Concordance and Discordance Between Patient-reported Remission, Patient-reported Outcomes, and Physician Global Assessment

BACKGROUND

Although validated patient-reported outcome (PRO) measurements can categorize patients with inflammatory bowel disease (IBD) into clinical remission or active disease, patients may have different definitions of remission. The purpose of this study was to compare patient-defined remission to remission based on PRO measures and physician global assessment (PGA) and to understand the clinical and demographic factors associated with disagreements.

METHODS

We retrospectively analyzed 3257 de-identified surveys from 2004 IBD patients who consented to participate in the Crohn's and Colitis Foundation's IBD Qorus Learning Health System between September 2019 and February 2021. We used logistic regression models with generalized estimating equations to analyze the clinical and demographic factors (eg, age, disease duration, health confidence) associated with discordance between patient-defined remission (yes/no) and PRO-defined remission for ulcerative colitis (UC; PRO2: stool frequency, rectal bleeding) and Crohn's disease (CD; PRO-3: average number of liquid stools, abdominal pain, well-being).

RESULTS

Among patients with UC, overall concordance was 79% between patient self-report and PRO2-defined remission and 49% between patient self-report and PGA-defined remission. Among patients with CD, overall concordance was 69% between patient self-report and PRO3-defined remission and 54% between patient self-report and PGA-defined remission. Patients in PRO-defined remission were more likely to report active disease if they had IBD <5 years and low health confidence. Patients with PRO-defined active disease were more likely to report remission if they were not using prednisone and had high health confidence.

CONCLUSION

Discordance exists between how remission is defined by patients, PRO measures, and PGA.

Bidirectional Correlations Between Health Confidence and Inflammatory Bowel Disease Activity: A Nationwide Longitudinal Cohort Study

Health confidence—an individual’s belief in their ability and agency to affect disease outcomes—has bidirectional temporal correlations with inflammatory bowel disease activity. Low health confidence is associated with higher risks for future disease activity, and inflammatory bowel disease flares erode confidence.

Health Confidence Is Associated With Disease Outcomes and Health Care Utilization in Inflammatory Bowel Disease: A Nationwide Cross-sectional Study

BACKGROUND

We aimed to examine the associations between health confidence (one's belief on the degree of control on their health and disease), inflammatory bowel disease (IBD) outcomes, and health care utilization among adults with IBD.

METHODS

In total, 17,205 surveys were analyzed from a cross-sectional sample of IBD patients at 23 gastroenterology (GI) practices participating in the Crohn's and Colitis Foundations' IBD Qorus Learning Health System. We used bivariate analyses and multivariable logistic regression to examine associations between health confidence and disease activity, opioid use, glucocorticoid use, well-being, and health care utilization. We used receiver operating curve analysis to determine a clinically relevant cutoff for health confidence (0-10 Likert scale).

RESULTS

Health confidence was highly correlated with patients' well-being, symptomatic disease activity, opioid use, and glucocorticoid use (all P < .0001). Health confidence scores <8 had 69% sensitivity for emergency department (ED) visits and 66% for hospitalizations. In patients with inactive disease, patients with low health confidence (<8) were 10 times more likely to call/message the GI office >4 times/month (adjusted odds ratio [aOR], 10.3; 95% CI, 6.1-17.3; P < .0001), 3-4 times more likely to have an IBD-related ED visit (aOR, 4.0; 95% CI, 2.9, 5.4. P < .0001), or hospitalization (aOR, 3.0, 95% CI, 2.1, 4.1, P < .0001) compared with patients with high health confidence (≥8).

CONCLUSIONS

In a large, national sample of adults with IBD, there were strong associations between patients' health confidence and multiple disease outcome measures. Health confidence scores <8 on a 0-10 Likert scale may be clinically useful to screen for patients who are at risk for ED visits and hospitalizations.

Development of Balanced Whole System Value Measures for Inflammatory Bowel Disease Care in the IBD Qorus Collaborative Using a Modified Delphi Process

BACKGROUND

The IBD Qorus Collaborative aims to reduce variation and increase the value of care for the adult inflammatory bowel disease (IBD) community. To evaluate the success of the collaborative, we aimed to develop a balanced set of outcome measures that reflect a multistakeholder view of value in IBD care. To achieve this, we used the Clinical Value Compass framework and engaged a mixed-stakeholder group to conduct a modified Delphi process. The end result was a 10-measure set to assess the value of IBD care.

METHOD

The modified Delphi process included 3 iterative rounds of blinded voting and interactive webinar-style discussion. We recruited 18 participants for the Delphi panel, including clinicians, researchers, patients, Crohn's & Colitis Foundation staff, and payers. Participants first identified constructs to measure, then identified the tools to measure those constructs. A literature review and environmental scan of current measures in 4 domains were performed, and relevant measures were proposed for discussion and voting in each domain. Throughout the process, participants were invited to contribute additional measures.

CONCLUSION

The modified Delphi process led to selection of 10 value measures across 4 domains: (1) patient experience; (2) functional status; (3) clinical status; and (4) health care costs and utilization. We have successfully completed a 3-stage modified Delphi process to develop a balanced set of value measures for adult IBD care. The value measure set expands upon prior efforts that have established quality measures for IBD care by adding cost and experience of care elements. This work positions IBD Qorus to better assess, study, improve, and demonstrate value at individual, system, and population levels and will inform and empower related research, improvement, and implementation efforts.

The Reliability of Patient Self-reported Utilization in an Inflammatory Bowel Diseases Learning Health System

Background

Inflammatory bowel disease (IBD) care is beset with substantial practice variation. Learning health systems (LHSs) aim to learn from this variation and improve quality of care by sharing feedback and improvement strategies within the LHS. Obtaining accurate information on outcomes and quality of care is a priority for LHS, which often includes patients' self-reported data. While prior work has shown that patients can accurately report their diagnosis and surgical history, little is known about their ability to self-report recent healthcare utilization, medication use, and vaccination status.

Methods

We compared patient self-reported data within the IBD Qorus LHS regarding recent IBD-related emergency department (ED) visits, hospitalizations, computerized tomography (CT) scans, corticosteroid use, opioid use, influenza vaccinations, and pneumococcal vaccinations with electronic health record (EHR) data.

Results

We compared 328 patient self-reports to data extracted from the EHR. Sensitivity was moderate-to-high for ED visits, hospitalizations, and CT scans (76%, 87%, and 87%, respectively), sensitivity was lower for medication use with 71% sensitivity for corticosteroid use and only 50% sensitivity for self-reported use of opioids. Vaccinations were reported with high sensitivity, but overall agreement was low as many patients reported vaccinations that were not registered in the EHR.

Conclusions

Self-reported IBD-related ED visits, hospitalizations, and CT scans are reported with high sensitivity and accuracy. Medication use, and in particular opioid use, is less reliably reported. Vaccination self-report is likely more accurate than EHR data as many vaccinations are not accurately registered.

Minimizing harm in agricultural animal experiments in New Zealand

Intrusive agricultural experiments published in New Zealand in the last five years are reviewed in terms of the degree of animal suffering involved, and the necessity for this suffering in relation to research findings. When measured against animal welfare criteria of the Ministry of Agriculture, thirty-six studies inflicted "severe" or "very severe" suffering. Many of these experiments had questionable short-term applications, had an application restricted to agricultural production or economic growth, or could have been modified to prevent or reduce suffering.

Phosphoinositide 3-kinases in the gut: a link between inflammation and cancer?

Carcinoma of the gastrointestinal tract is the most common internal malignancy affecting men and women in Western countries. Chronic intestinal inflammation, especially of the colon, is also a Western disease and correlates with a significantly increased risk of developing cancer. This has suggested that the immune processes involved in both conditions might share some common pathways. Indeed, there is increasing evidence that phosphatidylinositol 3-kinases (PI 3-kinases) are involved in both the pathogenesis of colorectal carcinoma and intestinal inflammation. Here, we discuss this rapidly progressing area of research, presenting evidence for a pivotal role of PI 3-kinase(s) in intestinal pathophysiology.

Endoscopic palliation and survival in malignant biliary obstruction

Malignant biliary obstruction is a common problem that is regarded as having a poor prognosis and is usually managed with palliation. Our aim was to investigate the survival of 182 consecutive subjects with malignant biliary obstruction where management was palliative with an [corrected] endoscopically placed biliary stent. We undertook a retrospective longitudinal study with date of death or confirmed survival of at least 23 months, as the primary end point. Diagnosis and blood indices from the 24 hr prior to first ERCP were obtained from hospital records. Of the 182 eligible subjects follow-up of date of death or confirmed survival of at least 23 months was obtained in 181 (99.5%). Of these 181 patients, 37 (20.4%) survived for more than one year. Histological confirmation was obtained in 47 of 182 subjects (25.8%). Increased age at first ERCP predicted increased survival (P < 0.05). In conclusion, in patients with malignant biliary obstruction, where management was endoscopic and palliative, 20.4% survived for more than one year with increased age at diagnosis being the only significant predictive marker.

Regulatory role of phosphatidylinositol 3-kinase on TNF-alpha-induced cyclooxygenase 2 expression in colonic epithelial cells

BACKGROUND AND AIMS

Cyclooxygenase (COX)-2 is up-regulated in most colonic cancers and in inflammatory bowel disease in which tumor necrosis factor (TNF)-alpha is believed to play a central role. There has been recent speculation on the activation of phosphatidylinositol 3-kinase (PI 3-kinase) by TNF-alpha and its role in the regulation of genes controlled by NF-kappaB. We investigated the regulatory role of PI 3-kinase on COX-2 expression in colonic epithelial cells.

METHODS

In HT-29 and Caco-2 colonic epithelial cells, COX-2 expression was induced by either TNF-alpha or interleukin (IL)-1alpha as observed by Northern and Western analyses. COX-2 activity was assessed by measuring prostaglandin E(2) (PGE2) production by enzyme-linked immunosorbent assay. NF-kappaB binding activity was assessed by electrophoretic mobility shift assay. PI 3-kinase activity was measured by quantifying the accumulation of PI 3-kinase-dependent D-3 lipid products by high-performance liquid chromatography.

RESULTS

The PI 3-kinase inhibitor wortmannin up-regulated induced COX-2 expression in a concentration-dependent manner in both HT-29 and Caco-2 cells. An alternative PI 3-kinase inhibitor, LY294002, caused up-regulation of induced COX-2 messenger RNA (mRNA) in HT-29 cells at concentrations of < or =1 micromol/L. IL-4 and IL-13, which are known to activate PI 3-kinase, down-regulated HT-29 COX-2 mRNA, protein, and PGE2 production. NF-kappaB binding activity was unaltered by PI 3-kinase inhibition in HT-29 cells, in which TNF-alpha was shown to activate PI 3-kinase directly.

CONCLUSIONS

COX-2 is negatively regulated by PI 3-kinase; we propose that the inhibitory effect of IL-4 and IL-13 is mediated via a PI 3-kinase-dependent pathway. This mechanism does not appear to involve NF-kappaB because PI 3-kinase inhibition did not alter NF-kappaB binding activity. TNF-alpha can activate PI 3-kinase directly in addition to inducing COX-2.

Western blotting for detection of glucocorticoid receptors in the brain and pituitary gland from adrenal intact pigs

The objectives of the experiments presented here were to develop a method for measuring total glucocorticoid receptors (GRs), in adrenal intact pigs, and to describe the distribution of this receptor in the pituitary gland and selected brain regions. Six male pigs, 14 days of age, were euthanized and the pituitary gland, hypothalamus, prefrontal cortex, and hippocampus were prepared for western blotting using a traditional soluble cytosolic preparation or a whole cell extract preparation. Samples were electrophoresed and immunoblotted using the anti-human GR antibodies #57 and #51. The #57 antibody labeled a doublet at 95 and 87 kDa whereas the #51 GR antibody labeled a single band at 87 kDa. Affinity labeling of GR with [(3)H] dexamethasone mesylate revealed a single band at 87 kDa. Using the soluble cytosolic preparation GR concentrations were highest in the pituitary gland followed by the hypothalamus (P<0. 0001). The amount of GR in the hippocampus and prefrontal cortex was equivalent but lesser (P<0.0001) than that found in the pituitary gland or hypothalamus. With the whole cell extract tissue preparation, GR concentrations were highest (P<0.05) in the prefrontal cortex and hippocampus with lower (P<0.05) levels detected in the hypothalamus. Taken together, these results indicated that the 87-kDa band was the functional GR and that regional distribution of GRs is specific to the type of tissue preparation used. In addition, we have described a procedure (from whole cell extracts) for measuring total GRs in neural and nonneural tissues from adrenal intact pigs.

The effects of mutated skeletal ryanodine receptors on hypothalamic-pituitary-adrenal axis function in boars

The objectives of the current experiment were to determine whether boars heterozygous for the mutation in skeletal ryanodine receptors (sRyR), known to cause porcine stress syndrome, differed from wild-type boars in hypothalamic-pituitary-adrenal axis (HPA) function. We have examined basal plasma ACTH, cortisol, and corticosteroid-binding globulin (CBG) concentrations; plasma ACTH and cortisol responses to a nose-snare stressor and at slaughter; dexamethasone suppression of plasma ACTH and cortisol concentrations; and glucocorticoid receptor (GR) density in the pituitary gland, hippocampus, hypothalamus, and frontal cortex. We have also examined carcass yields, composition, and meat quality to determine whether differences in HPA activity were accompanied by an increased incidence of meat quality characteristics associated with pale, soft, exudative (PSE) meat. Thirty boars either heterozygous or wild-type (n = 15 per genotype) for mutated sRyR were tested for HPA function at 7 mo of age. Heterozygous boars had lower basal plasma ACTH (P < .05) and cortisol (P < .04) concentrations. Integrated basal plasma ACTH and cortisol levels were also lower (P < .05 and P < .005, respectively). Genotype had no significant effect on basal CBG, stressor-induced (nose snare or slaughter) or dexamethasone suppression of plasma ACTH or cortisol concentrations. No differences in immunoreactive GR levels were found in the pituitary gland or any brain region examined. We did find a significant, negative correlation (r = -.62, P < .02) between peak (0800) basal plasma ACTH concentrations and hippocampal GR levels. The alterations in basal HPA function in heterozygous boars were accompanied by lighter body weights (P < .03), decreased carcass fat depth (P < .04), and increased carcass lean yields (P < .02). There was a higher incidence of meat quality characteristics associated with PSE meat in heterozygous boars indicated by higher carcass temperatures (P < .04) and meat brightness (P < .0001) with lower carcass pH at slaughter (P < .03) and after chilling (P < .003). In conclusion, we have found differences in basal and not stressor-induced HPA function between boars heterozygous and wild-type for mutated sRyR. This altered basal HPA activity was accompanied by an increased incidence of meat quality aspects associated with PSE meat in heterozygous boars.

Neonatal handling permanently alters hypothalamic-pituitary- adrenal axis function, behaviour, and body weight in boars

Neonatal handling permanently alters hypothalamic- pituitary-adrenal axis (HPA) function in rats. In the rat, this treatment increases hippocampal glucocorticoid receptors (GR) and dampens plasma ACTH and corticosterone responses to stressors. The objectives of this study were to determine whether neonatal handling of pigs would effect permanent changes in plasma corticosteroid binding capacity (CBG), basal or stressor-induced plasma cortisol and ACTH concentrations, brain or pituitary GR levels, dexamethasone suppression of plasma cortisol and ACTH concentrations, behaviour in an open field-test pen, and body weights. Twelve litters of pigs were randomly assigned to either neonatal handling or no disturbance. Handled litters were removed from the farrowing crate for 10 min per day for the first 14 days of life. Male pigs were kept for the study and the boars were weighed monthly. At 7 months of age, boars were tested for locomotory behaviour in an open field-test pen. The boars were implanted with indwelling ear-vein catheters and blood samples were obtained basally, during and after application of a nose snare, and after 0.04 mg/kg dexamethasone. Boars were killed and blood samples were obtained and the brain and pituitary glands collected. Handled boars had greater (P<0.05) plasma CBG binding and lower basal total (P<0.05) and calculated free (P<0.03) plasma cortisol concentrations. No significant differences between treatments were found in plasma ACTH or cortisol responses to a nose-snare stressor; however, when killed, handled boars had greater (P<0.02) plasma ACTH concentrations. Handled and non-handled boars did not differ in plasma ACTH or cortisol responses to dexamethasone. There was no treatment effect on GR expression in the pituitary gland, frontal cortex, hippocampus, or hypothalamus. Behaviourally, the handled boars had higher (P<0.03) locomotor scores over inner squares and a lower (P<0.05) ratio of outer:inner squares entered in open field-tests. During the first 7 months of life, body weights were lower (P<0.004) for handled boars. In conclusion, neonatal handling permanently altered HPA function in pigs, but in a manner dissimilar to that found in the rat. These changes induced in the pig were not beneficial for commercial production with respect to body weight.

The effects of mutated skeletal ryanodine receptors on calreticulin and calsequestrin expression in the brain and pituitary gland of boars

Mutations in skeletal ryanodine receptors (sRyR) result in malignant hyperthermia in humans and Porcine Stress Syndrome (PSS) in pigs. Whether the sRyR is expressed in neuronal tissue and what impact it has on neuronal function is relatively unexplored. We have hypothesized that the presence of mutated sRyR may be accompanied by compensatory changes in Ca(2+)-binding protein expression. We were interested in whether pigs heterozygous for mutated sRyR would show changes in the expression of Ca(2+)-binding proteins, in specific regions of the brain, and whether changes in this expression would be accompanied by the presence of sRyR within that region. The objectives of the current experiments were to determine (1) whether calreticulin (CR) and calsequestrin (CS) are expressed in the pituitary gland and brain of the pig, (2) if boars heterozygous for mutated sRyR differed from wild-type boars in the expression of CR or CS, and (3) if altered Ca(2+)-binding protein expression would be accompanied by the presence of sRyR mRNA. Boars either heterozygous or wild-type (n=6) for the mutation in sRyR known to cause PSS, were euthanized and the pituitary gland and brains were collected for western blotting for CR and CS. An additional four wild-type boars were sacrificed and brains were collected for in situ hybridization for sRyR mRNA. Immunoreactive CR was expressed in porcine tissues with highest (p<0.0001) expression in the pituitary gland and lower but equivalent expression in the hypothalamus, frontal cortex, and hippocampus. Immunoreactive CS was not detectable in the pituitary gland while low levels were observed in the hypothalamus and frontal cortex. Dramatically higher (p<0.0001) levels of CS were found in the hippocampus. Genotype did not affect CR expression in the pituitary gland or any brain region examined. Immunoreactive CS levels were lower (p<0.002) in the hippocampus of heterozygous compared to wild-type boars. In situ hybridization experiments revealed the presence of sRyR mRNA in the hippocampus equally distributed across all cell subfields. In conclusion, both CR and CS were expressed in the porcine brain with specific patterns of expression across the brain regions examined. Boars heterozygous for mutated sRyR had lower CS in the hippocampus, which was accompanied by the expression of mRNA for sRyR.

Superficial siderosis of the central nervous system: a neglected cause of sensorineural hearing loss

Superficial siderosis of the central nervous system is a rare, often unrecognized condition in which there is a deposition of intracellular and extracellular hemosiderin in the leptomeninges, subpial tissue, spinal cord, and cranial nerves as a result of chronic bleeding in the subarachnoid space. On the basis of our cases and a review of the literature, the majority of patients manifest sensorineural hearing loss in addition to cerebellar dysfunction, pyramidal tract signs, and progressive mental deterioration. Recent imaging techniques--particularly CT and MRI--can define the presence of iron deposition, confirming the diagnosis ante mortem. From post mortem specimens, histologic sections demonstrate severe damage to the eighth nerve, with microglial metabolism of iron. Cases will be presented to illustrate these points.

Comparison of myoelectric and conventional prostheses for adolescent amputees

We questioned whether myoelectric prostheses were a reasonable alternative to conventional prostheses for adolescents with unilateral, congenital, below-elbow amputations in respect to fit, function, cosmesis, and cost. Ten patients were studied. Each received a physical, functional, and psychosocial evaluation prior to prosthetic fitting. The physical evaluation included myopotential, residual limb length and circumference, active range of motion, terminal device grasp force, and mechanical range. The functional evaluation consisted of a questionnaire of 38 bimanual activities. The psychosocial evaluation included an assessment of both the patient and the family. Following prosthesis fabrication, each patient received 10 days of training, a 3-month checkup, and a 6-month reevaluation. Wearing patterns, perception of cosmesis, change in physical attributes of the residual limb, and functional performance were documented. Results indicate that for these subjects myoelectric prostheses with a hand were an acceptable alternative to conventional prostheses with a hook.