A105 RAPID INTERDISCIPLINARY IBD CLINIC RESULTS IN TIMELY IBD WAIT TIMES, IMPROVED PATIENT SATISFACTION & PATIENT REPORTED OUTCOMES

Background

Inflammatory Bowel Disease (IBD) patients often have disease flares and extraintestinal manifestations such as rashes, arthralgias & perianal fistulas that require timely assessments. We implemented a Rapid Interdisciplinary IBD program at Mount Sinai Hospital with expedited consultation by an IBD specialist and referral with clinical need to collaborative colorectal surgeon, dermatologist, rheumatologist, and/or high-risk obstetrician. The RAPID program includes an online IBD Dashboard for patients to respond to questionnaires which is closely monitored 90 days post-enrolment by the IBD nurse.

Aims

To assess the implementation of an Interdisciplinary IBD Clinic & online IBD Dashboard monitoring system on the ability to increase patient satisfaction regarding their IBD care.

Methods

Upon consent into the RAPID IBD program, patients are enrolled to the IBD Dashboard and complete a Patient Satisfaction (CACHE) questionnaire at baseline, 3, 6, 12 months follow up and clinical disease activity scores at baseline, 1, 2, 3 months post enrollment; the Modified Harvey Bradshaw Index (mHBI) for Crohn’s disease (CD); partial Mayo score and Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis (UC) and IBD unclassified (IBDU) patients. Results were compared pre/post enrollment with changes in median and interquartile ranges (IQR).

Results

109 patients were referred to RAPID, 88 (49 CD, 33 UC, 6 IBDU) enrolled & 62 consented to IBD Dashboard monitoring. Of those enrolled, 40 patients were referred based on flaring of clinical scores, 23 with potential flare or complication, 17 with acute extraintestinal manifestations, 4 pregnant and 4 with perianal disease. Median 4 (2–7) days to first GI IBD clinic. 15 patients were referred to dermatology, 12 to colorectal surgery, 8 to rheumatology and 3 to obstetrics. 6 patients visited the ER within the first 90 days after enrollment, with 1 (1–2) ER visits. Patient satisfaction improved from baseline 73.5% (68.4%-77.4%) (n=53) to 82.3% (75.5% - 84.0%) at 3 months (n=28). Clinical responses were seen post enrollment with a decrease in mHBI of 3.0 at 2 months, 1.5 on the 6-point Mayo (SF + RB) at 1 & 3 months and patient defined significant improvement in SCCAI greater than 1.5 after 1 month.

Conclusions

Preliminary results with RAPID IBD program demonstrate a short time to be seen by an IBD specialist, improvement in patient satisfaction and clinical responses in mHBI, pMayo and SCCAI scores 1–3 months post enrollment.

Funding Agencies

AMO

Kidney injury owing to Streptococcus pneumoniae infection in critically ill infants and children: report of four cases

Streptococcus pneumoniae sepsis has high morbidity, particularly if complicated by renal injury. Four patients with S. pneumonia invasive infections complicated by renal disorders are presented. The first case was an 18-month-old girl with pneumococcal empyema complicated by haemolytic uraemic (HUS) syndrome. She made a full recovery after mechanical ventilation, inotropic support and haemodiafiltration. The second was a 4-year-old boy who presented with acute post-infectious glomerulonephritis associated with bilateral pneumococcal pneumonia. He too made a complete recovery. The third was a newborn girl with pneumococcal meningitis complicated by acute respiratory distress syndrome and acute renal failure. The fourth patient was an 8-month-old boy with pneumococcal pneumonia and meningitis complicated by HUS and with fulminant thrombotic thrombocytopenic purpura. Despite full support including mechanical ventilation and haemodiafiltration, he died 4 days after admission. On follow-up, all three survivors recovered completely from their pulmonary symptoms and had normal renal function and cardio-circulatory status in the mid-term.

Transcranial magnetic stimulation shows impaired transcallosal inhibition in Marchiafava-Bignami syndrome

A case of Marchiafava-Bignami (MB) syndrome with selective callosal involvement was evaluated by clinical examination and magnetic resonance imaging (MRI) in the acute phase and 6 months after the onset of symptoms; at the same time, the corticospinally and transcallosally mediated effects elicited by transcranial magnetic stimulation (TMS) were investigated. The first MRI study showed the presence of extensive abnormal signal intensity throughout the entire corpus callosum. After high-dose corticosteroid administration her symptoms rapidly resolved, in parallel with the reversion of MRI changes, except for severe cognitive impairment. Follow-up TMS examination revealed persistent transcallosal inhibition (TI) abnormalities. This report indicates that the measurement of TI during the course of MB syndrome is useful for evaluating functional changes to the corpus callosum, including their evaluation with time and after treatment and for elucidating the pathophysiology of MB syndrome.

Transient ischaemic attacks in two cases of internal carotid artery hypoplasia

Congenital anomalies of the internal carotid arteries (ICA) and cerebral arteries have not been frequently reported. Moreover, in the literature there is no clear association between hypoplastic carotid and cerebral vessel systems and the occurrence of cerebral ischaemia. We report two cases of unilateral hypoplasia of the ICA affecting two young patients suffering from an episode of minor stroke and from recurrent transient ischaemic attacks, respectively. Congenital variations in the configuration and size of the carotid and cerebral arteries should not always be considered benign conditions and may predispose to cerebral ischaemia in young adults.

Changes in motor cortex excitability during muscle fatigue in amyotrophic lateral sclerosis

To further investigate the pathophysiology of amyotrophic lateral sclerosis (ALS), the silent period (SP) evoked by transcranial magnetic stimulation during a fatiguing muscle contraction was evaluated in 15 patients and in 15 healthy subjects. Physiological lengthening of the SP duration was not observed in patients with disease duration of > or = 2 years. Decreased intracortical inhibition, probably secondary to dysfunction of the inhibitory interneurons that modulate the corticomotoneuronal firing, appears in later stages of disease. Normal motor cortex adaptation is impaired and cortical hyperexcitability might be unmasked during fatigue in ALS patients with longer disease duration.

Changes in motor cortical excitability in humans following orally administered theophylline

The effects of theophylline on human corticospinal excitability were studied using transcranial magnetic stimulation (TMS) before and after double-blind oral administration of theophylline or placebo in 20 healthy volunteers. TMS measurements included resting and active motor threshold, silent period, intracortical inhibition (ICI), and intracortical facilitation. F-wave and compound muscle action potential (CMAP) were also measured. Theophylline produces a reduction in ICI, while other parameters of corticospinal excitability remained unaffected. Since ICI is thought to depend on GABAA intracortical inhibitory mechanisms, our data suggest that the increase of human motor cortex excitability is the result of a decrease in GABAergic transmission. Our results further support the hypothesis that theophylline might induce convulsions by inhibiting GABAA receptor binding.

Cytogenetic and molecular characterization of a de novo 4q24qter duplication and correlation to the associated phenotype

We report on a newborn with severe psychomotor retardation, minor anomalies, congenital heart defects, thumb and urogenital abnormalities. Cytogenetic analysis showed a 4q24qter duplication, never described before, as the result of a de novo t(4;14). The extension of the duplicated 4q region was defined by FISH using YAC probes. The breakpoint was localized between 106.3cM (YAC 800f2, D4S1572) and 111 cM (YAC 744e4, D4S1564). Comparing our patient with those previously reported in literature, we observed some features mature frequently reported in these patients: psychomotor retardation, retromicrognathia, low set and/or malformed ears and some more specific traits: congenital cardiac defects, hypoplastic thumb and urogenital abnormalities.

Serial measurements of C-reactive protein and interleukin-6 in the immediate postnatal period: reference intervals and analysis of maternal and perinatal confounders

BACKGROUND

There is a wide range of reported sensitivities and specificities for C-reactive protein (CRP) and interleukin-6 (IL-6) in the detection of early-onset neonatal infection. This prompted us to assess reference intervals for CRP and IL-6 during the 48-h period immediately after birth and to identify maternal and perinatal factors that may affect them.

METHODS

CRP and IL-6 values were prospectively obtained for 148 healthy babies (113 term, 35 near-term) at birth and at 24 and 48 h of life, and from their mothers at delivery.

RESULTS

Upper reference limits for CRP at each neonatal age were established. At birth, CRP was significantly lower than at 24 and 48 h of life. Rupture of membranes > or =18 h, perinatal distress, and gestational hypertension significantly affected the neonatal CRP dynamics, but at specific ages. There was no correlation between CRP concentrations in mothers and their offspring at birth. The IL-6 values observed in the delivering mothers and in their babies at all three neonatal ages were negatively associated with gestational age. In the immediate postnatal period, IL-6 dynamics for term babies were significantly different from those for near-term babies. Maternal IL-6 concentrations correlated with babies' IL-6 concentrations only for term deliveries. Apgar score had a significant effect on babies' IL-6 values at birth.

CONCLUSIONS

The patterns of CRP and IL-6 responses in the healthy neonate should be taken into account to optimize their use in the diagnosis of early-onset neonatal sepsis.

The cell cycle regulator p27kip1 contributes to growth and differentiation of osteoblasts

The cyclin-dependent kinase (cdk) inhibitors are key regulators of cell cycle progression. p27 and p21 are members of the Cip/Kip family of cdk inhibitors and regulate cell growth by inactivating cell cycle stage-specific CDK-cyclin complexes. Because down-regulation of osteoprogenitor proliferation is a critical step for osteoblast differentiation, we investigated expression of p27 and p21 during development of the osteoblast phenotype in rat calvarial osteoblasts and in proliferating and growth-inhibited osteosarcoma ROS 17/2.8 cells. Expression of these proteins indicates that p21, which predominates in the growth period, is related to proliferation control. p27 levels are maximal postproliferatively, suggesting a role in the transition from cell proliferation to osteoblast differentiation. We directly examined the role of p27 during differentiation of osteoprogenitor cells derived from the bone marrow (BM) of p27-/- mice. BM cells from p27 null mice exhibited increased proliferative activity compared with BM cells from wild-type mice and formed an increased number and larger size of osteoblastic colonies, which further differentiated to the mineralization stage. Although p27-/- adherent marrow cells proliferate faster, they retain competency for differentiation, which may result, in part, from observed higher p21 levels compared with wild type. Histological studies of p27-/- bones also showed an increased cellularity in the marrow cavity compared with the p27+/+. The increased proliferation in bone does not lead to tumorigenesis, in contrast to observed adenomas in the null mice. Taken together, these findings indicate that p27 plays a key role in regulating osteoblast differentiation by controlling proliferation-related events in bone cells.