Development of a Patient Reported Experience Measure (PREM) for Chronic Inflammatory Skin Diseases

Background

Patient involvement and high‐quality patient‐provider interactions are critical factors for quality of care in chronic inflammatory skin diseases. Also, assessing the patient's perspective contributes to optimizing care delivery and patient's experience. Until today, no user‐friendly tools to measure patient experiences exist within immunodermatology.

Objectives

The aim of this study was to identify the relevant items for patient's experience in immunodermatology and develop a concise questionnaire to assess patient's experience in routine clinical care.

Methods

Potential relevant items for measuring patient's perspective of immunodermatology care were identified by a literature search. From this longlist, a shortlist from patient's perspective was distilled by semi‐structured interviews with a diverse patient group. This list was reduced to final items using a modified Delphi method in a multi‐stakeholder focus group. For each item, one question was formulated to generate the Patient‐Reported Experience Measure (PREM) questionnaire. A first internal validation was achieved by an email round.

Results

Forty longlist items were categorized into five domains (access to care, patient centeredness, access to information, care process and satisfaction). During interview rounds, 19 shortlist items were selected if mentioned by ≥40% of interviewees. Via the focus group, the most important items were chosen by participant consensus. For each item, a question was formulated. The final PREM covers 11 items (plus 2 in case of a first consult). The first internal validation showed that the tool is clear, understandable and has an ideal length.

Conclusion

This short user‐friendly PREM can be used in scientific and routine settings to improve care for patients who suffer from chronic inflammatory skin diseases.

Linked Commentary: A.‐H. Fink‐Wagner. J Eur Acad Dermatol Venereol 2022; 36: 767–768. https://doi.org/10.1111/jdv.18153.

Is external contamination with organic pollutants important for concentrations measured in bird feathers?

Although there is increasing evidence that bird feathers can be used as a non-destructive biomonitoring tool for organic pollutants [such as polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs) and p,p'-dichlorodiphenyl-trichloroethane and metabolites (DDTs)], the importance of external contamination of these organic pollutants onto the feathers has not been considered. Here we examine to which extent external contamination of organic pollutants occurs onto the feathers of a predatory bird. We have analysed primary wing feathers of 16 common buzzards (Buteo buteo) collected in Belgium. In order to study differences in external contamination within and among wing feathers, the vane and the shaft of each feather were separated and were analysed in parallel, pooled for the three inner and the three outer primary wing feathers. Most organic pollutants could be measured in these pooled samples of both the vane and the shaft. Concentrations of hexachlorobenzene (HCB), DDTs, PCBs and PBDEs were significantly higher in the vane compared to the shaft. The profiles of PCBs and PBDEs in the shaft closely resembled the profiles in liver and muscle tissue, in contrast with the profile of the vane. The PBDE congeners 47, 99 and 153 had a similar contribution in shafts of primary feathers of common buzzards. Although these results suggest that external contamination could be important on the vane, no differences in the profile of PBDEs or PCBs were found between the inner and outer (more exposed) primary feathers. Furthermore, correlation coefficients with internal tissues were not univocally distinct between the shaft and the vane. Therefore our results indicate that the higher concentrations found in the vane in comparison to the shaft do not originate from external contamination via the air, but that other factors such as structure and chemical properties of the feathers may be of importance. The lack of significant external contamination onto the feather surface is an additional asset for the use of feathers as a non-destructive biomonitor for organic pollutants.

Accumulation, tissue-specific distribution and debromination of decabromodiphenyl ether (BDE 209) in European starlings (Sturnus vulgaris)

In this study we investigated the accumulation, tissue-specific distribution and possible debromination of BDE 209 in a terrestrial songbird species, the European starling, using silastic implants as a method of exposure. BDE 209 accumulated in the blood of the exposed starlings to a mean peak concentration of 16+/-4.1 ng/ml on day 10. After this peak, there was a decline to 3.3+/-0.4 ng/ml blood at the end of the exposure period of 76 days, which suggests elimination of BDE 209. In the exposed group, the muscle concentrations (461 ng/g lipid weight [lw], 430 ng/g lw) were about twofold those in liver (269 ng/g lw, 237 ng/g lw). In addition to BDE 209, other PBDE congeners, particularly octa- and nonaBDEs, were also present in the muscle and liver, suggesting bioformation from BDE 209. To our knowledge, these results are the first indications for the debromination of BDE 209 in birds.

Experimental evaluation of the usefulness of feathers as a non-destructive biomonitor for polychlorinated biphenyls (PCBs) using silastic implants as a novel method of exposure

Risk assessment of pollutants requires both monitoring studies in the field and experimental exposure studies. In this study, we evaluated silastic implants as an alternative method of exposure for use in toxicological studies and at the same time evaluated the usefulness of feathers as a non-destructive biomonitor for PCBs. European starlings (Sturnus vulgaris) were exposed to different doses (including a control group) of environmentally relevant concentrations of PCB 153 during a 15-week period using silastic implants with both ends/only one end sealed. After implantation, there was a rapid and significant increase in PCB 153 blood concentration in the exposed groups. The significant differences in blood concentrations among the treatment groups show that silastic implants are useful as a method of exposure. Moreover, the ratio between the tissue concentrations of two treatment groups reflected the difference in implantation doses between these groups. There was also a clear difference in tissue concentrations among the treatment groups, although we could not test this statistically due to the small sample sizes. The slow release kinetics for a prolonged period and the relatively stable blood concentrations during the 15-week period render silastic tubes very interesting to study the effects of chronic exposure to pollutants. Our results also revealed that sealing both ends of the implant instead of only one did not significantly affect the exposure. There were strong, significant positive correlations between the blood and the tissues, which confirm the use of blood to monitor PCBs. To evaluate the usefulness of feathers as a non-destructive biomonitor for PCBs, we plucked the original and newly grown wing and tail feathers. We observed strong, significant positive correlations between the concentrations in the newly grown feathers and concentrations in the muscle, liver, brain and blood. PCB 153 concentrations in the newly grown feathers differed among the treatment groups. To our knowledge, our results provide the first experimental evidence that feathers are useful as a non-destructive biomonitoring tool for PCBs.