.06, TELE-IBD EOW 172.3 ± 33.1 to 181.5 ± 28.2, p = 0.03, and TELE-IBD Weekly 172.3 ± 34.5 to 179.2 ± 32.8, p = 0.10). Unadjusted and adjusted changes in disease activity and QoL were not significantly different among groups. Healthcare utilization increased in all groups. TELE-IBD weekly were less likely to have IBD-related hospitalizations and more likely to have non-invasive diagnostic tests and electronic encounters compared to controls; both TELE-IBD groups had decreased non-IBD related hospitalizations and increased telephone calls compared to controls.

DISCUSSION

Disease activity and QoL, although improved in all participants, were not improved further through use of the TELE-IBD system. TELE-IBD participants experienced a decrease in hospitalizations with an associated increase in non-invasive diagnostic tests, telephone calls and electronic encounters. Research is needed to determine if TELE-IBD can be improved through patient engagement and whether it can decrease healthcare utilization by replacing standard care.

Risk of Malignancy in a Nationwide Cohort of Elderly Inflammatory Bowel Disease Patients

BACKGROUND

Management of elderly inflammatory bowel disease (IBD) patients (≥ 65 years of age) is complicated due to many factors, including a higher risk of cancer, which may impact therapeutic decisions.

OBJECTIVE

The aim of this study was to determine the risk of cancer among elderly IBD patients compared with younger IBD patients. Additionally, the absolute risk of malignancy and factors contributing to it were evaluated, and therapeutic patterns among the elderly were assessed.

METHODS

This retrospective cohort study extracted data from the Truven Health Analytics MarketScan^® database. Among adult IBD patients who were free of cancer before starting on corticosteroids, immunomodulators, or biologics, a Cox model for time to cancer was fitted that adjusted for several covariates, including time-dependent treatment. Baseline results were evaluated by age group, as were the incidence of cancer and the distribution of cancer subtypes.

RESULTS

The elderly IBD cohort (n = 8788) had a higher prevalence of cancer and several other ailments before starting treatment, relative to the younger IBD cohort aged 18-64 years (n = 54,971). During follow-up, the elderly IBD cohort experienced a higher incidence of malignancy, confirmed by a hazard ratio (HR) of 3.04 (95% confidence interval [CI] 2.71-3.41) from the Cox model fit. The risk of cancer was also significantly associated with male sex (HR 0.82 female), duration of disease (HR 1.08), several comorbidities and corticosteroid use (HR 1.35), but not with the use of immunomodulators or biologics. Non-Hodgkin's lymphoma, urinary tract malignancy, and prostate, lung, and female breast cancers were observed more commonly in this elderly IBD cohort when compared with the same age group in the Surveillance, Epidemiology, and End Results (SEER) database.

CONCLUSIONS

The elderly with IBD have a higher risk of malignancy when compared with younger IBD patients and the general age-matched population, with certain cancers being more common among these patients.

Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy (including a review of TA140 and TA262): clinical effectiveness systematic review and economic model

BACKGROUND

Ulcerative colitis (UC) is the most common form of inflammatory bowel disease in the UK. UC can have a considerable impact on patients' quality of life. The burden for the NHS is substantial.

OBJECTIVES

To evaluate the clinical effectiveness and safety of interventions, to evaluate the incremental cost-effectiveness of all interventions and comparators (including medical and surgical options), to estimate the expected net budget impact of each intervention, and to identify key research priorities.

DATA SOURCES

Peer-reviewed publications, European Public Assessment Reports and manufacturers' submissions. The following databases were searched from inception to December 2013 for clinical effectiveness searches and from inception to January 2014 for cost-effectiveness searches for published and unpublished research evidence: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and NHS Economic Evaluation Database; ISI Web of Science, including Science Citation Index, and the Conference Proceedings Citation Index-Science and Bioscience Information Service Previews. The US Food and Drug Administration website and the European Medicines Agency website were also searched, as were research registers, conference proceedings and key journals.

REVIEW METHODS

A systematic review [including network meta-analysis (NMA)] was conducted to evaluate the clinical effectiveness and safety of named interventions. The health economic analysis included a review of published economic evaluations and the development of a de novo model.

RESULTS

Ten randomised controlled trials were included in the systematic review. The trials suggest that adult patients receiving infliximab (IFX) [Remicade(®), Merck Sharp & Dohme Ltd (MSD)], adalimumab (ADA) (Humira(®), AbbVie) or golimumab (GOL) (Simponi(®), MSD) were more likely to achieve clinical response and remission than those receiving placebo (PBO). Hospitalisation data were limited, but suggested more favourable outcomes for ADA- and IFX-treated patients. Data on the use of surgical intervention were sparse, with a potential benefit for intervention-treated patients. Data were available from one trial to support the use of IFX in paediatric patients. Safety issues identified included serious infections, malignancies and administration site reactions. Based on the NMA, in the induction phase, all biological treatments were associated with statistically significant beneficial effects relative to PBO, with the greatest effect associated with IFX. For patients in response following induction, all treatments except ADA and GOL 100 mg at 32-52 weeks were associated with beneficial effects when compared with PBO, although these were not significant. The greatest effects at 8-32 and 32-52 weeks were associated with 100 mg of GOL and 5 mg/kg of IFX, respectively. For patients in remission following induction, all treatments except ADA at 8-32 weeks and GOL 50 mg at 32-52 weeks were associated with beneficial effects when compared with PBO, although only the effect of ADA at 32-52 weeks was significant. The greatest effects were associated with GOL (at 8-32 weeks) and ADA (at 32-52 weeks). The economic analysis suggests that colectomy is expected to dominate drug therapies, but for some patients, colectomy may not be considered acceptable. In circumstances in which only drug options are considered, IFX and GOL are expected to be ruled out because of dominance, while the incremental cost-effectiveness ratio for ADA versus conventional treatment is approximately £50,300 per QALY gained.

LIMITATIONS

The health economic model is subject to several limitations: uncertainty associated with extrapolating trial data over a lifetime horizon, the model does not consider explicit sequential pathways of non-biological treatments, and evidence relating to complications of colectomy was identified through consideration of approaches used within previous models rather than a full systematic review.

CONCLUSIONS

Adult patients receiving IFX, ADA or GOL were more likely to achieve clinical response and remission than those receiving PBO. Further data are required to conclusively demonstrate the effect of interventions on hospitalisation and surgical outcomes. The economic analysis indicates that colectomy is expected to dominate medical treatments for moderate to severe UC.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006883.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Systematic review and meta-analysis: assessment of factors affecting disability in inflammatory bowel disease and the reliability of the inflammatory bowel disease disability index

BACKGROUND

The Inflammatory Bowel Disease Disability Index (IBD-DI) has recently been developed for patients with Crohn's disease (CD) and ulcerative colitis (UC).

AIM

To assess the severity of disability and associated factors using the IBD-DI, and review the validity of the IBD-DI as a tool.

METHOD

Systematic review of cross-sectional studies. Patients included had UC or CD and were classified as active, in remission, or needing surgery, biological and/or steroid treatment. We included studies assessing disability using the IBD-DI and that were captured by electronic and manual searches (January 2017). The possibility of bias was evaluated with the Newcastle-Ottawa Scale.

RESULTS

Nine studies were included with 3167 patients. Comparatively, patients with active disease had higher disability rates than those in remission (SMD [CI95] = 1.49[1.11, 1.88], I²  = 94%, P<.01), while patients on biological treatment had lower disability rates than those receiving corticosteroid treatment (SMD [CI95] = -0.22[-0.36, -0.08], I²  = 0%, P<.01). Disease activity and unemployment were found to be associated factors. The IBD-DI scored "good" for internal consistency, "fair" to "excellent" for intra-rater reliability and "excellent" for inter-rater reliability. Construct validity was "moderately strong" to "very strong" and structural validity was found to be mainly unidimensional. The IBD-DI had excellent responsiveness, while its interpretability was only useful on a group level.

CONCLUSIONS

This systematic review and meta-analysis found a significant association between disease activity, treatment received and disability; although significant heterogeneity was found. The IBD-DI is reliable and valid, but further studies are needed to measure its interpretability.

Machine learning approaches to personalize early prediction of asthma exacerbations

Patient telemonitoring results in an aggregation of significant amounts of information about patient disease trajectory. However, the potential use of this information for early prediction of exacerbations in adult asthma patients has not been systematically evaluated. The aim of this study was to explore the utility of telemonitoring data for building machine learning algorithms that predict asthma exacerbations before they occur. The study dataset comprised daily self-monitoring reports consisting of 7001 records submitted by adult asthma patients during home telemonitoring. Predictive modeling included preparation of stratified training datasets, predictive feature selection, and evaluation of resulting classifiers. Using a 7-day window, a naive Bayesian classifier, adaptive Bayesian network, and support vector machines were able to predict asthma exacerbation occurring on day 8, with sensitivity of 0.80, 1.00, and 0.84; specificity of 0.77, 1.00, and 0.80; and accuracy of 0.77, 1.00, and 0.80, respectively. Our study demonstrated that machine learning techniques have significant potential in developing personalized decision support for chronic disease telemonitoring systems. Future studies may benefit from a comprehensive predictive framework that combines telemonitoring data with other factors affecting the likelihood of developing acute exacerbation. Approaches implemented for advanced asthma exacerbation prediction may be extended to prediction of exacerbations in patients with other chronic health conditions.

Optimizing the Care and Health of Women with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) including both ulcerative colitis and Crohn's disease is increasing worldwide. Although diagnosis is equally found in men and women, the chronicity of IBD poses a unique impact on the milestones of a woman's life. As the gastroenterologist becomes increasingly important in the health maintenance of patients with IBD, this review stresses the unique gender issues in women with IBD related to menstruation, cervical cancer, sexual health, contraception, and menopause that may affect the course of disease, treatment decisions, and quality of life.

Development of a conceptual model evaluating the humanistic and economic burden of Crohn's disease: implications for patient-reported outcomes measurement and economic evaluation

The primary objective of this review is to develop a conceptual model for Crohn's disease (CD) outlining the disease burden for patients, healthcare systems and wider society, as reported in the scientific literature. A search was conducted using MEDLINE, PsycINFO, EconLit, Health Economic Evaluation Database and Centre for Reviews and Dissemination databases. Patient-reported outcome (PRO) measures widely used in CD were reviewed according to the US FDA PRO Guidance for Industry. The resulting conceptual model highlights the characterization of CD by gastrointestinal disturbances, extra-intestinal and systemic symptoms. These symptoms impact physical functioning, ability to complete daily activities, emotional wellbeing, social functioning, sexual functioning and ability to work. Gaps in conceptual coverage and evidence of reliability and validity for some PRO measures were noted. Review findings also highlight the substantial direct and indirect costs associated with CD. Evidence from the literature confirms the substantial burden of CD to patients and wider society; however, future research is still needed to further understand burden from the perspective of patients and to accurately understand the economic burden of disease. Challenges with existing PRO measures also suggest the need for future research to refine or develop new measures.

Web-based interventions for ulcerative colitis and Crohn's disease: systematic review and future directions

Behavioral intervention technologies (BITs), the application of psychological and behavioral interventions through the use of technology, provide the opportunity for clinicians to deliver care through a means that overcomes a number of treatment barriers. Web-based interventions are a subset of BITs developing as promising alternatives to face-to-face delivery of treatments and monitoring for patients with ulcerative colitis (UC) and Crohn’s disease (CD). A systematic review of literature resulted in five empirical studies of web-based interventions for UC and CD. Additionally, an informal search of a popular search engine yielded limited, currently available, web-based interventions for patients with UC and CD. Despite being an ideal population for the development and dissemination of online interventions, patients with UC and CD have far less treatment options compared to other behavioral health concerns. However, given the growing body of research involving web-based interventions for other conditions, researchers and clinicians targeting UC and CD management and treatment have the benefit of being able to utilize the BIT model, an existing conceptual framework for the development of web-based interventions for both conditions. The BIT model is presented and applied to the treatment of UC and CD, as well as a technology development program, Purple, and usability guidelines to guide clinical researchers in the future development, evaluation, and dissemination of BITs for patients with UC and CD.

Impact of drug therapy and surgery on quality of life in Crohn's disease: a systematic review

Crohn's disease is associated with substantially impaired health-related quality of life (HRQoL). Even in the absence of active disease, patients with Crohn's disease report lower HRQoL, poorer function, and greater concerns, than those without disease. Achievement of disease remission in Crohn's disease, whether by pharmacological or surgical means, is associated with improved HRQoL, although the durability of the improvement seen after intestinal resection is uncertain because of the high rate of postoperative disease recurrence. This review focuses on the available literature on HRQoL in patients with Crohn's disease with an emphasis on the effects of intestinal resection and immunomodulatory therapy.

TELEmedicine for Patients with Inflammatory Bowel Disease (TELE-IBD): Design and implementation of randomized clinical trial

BACKGROUND

Inflammatory bowel diseases (IBD), comprised of ulcerative colitis and Crohn's disease, are chronic disorders characterized by worsening of symptoms followed by symptom-free periods. Symptoms have a profound negative impact on quality of life and are associated with increased health care utilization. Despite effective treatments, outcomes are suboptimal secondary to nonadherence, medication intolerance, inconsistent monitoring, poor patient knowledge and limited access to care.

OBJECTIVES

Compare disease activity and quality of life over 1 year in a randomized trial of IBD patients receiving standard care versus telemedicine.

METHODS

Patients evaluated at 3 IBD referral centers with worsening symptoms within the last 2 years are eligible for randomization to one of two interventions or standard care. The interventions consist of either every other week or weekly assessment of symptoms, side effects, weight and delivery of medication prompts and education via texts to the participant's mobile phone. Individualized alerts and action plans are created on a secure portal. Participants in the standard care group undergo routine and urgent follow-up visits and telephone calls. The primary outcomes group comparisons of changes in disease activity and quality of life scores from baseline to 6 and 12 months.

CONCLUSIONS

Methods such as telemedicine are needed to improve monitoring, adherence, self-efficacy, and patient knowledge in IBD. If effective, telemedicine should decrease symptoms, improve quality of life, and decrease health care utilization. The burden associated with use of telemedicine for patients and providers needs to be assessed. The trial is ongoing and will be completed in July 2016.

Adverse clinical phenotype in inflammatory bowel disease: a cross sectional study identifying factors potentially amenable to change

BACKGROUND AND AIM

A significant proportion with inflammatory bowel disease (IBD) exhibit an adverse clinical phenotype reflected in endpoints like surgery and hospitalizations. We sought to identify clinico-demographic factors associated with these adverse consequences that may be amenable to change.

METHODS

Over 6 months IBD patients visiting a metropolitan center were prospectively identified and given a comprehensive survey addressing patient knowledge, mental health and satisfaction with medical care along with other clinical data. Logistic regression analyses assessed for associations between clinico-demographic variables and adverse clinical endpoints (previous surgery [ever] and/or recent inpatient admission over a 16 month observation period).

RESULTS

Of 256 IBD patients, 162 responded (response rate 63%); 95 (59%) had Crohn's disease (CD), 63 (40%) ulcerative colitis (UC), four indeterminate colitis; 53% were female. Factors associated with a greater likelihood of hospitalization included moderate/severe disease activity, psychological co-morbidity, numbers of medications and outpatient visits (odds ratio [OR] 7.09 [2.83-17.76], 4.13 [1.25-13.61], 1.26 [1.03-1.54], 1.17 [1.00-1.37] respectively; all P < 0.05). Post-surgical patients were more likely to have CD, more currently active disease and longer disease duration (OR 8.55 [2.43-29.4], 3.52 [1.26, 9.87], 1.14 [1.08, 1.21] respectively; all P < 0.02), yet were less likely to have previously seen a gastroenterologist, OR 0.25 [0.08-0.76] (P = 0.01).

CONCLUSIONS

'At risk' patients (those previously operated, with ongoing disease activity, dissatisfaction and/or psychological comorbidities) may benefit from early identification and more intensive management. Specialist gastroenterology care appears to be under-utilized in operated patients yet may reduce future IBD morbidity.

Volitional and accidental nonadherence to pediatric inflammatory bowel disease treatment plans: initial investigation of associations with quality of life and disease activity

OBJECTIVE

To examine rates of volitional and accidental nonadherence, and explore potential differential associations of each with disease activity and quality of life (QOL), in pediatric patients with inflammatory bowel disease (IBD).

METHODS

One hundred families (100 parents, 78 adolescents) recruited from a large Midwestern children's hospital reported on the child's medication nonadherence and QOL. Healthcare providers supplied disease activity ratings.

RESULTS

Most adolescents (73.1%) and parents (70.1%) reported engaging in accidental nonadherence, whereas a smaller group (35 and 30%, respectively) reported engaging in volitional nonadherence to the child's prescribed medication regimen. Frequency of accidental nonadherence was unrelated to disease activity or any specific QOL area examined, whereas greater frequency of volitional nonadherence was associated with greater disease activity and poorer parent reported psychosocial QOL.

CONCLUSIONS

Nonadherence and the relationship with disease severity and QOL may be more complex for children with IBD than understood through previous work.

Home telemanagement for patients with ulcerative colitis (UC HAT)

Effective therapies exist to treat ulcerative colitis (UC); nonadherence, inadequate monitoring, and side-effects result in suboptimal outcomes. Novel methods for monitoring are needed. Our objectives were to assess acceptance of home automated telemanagement in ulcerative colitis (UC HAT). The UC HAT system consists of a laptop connected to a scale, a decision support server, and a web-based clinician portal. The UC HAT system facilitates self-care in UC patients by monitoring patient symptoms, side-effects, and adherence, and helping patients in following their individualized treatment plans. Ten adult patients with UC were trained to use UC HAT. Attitudinal surveys and qualitative interviews were performed. The results showed that all patients reported that use of the computer was not complicated. 90% reported that the symptom diary and side-effect questions were not difficult. All patients reported that the training was adequate and 70% reported that testing took little time. Seventy percent would feel safer using the system, and 90% would agree to use UC HAT in the future. Patients felt UC HAT would keep the patient and provider up to date on changes in symptoms. Self-testing appeared to make patients accountable for managing the disease. It was discussed that improved monitoring is needed for UC. Patients with UC can be easily trained to use HAT, and patient acceptance of the UC HAT system is high. Home automated telemanagement has potential to improve clinical outcomes and patient satisfaction in UC.

Challenges in the design of a Home Telemanagement trial for patients with ulcerative colitis

BACKGROUND

Nonadherence, inadequate monitoring, and side-effects result in suboptimal outcomes in ulcerative colitis (UC). We hypothesize that telemanagement for UC will improve symptoms, quality of life, adherence, and decrease costs.

PURPOSE

This article describes the challenges encountered in the design of the home telemanagement in patients with UC trial.

METHODS

In a randomized trial to assess the effectiveness of telemanagement for UC compared to best available care, 100 patients will be enrolled. Subjects in the intervention arm will complete self-testing with telemanagement weekly; best available care subjects will receive scheduled follow up, educational fact sheets, and written action plans. Telemanagement consists of a home-unit, decision support server, and web-based clinician portal. The home-unit includes a scale and laptop. Subjects will respond to questions about symptoms, side-effects, adherence, and knowledge weekly; subjects will receive action plans after self-testing. Outcome variables to be assessed every 4 months include: disease activity, using the Seo index; quality of life, using the Inflammatory Bowel Disease Questionnaire; adherence, using pharmacy refill data and the Morisky Medication Adherence Scale; utilization of healthcare resources, using urgent care visits and hospitalizations.

RESULTS

We encountered several challenges during design and implementation of our trial. First, we selected a randomized controlled trial design. We could have selected a quasiexperimental design to decrease the sample size needed and costs. Second, identification of a control group was challenging. Telemanagement patients received self-care plans and an educational curriculum. Since controls would not receive these interventions, we thought our results would be biased in favor of telemanagement. In addition, we wanted to evaluate the mode of delivery of these components of care. Therefore, we included written action plans and educational materials for patients in the control group ('best available care'). Third, we could not blind subjects to group assignment. In an attempt to decrease bias, staff was masked to group assignment to decrease measurement bias. Fourth, we selected outcome measures that were not invasive to decrease risks to subjects and to enhance recruitment.

LIMITATIONS

Our results may not be generalizable as our program is a tertiary center. Further, subjects are not blinded to the intervention potentially resulting in bias; we attempt to minimize this bias by having staff masked to treatment group at the time of assessment of outcome measures.

CONCLUSIONS

To the best of our knowledge, our trial will be the first randomized controlled trial to evaluate telemedicine in subjects with gastrointestinal disease. We describe several issues encountered in design and implementation of our trial that will aid investigators when planning telemedicine trials in inflammatory bowel disease.

Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management

While there has been a great deal of speculation over the years on the importance of emotional factors in inflammatory bowel disease (IBD), it is only in the last decade or so that studies with stronger designs have been available to clarify the nature of this relationship. This review considers recent evidence on the prevalence of anxiety and depressive disorders in IBD, the role of these disorders as a risk factor for IBD onset, the degree to which they affect the course of the IBD, and the contribution of corticosteroid treatment to psychiatric symptom onset. There is evidence that anxiety and depression are more common in patients with IBD and that the symptoms of these conditions are more severe during periods of active disease. The few studies that address the issue of anxiety and depression as risk factors for IBD do not yet provide enough information to support definite conclusions. There is evidence, however, that the course of the disease is worse in depressed patients. Treatment with corticosteroids can induce mood disorders or other psychiatric symptoms. The second part of the review focuses on patient management issues for those with comorbid anxiety or depression. Practical approaches to screening are discussed, and are recommended for routine use in the IBD clinic, especially during periods of active disease. We review evidence-based pharmacological and psychological treatments for anxiety and depression and discuss practical considerations in treating these conditions in the context of IBD to facilitate overall management of the IBD patient.