CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study

BACKGROUND AND OBJECTIVES

Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV.

METHODS

We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference.

RESULTS

A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01).

CONCLUSIONS

CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.

Sexual Orientation and Gender Identity (SOGI) Data Collection: Opportunities to Advance Best Clinical Practices for LGBTQ+ Patients in Radiation Oncology

PURPOSE/OBJECTIVE(S)

A long-standing barrier to progress against health disparities is the lack of data regarding cancer risks, prevalence, treatment, and outcomes for sexual and gender minority (SGM) patients. Sexual orientation and gender identity (SOGI) data are not routinely collected by individual oncologists, cancer centers, or most non-federal hospital systems. Alarmingly high proportions of SGM patients report discrimination in healthcare or avoid routine care due to perceived lack of acceptance in the healthcare system. For these and other reasons, healthcare institutions must adopt practices that promote an inclusive environment for all patients including those self-identified from SGM groups. One strategy to achieve this aim is through SOGI data collection. The purpose of this study was to pilot new procedures and training for SOGI data collection, the aims of this project were to standardize the collection of SOGI data for all new patients referred to the Division of Radiation Oncology; promote clinical staff awareness of SGM health disparities and strategies for fostering an inclusive hospital environment; and to provide SGM patients and caregivers educational resources and support systems tailored to their needs.

MATERIALS/METHODS

We designed a Quality Improvement program for collecting SOGI data, which was approved by our institution's QIAB. Patient access specialists (PAS) were trained to collect SOGI data from newly registered patients and enter the data into the electronic health record. Radiation Oncology staff completed surveys before and after SOGI training to estimate its impact on the provision of patient care. A Fisher's exact test was utilized to evaluate associations between training and provider-reported outcomes.

RESULTS

Within a 3-week period starting in January 2023, two 1-hour interactive training sessions were offered to twenty-five PAS. Three 1-hour training sessions were offered to twenty-seven Radiation Oncology clinical staff. (1) Confidence for incorporating SOGI classifiers around patients improved from before training (52%, 13/25) to after training (100%, 17/17) among medical providers surveyed (odds ratio (OR) 32, 95% confidence interval (CI) 0.70-1493, p = 0.005). Use of SOGI data in clinical decision making increased from before training (9/25, 36%) to after training (100%, 17/17) among medical providers (OR 60.79, 95% CI 3.271-1130, p<0.0001). (2) A clinical pathway for SGM patients was developed to facilitate referral to our institution's SGM patient support group and distribution of patient education materials focused on sexual health.

CONCLUSION

Establishing standardized SOGI data collection can facilitate the provision of tailored resources and care that meets the needs of patients and staff in a large comprehensive cancer center. Specialized training for staff developed through this initiative helps foster an inclusive and welcoming environment that promotes the integration, visibility, and advancement of SGM cancer care at our institution.

The effect of digital interventions on related health literacy and skills for individuals living with chronic diseases: A systematic review and meta-analysis

BACKGROUND

Chronic diseases are a leading cause of death and disease burden globally. Digital interventions could be an approach to improve patients' ability to find, evaluate, and use health information.

OBJECTIVES

The main objective was to conduct a systematic review to determine the effect of digital interventions on digital health literacy for patients living with chronic disease. Secondary objectives were to provide an overviewof the design and delivery characteristics of interventions that impact digital health literacy in people with chronic disease.

METHODS

Randomized controlled trials examining digital health literacy (and related components) for individuals with cardiovascular disease, chronic lung disease, osteoarthritis, diabetes, chronic kidney disease, and HIV were identified. This review was conducted following the PRIMSA guidelines. Certainty was assessed using GRADE and the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.1. The protocol was registered on PROSPERO (CRD42022375967).

RESULTS

9386 articles were identified and 17 articles representing 16 unique trials were included. Studies evaluated 5138 individuals with one or more chronic conditions (50% women, ages 42 ± 7-71 ± 12 years). The most targeted conditions were cancer, diabetes, cardiovascular disease, and HIV. Interventions included: skills training, websites, electronic personal health records, remote patient monitoring, and education. The effects of the interventions were related to: (i) digital health literacy, (ii) health literacy, (iii) health information skills, (iv) technology skills and access, and (v) self-management and participation in care. A meta-analysis of three studies identified the effect of digital interventions was better than usual care for eHealth literacy (1.22 [CI 0.55, 1.89], p < 0.001).

CONCLUSIONS

The evidence of the effects of digital interventions on related health literacy is limited. Existing studies reflect the heterogeneity in study design, population, and outcome measures. There is a need for further studies on the effects of digital interventions on related health literacy for individuals with chronic conditions.

Leukocytes, microRNA, and complement activity in raw, heat-treated, and frozen colostrum and their dynamics as colostrum transitions to mature milk in dairy cows

The objectives of this study were to evaluate the abundance and viability of leukocytes, the abundance of microRNA, and the activity of the complement pathway in (1) colostrum following heat-treatment or freezing, and (2) colostrum, transition milk, and mature milk. In experiment 1, composite colostrum samples were harvested from individual cows (n = 14) on a commercial dairy farm in NY and split into 3 aliquots using single-use colostrum bags. One aliquot was immediately cooled on ice following harvest (RAW) and stored at 4°C overnight, one was heat-treated for 60 min at 60°C (HT) before being cooled on ice and stored at 4°C overnight, and one was frozen at -20°C overnight (FR). The following morning, all samples were warmed to 40°C before further processing. In experiment 2, cows were sampled in a longitudinal study where composite samples were collected from colostrum (first milking, n = 23), transition milk (3 to 4 d postpartum, n = 13), and mature milk (6 to 7 d postpartum, n = 13). In both experiments colostrum was harvested from the first milking within 8 h of calving and samples were processed within 14 h of collection. Colostral leukocytes were isolated before viability was determined by trypan blue exclusion and manual differential cell counts were performed. Extracellular vesicles were isolated from whey by ultracentrifugation to isolate and quantify microRNA. Activity of the alternative complement pathway was determined in casein-depleted whey by semi-solid phase hemolysis assay. Somatic cell counts were determined for all raw samples. Macrophages and neutrophils made up the greatest proportion of leukocytes in colostrum followed by lymphocytes. Lymphocyte proportion increased as colostrum transitioned to mature milk, but overall somatic cell numbers declined concurrently. Viable cells were not isolated from HT or FR samples. Abundance of microRNA isolated from transition and mature milk was decreased compared with colostrum, did not differ between HT and RAW, but was increased in FR compared with RAW. Alternative complement pathway activity was decreased in HT, but not FR compared with RAW, and was not measurable in transition or mature milk. Postharvest heat-treatment and freezing of colostrum eliminated viable colostral leukocytes and affected microRNA abundance and complement activity. Leukocyte proportions, microRNA abundance, and complement activity changed as colostrum transitioned to mature milk. Although there were clear changes in the colostral components under study in relation to treatment and transition to mature milk, the biological significance of the described treatment effects and temporal changes were not investigated here.

Monitoring COVID-19 initiatives and safety concerns at a comprehensive cancer center

247

Background: The COVID-19 pandemic brought national and local concerns, particularly to a comprehensive cancer center. Cancer patients’ clinical immunosuppressed status puts them in a vulnerable position for serious complications from COVID-19, including a higher risk of death. The institution developed five operational priorities (OP) to minimize exposure to the virus and contain and mitigate COVID-19 transmission and saw the need to monitor and evaluate those priorities. The project aim was to develop a monitoring system to promote timely identification of system threats and failures of the multiple safety processes implemented by engaging and empowering the front line workforce and area leaders to report concerns through a reporting tool. Methods: The COVID-19 Safety Control Center was developed, which consisted of a triage controller, SharePoint tool for front-line and area managers to report concerns or questions using handheld devices and a telephone hotline for urgent/emergent issues. Delegates from each were designated to review and respond to the reports within 24 hours. Metrics were developed for each of the initiatives. An interactive dashboard was built to communicate to leadership the status and trends of safety concerns. Project leadership met weekly to evaluate its’ efficiency and efficacy. Results: During the first 60 days, 476 events were reported and, on average, closed within 19 hours. The highest entries were related to policy and procedures of the hospital entry points, COVID-19 testing, and patient care. No high harm events were reported. A decreasing trend in entries was observed coinciding with the institution providing timely information to employees through daily COVID-19 briefings, weekly town hall meetings and increased familiarity with institutional COVID-19 processes. Conclusions: When multiple interventions are instituted and compliance to these measures are required in a rapid time frame, there needs to be a platform to monitor the process changes and address safety concerns quickly. Providing timely resolution to concerns of the front line staff serve to identify the threats, decrease the potential failures and provide opportunities to improve processes. The steps taken by the institution are a part of the journey toward high reliability.

Invited Review: APOE at the interface of inflammation, neurodegeneration and pathological protein spread in Alzheimer's disease

Despite more than a century of research, the aetiology of sporadic Alzheimer's disease (AD) remains unclear and finding disease modifying treatments for AD presents one of the biggest medical challenges of our time. AD pathology is characterized by deposits of aggregated amyloid beta (Aβ) in amyloid plaques and aggregated tau in neurofibrillary tangles. These aggregates begin in distinct brain regions and spread throughout the brain in stereotypical patterns. Neurodegeneration, comprising loss of synapses and neurons, occurs in brain regions with high tangle pathology, and an inflammatory response of glial cells appears in brain regions with pathological aggregates. Inheriting an apolipoprotein E ε4 (APOE4) allele strongly increases the risk of developing AD for reasons that are not yet entirely clear. Substantial amounts of evidence support a role for APOE in modulating the aggregation and clearance of Aβ, and data have been accumulating recently implicating APOE4 in exacerbating neurodegeneration, tau pathology and inflammation. We hypothesize that APOE4 influences all the pathological hallmarks of AD and may sit at the interface between neurodegeneration, inflammation and the spread of pathologies through the brain. Here, we conducted a systematic search of the literature and review evidence supporting a role for APOE4 in neurodegeneration and inflammation. While there is no direct evidence yet for APOE4 influencing the spread of pathology, we postulate that this may be found in future based on the literature reviewed here. In conclusion, this review highlights the importance of understanding the role of APOE in multiple important pathological mechanisms in AD.

Outcomes for Patients with apparent Chronic Idiopathic Pelvic Pain and associated Pelvic Floor Disorders undergoing Laparoscopic Ventral Mesh Rectopexy

This article has been temporarily withdrawn, with the agreement of all authors and the journal editor, whilst an investigated is being carried out by the North Bristol NHS Trust and the General Medical Council following some concerns raised.

Neurophysiological assessment of acute pain in infants: a scoping review of research methods

A systematic scoping search to describe the neurophysiological methods used in infant acute pain assessment research was conducted. Of the 2411 abstracts screened, 19 articles were retained. Nine studies utilised near-infrared spectroscopy (NIRS), two utilised functional magnetic resonance imaging (fMRI), and eight utilised electroencephalography (EEG). There was methodological variability in studies utilising NIRS, whereas EEG and fMRI studies reported consistent methods. Of the eight EEG studies, six identified a nociceptive-specific event-related potential.

CONCLUSION

While more methodologically rigorous studies are needed, ERPs appear to hold some promise as indicators of infant nociception during clinical procedures to supplement existing measures.

The Effect of Chronic Kidney Disease on a Physical Activity Intervention: Impact on Physical Function, Adherence, and Safety

Background

Because chronic kidney disease (CKD) is associated with muscle wasting, older adults with CKD are likely to have physical function deficits. Physical activity can improve these deficits, but whether CKD attenuates the benefits is unknown. Our objective was to determine if CKD modified the effect of a physical activity intervention in older adults.

Methods

This is an exploratory analysis of the LIFE-P study, which compared a 12-month physical activity program (PA) to a successful aging education program (SA) in older adults. CKD was defined as a baseline eGFR < 60 mL/min/1.73 m². We examined the Short Physical Performance Battery (SPPB) at baseline, 6 and 12 months. Secondary outcomes included serious adverse events (SAE) and adherence to intervention frequency. Linear mixed models were adjusted for age, sex, diabetes, hypertension, CKD, intervention, site, visit, baseline SPPB, and interactions of intervention and visit and of intervention, visit, and baseline CKD.

Results

The sample included 368 participants. CKD was present in 105 (28.5%) participants with a mean eGFR of 49.2 ± 8.1 mL/min/1.73 m². Mean SPPB was 7.38 ± 1.41 in CKD participants; 7.59 ± 1.44 in those without CKD (p = 0.20). For CKD participants in PA, 12-month SPPBs increased to 8.90 (95% CI 8.32, 9.47), while PA participants without CKD increased to 8.40 (95% CI 8.01, 8.79, p = 0.43). For CKD participants in SA, 12-month SPPBs increased to 7.67 (95% CI 7.07, 8.27), while participants without CKD increased to 8.12 (95% CI 7.72, 8.52, p = 0.86). Interaction between CKD and intervention was non-significant (p = 0.88). Number and type of SAEs were not different between CKD and non-CKD participants (all p > 0.05). In PA, adherence for CKD participants was 65.5 ± 25.4%, while for those without CKD was 74.0 ± 22.2% (p = 0.12).

Conclusion

Despite lower adherence, older adults with CKD likely derive clinically meaningful benefits from physical activity with no apparent impact on safety, compared to those without CKD.

Impact of dietary plane of energy during the dry period on lipoprotein parameters in the transition period in dairy cattle

The high energy demands of dairy cows during the transition period from late gestation into early lactation can place them at an increased risk for the development of metabolic and infectious diseases. Modification of the dry period diet has been investigated as a preventive means to minimize the detrimental aspects of metabolic shifts during the transition period. Studies investigating the impact of dry period diet on lipid parameters during the transition period have largely focused on markers of lipolysis and ketogenesis. Total cholesterol declines during the periparturient period and increases in early lactation. The impact total energy in the dry period diet has on the ability of the cow to maintain total serum cholesterol, as well as its natural high-density lipoprotein-rich status, during this metabolically challenging window is not clear. The impact of lipoproteins on inflammation and immune function may have a clinical impact on the cow's ability to ward off production-related diseases. In this study, we hypothesized that the provision of adequate, but not excessive, total metabolizable energy, would better allow the cow to maintain total cholesterol and a higher relative proportion of HDL throughout the transition period. Cows were allocated to one of three dry period dietary treatment groups following a randomized block design. Total serum triglycerides, cholesterol and lipoprotein fractions were measured on a weekly basis from approximately 7 weeks pre-calving to 6 weeks post-calving. The cows on the high energy diet maintained total serum cholesterol as compared to the cows provided a lower energy diet, but there was no significant increase in the LDL fraction of lipoproteins between diet treatment groups.

Arterialized venous bicarbonate is associated with lower bone mineral density and an increased rate of bone loss in older men and women

CONTEXT

Higher dietary net acid loads have been associated with increased bone resorption, reduced bone mineral density (BMD), and increased fracture risk.

OBJECTIVE

The objective was to compare bicarbonate (HCO3) measured in arterialized venous blood samples to skeletal outcomes.

DESIGN

Arterialized venous samples collected from participants in the Health, Aging and Body Composition (Health ABC) Study were compared to BMD and rate of bone loss.

SETTING

The setting was a community-based observational cohort.

PARTICIPANTS

A total of 2287 men and women age 74 ± 3 years participated.

INTERVENTION

Arterialized venous blood was obtained at the year 3 study visit and analyzed for pH and pCO2. HCO3 was determined using the Henderson-Hasselbalch equation.

MAIN OUTCOME MEASURE

BMD was measured at the hip by dual-energy x-ray absorptiometry at the year 1 (baseline) and year 3 study visits.

RESULTS

Plasma HCO3 was positively associated with BMD at both year 1 (P = .001) and year 3 (P = .001) in models adjusted for age, race, sex, clinic site, smoking, weight, and estimated glomerular filtration rate. Plasma HCO3 was inversely associated with rate of bone loss at the total hip over the 2.1 ± 0.3 (mean ± SD) years between the two bone density measurements (P < .001). Across quartiles of plasma HCO3, the rate of change in BMD over the 2.1 years ranged from a loss of 0.72%/y in the lowest quartile to a gain of 0.15%/y in the highest quartile of HCO3.

CONCLUSIONS

Arterialized plasma HCO3 was associated positively with cross-sectional BMD and inversely with the rate of bone loss, implying that systemic acid-base status is an important determinant of skeletal health during aging. Ongoing bone loss was linearly related to arterialized HCO3, even after adjustment for age and renal function. Further research in this area may have major public health implications because reducing dietary net acid load is possible through dietary intervention or through supplementation with alkaline potassium compounds.

Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study

OBJECTIVE

More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia.

DESIGN

Retrospective cohort study.

SETTING

Population based in Ontario, Canada, from 2002 to 2011.

POPULATION

Ontario women aged 15-49 years who gave birth to a liveborn or stillborn singleton infant.

METHODS

Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy.

MAIN OUTCOME MEASURES

The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators.

RESULTS

Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28-2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04-2.85), preterm birth (aOR 1.75, 95% CI 1.46-2.08), SGA (aOR 1.49, 95% CI 1.19-1.86), and LGA (aOR 1.53, 95% CI 1.17-1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity.

CONCLUSIONS

Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

Using the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict 1-year mortality in population-based cohorts of patients with diabetes in Ontario, Canada

AIMS

There are limited validated methods to ascertain comorbidities for risk adjustment in ambulatory populations of patients with diabetes using administrative health-care databases. The objective was to examine the ability of the Johns Hopkins' Aggregated Diagnosis Groups to predict mortality in population-based ambulatory samples of both incident and prevalent subjects with diabetes.

METHODS

Retrospective cohorts constructed using population-based administrative data. The incident cohort consisted of all 346,297 subjects diagnosed with diabetes between 1 April 2004 and 31 March 2008. The prevalent cohort consisted of all 879,849 subjects with pre-existing diabetes on 1 January, 2007. The outcome was death within 1 year of the subject's index date.

RESULTS

A logistic regression model consisting of age, sex and indicator variables for 22 of the 32 Johns Hopkins' Aggregated Diagnosis Group categories had excellent discrimination for predicting mortality in incident diabetes patients: the c-statistic was 0.87 in an independent validation sample. A similar model had excellent discrimination for predicting mortality in prevalent diabetes patients: the c-statistic was 0.84 in an independent validation sample. Both models demonstrated very good calibration, denoting good agreement between observed and predicted mortality across the range of predicted mortality in which the large majority of subjects lay. For comparative purposes, regression models incorporating the Charlson comorbidity index, age and sex, age and sex, and age alone had poorer discrimination than the model that incorporated the Johns Hopkins' Aggregated Diagnosis Groups.

CONCLUSIONS

Logistical regression models using age, sex and the John Hopkins' Aggregated Diagnosis Groups were able to accurately predict 1-year mortality in population-based samples of patients with diabetes.

Connectivity of a large embayment and coastal fishery: spawning aggregations in one bay source local and broad-scale fishery replenishment

Ichthyoplankton sampling and otolith chemistry were used to determine the importance of transient spawning aggregations of snapper Chrysophrys auratus (Sparidae) in a large embayment, Port Phillip Bay (PPB), Australia, as a source of local and broad-scale fishery replenishment. Ichthyoplankton sampling across five spawning seasons within PPB, across the narrow entrance to the bay and in adjacent coastal waters, indicated that although spawning may occur in coastal waters, the spawning aggregations within the bay were the primary source of larval recruitment to the bay. Otolith chemical signatures previously characterized for 0+ year C. auratus of two cohorts (2000 and 2001) were used as the baseline signatures to quantify the contribution that fish derived from reproduction in PPB make to fishery replenishment. Sampling of these cohorts over a 5 year period at various widely dispersed fishery regions, combined with maximum likelihood analyses of the chemistry of the 0+ year otolith portions of these older fish, indicated that C. auratus of 1 to 3+ years of age displayed both local residency and broad-scale emigration from PPB to populate coastal waters and an adjacent bay (Western Port). While the PPB fishery was consistently dominated (>70%) by locally derived fish irrespective of cohort or age, the contribution of fish that had originated from PPB to distant populations increased with age. At 4 to 5+ years of age, when C. auratus mature and fully recruit to the fishery, populations of both cohorts across the entire central and western Victorian fishery, including two major embayments and c. 800 km of coastal waters, were dominated (>70%) by fish that had originated from the spawning aggregations and nursery habitat within PPB. Dependence of this broadly dispersed fishery on replenishment from heavily targeted spawning aggregations within one embayment has significant implications for management and monitoring programmes.

Trough serum infliximab: a predictive factor of clinical outcome for infliximab treatment in acute ulcerative colitis

BACKGROUND AND AIMS

Antibodies to infliximab reduce serum infliximab with loss of clinical benefit, but undetectable trough serum concentrations of infliximab may occur without antibody formation. The relationship between trough serum infliximab and clinical outcomes was evaluated in acute ulcerative colitis.

METHODS

In a cohort of 115 patients with ulcerative colitis treated with three-dose induction followed by scheduled maintenance infliximab, rates of clinical remission, colectomy, antibodies to infliximab and trough serum infliximab were determined.

RESULTS

Rates of remission were 32% at week 10 and 37% at week 54. Colectomy occurred in 40% of patients, at a median of 5.3 (IQR 1.9-12.1) months. Detectable trough serum infliximab was present in 39% of patients and, among patients with undetectable infliximab, 41% were antibody positive and 20% were antibody negative. For antibody-positive and antibody-negative patients, rates of remission (18% vs 14%), endoscopic improvement (25% vs 35%) and colectomy (52% vs 59%) were not different. A detectable serum infliximab was associated with higher rates of remission (69% vs 15%; p<0.001) and endoscopic improvement (76% vs 28%, p<0.001). An undetectable serum infliximab predicted an increased risk for colectomy (55% vs 7%, OR 9.3; 95% CI 2.9 to 29.9; p<0.001). Concurrent immunosuppression was not associated with clinical outcomes.

CONCLUSIONS

For patients with ulcerative colitis treated with infliximab, a detectable trough serum infliximab predicts clinical remission, endoscopic improvement and a lower risk for colectomy. An undetectable trough serum infliximab, irrespective of antibody status, is associated with less favourable outcomes.

Trough serum infliximab: a predictive factor of clinical outcome for infliximab treatment in acute ulcerative colitis

BACKGROUND AND AIMS

Antibodies to infliximab reduce serum infliximab with loss of clinical benefit, but undetectable trough serum concentrations of infliximab may occur without antibody formation. The relationship between trough serum infliximab and clinical outcomes was evaluated in acute ulcerative colitis.

METHODS

In a cohort of 115 patients with ulcerative colitis treated with three-dose induction followed by scheduled maintenance infliximab, rates of clinical remission, colectomy, antibodies to infliximab and trough serum infliximab were determined.

RESULTS

Rates of remission were 32% at week 10 and 37% at week 54. Colectomy occurred in 40% of patients, at a median of 5.3 (IQR 1.9-12.1) months. Detectable trough serum infliximab was present in 39% of patients and, among patients with undetectable infliximab, 41% were antibody positive and 20% were antibody negative. For antibody-positive and antibody-negative patients, rates of remission (18% vs 14%), endoscopic improvement (25% vs 35%) and colectomy (52% vs 59%) were not different. A detectable serum infliximab was associated with higher rates of remission (69% vs 15%; p<0.001) and endoscopic improvement (76% vs 28%, p<0.001). An undetectable serum infliximab predicted an increased risk for colectomy (55% vs 7%, OR 9.3; 95% CI 2.9 to 29.9; p<0.001). Concurrent immunosuppression was not associated with clinical outcomes.

CONCLUSIONS

For patients with ulcerative colitis treated with infliximab, a detectable trough serum infliximab predicts clinical remission, endoscopic improvement and a lower risk for colectomy. An undetectable trough serum infliximab, irrespective of antibody status, is associated with less favourable outcomes.