Disease Activity Questionnaires Research Articles

Calprotectin as a marker of disease activity in spondyloarthritis

Introduction: Spondyloarthritis is a group of arthritic diseases that classically manifest as inflammation of the sacroiliac and limb joints, as well as the axial skeleton. Microscopic bowel inflammation is identifiable in over 50% of these patients. Calprotectin measured in the serum and stool is an emerging surrogate marker of disease activity and/or bowel inflammation in spondyloarthritis. Objective: This article aims to review published literature to determine the accuracy of serum and faecal calprotectin levels for use in monitoring bowel inflammation and spondyloarthritis disease activity. Methods: Boolean operator strategy was used to search two databases (Embase and PubMed) and 52 relevant articles were identified. Duplicate results were eliminated, inclusion and exclusion criteria were applied. Results: Ten studies met the inclusion criteria and were summarized and analyzed. The EBL Validity questionnaire was applied to determine study quality. All research articles found calprotectin to be elevated in spondyloarthritis patients when compared to controls. Faecal calprotectin was superior in detecting disease activity and correlated with disease activity questionnaires, radiology and endoscopy results. Only one study assessed the effect of treatment on calprotectin and its correlation to bowel inflammation. Conclusion: Faecal calprotectin shows promise as a surrogate marker for disease activity and bowel inflammation in spondyloarthritis. Future studies should focus on the effect of treatment on faecal calprotectin and whether some treatments are better at preventing the progression of bowel inflammation in addition to treating spondyloarthritis. Supplementary investigations are needed to identify whether faecal calprotectin is useful as a marker of disease activity in response to treatment.

Agreement between patients and physicians on scores of inflammatory bowel disease activity and burden assessed on a telemonitoring platform

Background and aims Telemonitoring is increasingly used in the management of IBD patients. We investigated the agreement between patients and physicians on scores of disease activity and burden. Methods Consecutive outpatients at one IBD clinic were recruited between February and December 2021. Enrolled patients completed a questionnaire for disease activity (Harvey-Bradshaw Index [HBI] for Crohn’s disease or Simple Clinical Colitis Activity Index [SCCAI] for ulcerative colitis) and a test of disease burden (Pictorial Representation of Illness and Self Measure [PRISM]). They did the tests within 5 days of an outpatient visit, working independently on IBD Tool, a new web-based telemonitoring application. Concomitantly, the senior and junior physicians who examined them completed the same tests. The agreement was tested for every pair of scores. Results Five hundred and sixty patients (289 Crohn’s disease; 271 ulcerative colitis) completed disease questionnaires on IBD Tool (in total, 742 times). By Spearman’s correlation, the agreement was substantial both for HBI (rho 0.685–0.837) and SCCAI (rho 0.694–0.888) for comparisons between patients, junior and senior physicians. The agreement was moderate-to-substantial for PRISM (rho 0.406–0.725) for the same comparisons. The correlation between disease activity (HBI/SCCAI) and PRISM scores was substantial for senior (rho 0.757–0.788) or junior (rho 0.746–0.753) physicians and moderate for patients (rho 0.458–0.486). The median PRISM score difference was 2.3–1.6 points lower between patients and senior-junior physicians. Conclusion Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease impact. The inclusion of disease burden scoring in telemonitoring platforms provides important information for the management of IBD patients. Study highlights What IS known •Continuous response to treatments and patient-reported outcomes became an essential goal for IBD patient management. •The use of tele-monitoring and eHealth technologies allows for regular disease assessments and for managing more efficiently IBD patients; disease questionnaires and tests are key to support eHealth tools. What is new here •Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease burden, while agreement among junior and senior physicians was substantial for both. •PRISM performs as well for ulcerative colitis as for Crohn’s patients. •The inclusion of disease burden tests might add to eHealth platforms valuable information, complemental to disease activity questionnaires.

E-Health and remote management of patients with inflammatory bowel disease: lessons from Denmark in a time of need.

In Denmark, remote monitoring and management of inflammatory bowel disease (IBD) started two decades ago with the web application Constant Care. The disease monitoring in Constant Care consists of simple disease activity questionnaires and home measurement of faecal calprotectin, a stool biomarker for inflammation. It has now been implemented in clinical practice at North Zealand University Hospital in Denmark. Digital health care solutions facilitate remote contact between patients and healthcare providers and have been shown to reduce time to remission, outpatient visits and hospital admissions, and increase adherence to medical therapy, quality of life and disease and treatment knowledge. In Australia, E-Health is an area of increasing interest, particularly given the significant distances travelled by rural patients to access specialist care. There are several foreseeable benefits to incorporating E-Health/remote monitoring into Australian IBD management, including reduced burdens of time and cost on rural patients, and more efficient management of well outpatients, thereby increasing clinic availability for acutely unwell patients. The significant portion of IBD patients managed in private practice in Australia, and the infrastructure within private practice that is well suited to implementation of E-Health makes Australia a viable setting for an E-Health IBD management model like Denmark's Constant Care model. One pilot study is currently underway investigating the feasibility of rapid and remote IBD monitoring and E-Health in an Australian IBD population. The current COVID-19 pandemic has further illustrated the importance of telehealth as a means of maintaining health services to patients in geographic, or social, isolation.

P520 ‘Eetscore’ in patients with Inflammatory Bowel Disease: an online tool to assess diet quality and provide personalised dietary advice

Abstract Background Many patients with IBD believe diet affects the course of disease and is at least as important as medication in their IBD treatment. However, easy assessment of patients’ food intake and structured support of a healthy diet are lacking. The Eetscore is an online tool which assesses diet quality and subsequently gives personal dietary advice. We used the Eetscore to assess diet quality of IBD patients, evaluated if diet quality improved over time and studied correlations with quality of life (QoL) and clinical disease activity. Methods A prospective cohort study with adult IBD patients was performed. Participants completed the Eetscore, the short IBDQ and a clinical disease activity questionnaire (P-HBI or P-SCCAI) at baseline and after 1 month. The Eetscore is a validated web-based screening tool to assess diet quality based on 16 food components (e.g. meat, vegetables, fruit and fish). It consists of a short Food Frequency Questionnaire and is scored with the Dutch Healthy Diet 2015-index based on the Dutch dietary guidelines. The score of each component ranges from 0 to 10, resulting in a total score between 0 and 160. Higher scores indicate better adherence to Dutch dietary guidelines. The Eetscore subsequently provides personalised dietary advice based on the assessment. We assessed changes over time using paired samples t-tests or McNemar’s test and correlations using Pearson’s or Spearman’s correlation. Results We included 212 participants. At time of this preliminary analysis, 175 participants (60% female, 49% Crohn’s disease) completed baseline and 1-month assessments. Their median age was 49 years [IQR 32–58], BMI 25 kg/m2 [IQR 22–28] and disease duration 10 years [IQR 4–18]. At baseline, mean Eetscore was 98 ± 19, with highest median scores (≥8.5) on red meat, fat and oils, sweetened beverages, alcohol and salt intake, and lowest median scores (≤5) on nuts, legumes, processed meat and unhealthy choices (Figure 1). Diet quality increased with 5.6 points (95%CI 3.7–7.5) to a mean Eetscore of 103 ± 21 (p<0.001) after 1 month. QoL improved from 53 ± 10 to 55 ± 9 (∆2.0 (95%CI 1.2–2.8); p<0.001). The proportion of participants with clinically quiescent disease was comparable at both time points (71% vs 74%, p=0.29). Diet quality was not correlated with QoL or clinical disease activity. Conclusion This study suggests the Eetscore is a useful tool to monitor and support a healthy diet in IBD patients. Diet quality improved significantly following personalised dietary advice of the Eetscore. Short term results did not indicate a correlation between diet quality and QoL or clinical disease activity.

P550 Short term effects of a combined lifestyle intervention in patients with Inflammatory Bowel Disease

BackgroundDiet and physical activity might help to improve quality of life and maintain remission in patients with inflammatory bowel disease (IBD). In other conditions, interventions in which diet and physical activity are combined seem to be more effective than separate interventions. Therefore, we assessed the effect of a combined lifestyle intervention on the impact of disease on daily life, clinical disease activity, fatigue and quality of life in patients with Crohn’s disease (CD) or ulcerative colitis (UC).MethodsA single arm intervention study was performed in IBD patients in remission or with mildly active disease. Participants received personal advice to improve their diet and level of physical activity by a dietician and a physiotherapist in one face-to-face and one telephone consult. These advices were supported by guidelines based on the Dutch dietary and physical activity guidelines, a recipe app and a booklet with physical activity exercises. IBD disability index (IBD-DI) to assess impact of disease on daily life, clinical disease activity questionnaires (P-HBI or P-SCCAI), IBD fatigue (IBD-F) patient self-assessment scale and IBD quality of life questionnaire (IBDQ) were completed. The Eetscore Food Frequency Questionnaire (Eetscore FFQ) and Short Questionnaire to Assess Health-enhancing physical activity (SQUASH) were used to assess diet and physical activity. Changes from baseline to 5 weeks after start were investigated by paired samples t-tests or Wilcoxon signed rank tests.ResultsWe included 29 participants. At time of this preliminary analysis, 25 participants completed baseline and 5-week assessments (11 males, 11 CD, median age 36 years [IQR 29–53], median BMI 25 kg/m2 [IQR 24–28]). After 5 weeks, diet quality had significantly improved (p<0.001), but level of physical activity had not (p=0.509). Impact of disease on daily life (IBD-DI) decreased with 2.5 points (95%CI -5.5-0.4; p=0.09). Disease activity did not change significantly. There was a significant decrease in fatigue (median IBD-F 20 [IQR 8–29] to 15 [IQR 3–24; p=0.03]) and a significant increase in quality of life (median IBDQ 194 [IQR 179–206] to 196 [IQR 186–209; p=0.03]).ConclusionThese preliminary results suggest that a combined lifestyle intervention is effective to reduce fatigue and to increase quality of life in patients with IBD, at least in the short term. Impact of disease on daily life and clinical disease activity did not improve significantly. Participants reported their level of physical activity to be restricted due to COVID-19 measures, which could explain the lack of effect on this outcome. This study is still ongoing and we expect follow-up data up till 1 year after start.

Repeated prolonged moderate-intensity walking exercise does not appear to have harmful effects on inflammatory markers in patients with inflammatory bowel disease

Background and objectives The role of exercise in the management of inflammatory bowel disease (IBD) is inconclusive as most research focused on short or low-intensity exercise bouts and subjective outcomes. We assessed the effects of repeated prolonged moderate-intensity exercise on objective inflammatory markers in IBD patients. Methods In this study, IBD patients (IBD walkers, n = 18), and a control group (non-IBD walkers, n = 19), completed a 30, 40 or 50 km walking exercise on four consecutive days. Blood samples were taken at baseline and every day post-exercise to test for the effect of disease on exercise-induced changes in cytokine concentrations. A second control group of IBD patients who did not take part in the exercise, IBD non-walkers (n = 19), was used to test for the effect of exercise on faecal calprotectin. Both IBD groups also completed a clinical disease activity questionnaire. Results Changes in cytokine concentrations were similar for IBD walkers and non-IBD walkers (IL-6 p = .95; IL-8 p = .07; IL-10 p = .40; IL-1β p = .28; TNF-α p = .45), with a temporary significant increase in IL-6 (p < .001) and IL-10 (p = .006) from baseline to post-exercise day 1. Faecal calprotectin was not affected by exercise (p = .48). Clinical disease activity did not change in the IBD walkers with ulcerative colitis (p = .92), but did increase in the IBD walkers with Crohn’s disease (p = .024). Conclusion Repeated prolonged moderate-intensity walking exercise led to similar cytokine responses in participants with or without IBD, and it did not affect faecal calprotectin concentrations, suggesting that IBD patients can safely perform this type of exercise.

The association between inflammatory potential of diet and disease activity: results from a cross-sectional study in patients with inflammatory bowel disease

BackgroundDiet may play a role in disease status in patients with inflammatory bowel disease. We tested whether the inflammatory potential of diet, based on a summation of pro- and anti-inflammatory nutrients, is associated with disease activity in patients with Crohn’s disease and ulcerative colitis.MethodsParticipants completed a disease activity questionnaire (short Crohn’s Disease Activity (sCDAI) or Patient Simple Clinical Colitis Activity Index (P-SCCAI)) and a Food Frequency Questionnaire (FFQ). FFQ data were used to calculate the Dietary Inflammatory Index (DII) which enables categorization of individuals’ diets according to their inflammatory potential on a continuum from pro- to anti-inflammatory. Associations with disease activity were investigated by multiple linear regression.ResultsThe analysis included 329 participants; 168 with Crohn’s disease (median sCDAI score 93 [IQR 47–156]), and 161 with ulcerative colitis (median P-SCCAI score 1 [IQR 1–3]). Mean DII was 0.71 ± 1.33, suggesting a slightly pro-inflammatory diet. In Crohn’s disease, the DII was positively associated with disease activity, even after adjustment for confounders (p = 0.008). The mean DII was significantly different between participants in remission and with mild and moderately active disease (0.64, 0.97 and 1.52 respectively, p = 0.027). In ulcerative colitis, the association was not significant.ConclusionsDisease activity was higher in IBD participants with a more pro-inflammatory diet with statistical significance in Crohn’s disease. Although the direction of causality is not clear, this association strengthens the role for diet in medical treatment, which should be tested in an intervention study.

Add-On Effects of Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs in Ankylosing Spondylitis: Data from a Real-World Registered Study in China.

BackgroundThe aim of this study was to investigate the effects of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) on patients with ankylosing spondylitis (AS) using real-world data, and to analyze patients’ choices of csDMARDs and reasons for discontinuation.Material/MethodsThis observational study included 320 patients satisfying the modified New York criteria for AS. Patients were grouped according to medication: Group 1: 122 patients receiving non-steroidal anti-inflammatory drug (NSAID) monotherapy; Group 2: 198 patients receiving csDMARDs and NSAIDs. Patients were followed for 18 months at 6-month intervals. The change in AS Disease Activity Score and C-reactive protein (ASDAS-CRP) at each visit was the primary outcome. Secondary outcomes were based on validated disease activity questionnaires, clinical assessment, and acute-phase biomarkers (CRP and erythrocyte sedimentation rate [ESR]). Inter-group relationships were assessed across the 18-month follow-up period using generalized additive mixed models.ResultsSulfasalazine and thalidomide were the most commonly used csDMARDs, with cumulative use times of 8.9±4.1 months and 9.1±4.7 months, respectively. In Group 2, 56 patients discontinued or switched csDMARDs during the follow-up period, with lack of efficacy being the primary reason. The ASDAS-CRP was found to decrease significantly in both groups; however, improvements in many parameters (including ASDAS-CRP, disease activity questionnaires and ESR) were greater in Group 2.ConclusionsUse of csDMARDs can improve disease activity in terms of ASDAS-CRP. The addition of csDMARDs may provide increased benefits compared with NSAID monotherapy, particularly in the reduction of AS disease activity, in the Chinese population.

MONITORING THE ACTIVITY OF ANCA-ASSOCIATED VASCULITIS: SOME QUESTIONNAIRES AND LABORATORY PARAMETERS

Systemic vasculitis is a group of diseases manifested by symptoms from many organs. ANCA-associated vasculitis (AAV) require chronic and often aggressive immunosuppressive treatment. This treatment should be adapted to the disease activity. Assessment of AAV is based on various disease activity questionnaires which contain clinical symptoms of the disease and lab results. The most useful questionnaire is BVAS version 3 (Birmingham Vasculitis Activity Score). In every patients, distinction between activity of AAV and irreversible damage is needed. ANCA antibodies are a predictor of poor prognosis in some patients. Using of these antibodies in monitoring of AAV activity has got minor importance.

Evaluation and Clinical Validity of a New Questionnaire for Mikulicz's Disease

Objectives. The characteristic features of Mikulicz's disease (MD) are diffuse enlargement of the lacrimal and submandibular glands, elevated levels of serum immunoglobulin (Ig)G4, and abundant infiltration of IgG4-positive plasmacytes into both glands. No disease index is available to properly evaluate MD, so we developed a functional assessment of MD, the Mikulicz's disease activity questionnaire (MAQ), and evaluated its clinical efficacy. Methods. We selected 18 patients who were either being treated for MD or who had presented with recurrence. The patients completed a self-assessment and were scored according to the MAQ sheet during each visit between December 2009 and August 2011. Assessment items were in regard to increases or decreases in lacrimal and salivary gland enlargement and severity of sicca symptoms. Results. On the first visits, MAQ scores were high, but scores decreased rapidly as treatment progressed. When doses of glucocorticoid were reduced, some patients showed increased scores. Dry-symptom scores increased initially. MAQ scores for patients with recurrent MD gradually increased over several months before relapse. However, some patients displayed no elevation in MAQ scores due to relapses at other sites. Conclusion. MAQ score can be used to quantify flares and treatment response and is useful for functional assessment of MD.

Medical Therapy of IBD in the First Year After Diagnosis: Preliminary Results from the Ocean State Crohnʼs and Colitis Area Registry (OSCCAR)

Purpose: The Ocean State Crohn's and Colitis Area Registry (OSCCAR) is a novel population-based, prospective inception cohort of patients with inflammatory bowel disease (IBD) in Rhode Island. The frequency of medications used to treat IBD during the first year after diagnosis was analyzed with a focus on steroids, immunomodulators and biologics. Methods: Residents of Rhode Island with newly diagnosed Crohn's disease (CD), ulcerative colitis (UC), or indeterminate colitis (IC) were eligible for enrollment beginning January 1, 2008. Diagnosis of IBD was confirmed using criteria from the NIDDK IBD Genetics Consortium. Individuals diagnosed before January 2008, unwilling to provide consent, and those imprisoned or pregnant at diagnosis were excluded. Research assistants collected demographic data, medical history and disease related information, quality of life and disease activity questionnaires, blood, urine and stool samples, with quarterly follow-up in the first year, then every 6 months. 97 of 98 gastroenterologists/colorectal surgeons in RI and 11 in MA agreed to refer patients. Practice billing data were queried and chart reviews were conducted to capture missed referrals. IRB approval was obtained. Results: For enrolled patients, medical therapy during the first year is summarized in tables 1 & 2. 5-ASA was the mainstay of therapy for UC, and a high rate of 5-ASA use was observed in CD. The rate of immunomodulator use was much higher in pediatric compared to adult patients (both CD and UC). CD patients were more likely to be on an immunomodulator or anti-TNF agent compared with UC patients. A substantial percentage of patients were started on anti-TNF therapy early after diagnosis. Conclusion: Among patients captured in this prospective, inception cohort from RI, different patterns of medication usage are seen in adult and pediatric patients, as well as in UC and CD. More than half of patients were exposed to steroids in the first year after diagnosis. A large portion of CD patients were on 5-ASA despite the lack of evidence supporting its use for this indication. Long term follow-up of these patients will yield insight into prescribing patterns and clinical effectiveness of various IBD therapies. Funding:CCFA/CDC 5U01DP000340-03 and NIH 1R21DK078555-02.Table: OSCCAR: medication use in patients with Crohn's diseaseTable: OSCCAR: medication use in patients with ulcerative colitis and indeterminant colitis

Survival and relapses assessment in patients with Wegener’s granulomatosis and predominant renal involvement

Wegener's granulomatosis (WG) is a potentially fatal condition with remissions and high relapses rates. Assessment of survival and relapses in a population based cohort of patients with WG with predominant renal involvement. A prospective cohort study including 60 patients--median age of 42 years with different dynamics and clinical presentation. Patients were divided into 3 groups (group 1, group 2 and group 3 respectively, and subgroups: 3.1, 3.2, 3.3): group 1--WG patients without renal involvement, group 2--WG patients with abnormalities in urinary sediment, group 3.1--WG patients with chronic renal failure, group 3.2--WG patients with diffuse alveloar hemorrhage (DAH) and rapid progressive glomerulonephritis (RPGN), and group 3.3--WG patients with RPGN. The clinical analysis has been conducted using the disease extent index (DEl) only and Birmingham Vasculitis Activity Score-Wegener's granulomatosis (BVAS-WG) disease activity questionnaire. Logistic regression analysis and the Wilcoxon test were used. Survival time and death risk were assessed using the Kaplan-Meier estimator and Cox proportional hazard model. Eighty-eight percent of patients survived the first year follow-up since the diagnosis, while 84% of patients remained alive after the second year of observation. Life expectancy was 67.1 +/- 4.4 months. During the first year of observation 9.8% of patients died, after 2 years death hazard amounted to 3.7% per year, and after 4 years 2.6% per year (p < 0.05). Death risk was 1.3-fold higher in group 2 and 3.3-fold higher in group 3 compared to group 1 (p > 0.05). Mortality in patients from group 3.1 was 6-fold lower than in patients from group 3.2 (p < 0.03) and in group 3.3 was more than 4-fold lower than in patients from group 3.2 (p < 0.04). Relapse risk after first the year of follow-up was 20% per year and minimally changed after 3 years of observation, then decreased to 6% after 5 years. Relapse hazard ratio in group 2 was significantly lower in comparison with group 1 (HR1/3.6, p < 0.04). We found significant differences in survival and relapses in various subpopulationsof WG patients.

Review article: faecal markers in the assessment of activity in inflammatory bowel disease.

The fundamental pathological process behind ulcerative colitis and Crohn's disease is intestinal inflammation. As the precise cause of this is not yet completely understood, current treatment strategies are aimed at reducing or eliminating the inflammation. Endoscopic examination and histological analysis of biopsy specimens remain the 'gold standard' methods for detecting and quantifying bowel inflammation; however, these techniques are costly, invasive, and repeated examinations are unpopular with patients. Disease activity questionnaires and laboratory 'inflammatory markers', although widely used, show an unreliable correlation with endoscopy and histology. New markers need to be developed to detect and quantify bowel inflammation. These would be of use diagnostically and also an aid to pharmacological treatment.