Remote Patient Monitoring in IBD: Current State and Future Directions

Purpose of Review

Mobile apps are now increasingly used in conjunction with telemedicine and wearable devices to support remote patient monitoring (RPM). The goal of this paper is to review the available evidence and assess the scope of RPM integration into standard practices for care and management of chronic disease in general and, more specifically, inflammatory bowel disease (IBD).

Recent Findings

RPM has been associated with improvements in health outcomes and indicators across a broad range of chronic diseases. However, there is limited data on the effectiveness of RPM in IBD care. From the emerging literature and body of research, we found promising results about the feasibility of integrating RPM in IBD care and RPM’s capacity to support IBD improvement in key process and outcome metrics.

Summary

Concerns regarding privacy and provider acceptability have limited the mass integration of RPM to date. However, with the healthcare industry’s move toward value-based population care and the advent of novel payment models for RPM reimbursement, the adoption of RPM into standard IBD care practices will likely increase as the technology continues to improve and become a mainstream tool for healthcare delivery in the near future.

     

Esophagitis Dissecans Superficialis: Clinical,Endoscopic, and Histologic Features

Digestive Diseases and Sciences - Esophagitis dissecans superficialis (EDS) is a desquamative disorder of the esophagus, but there is a paucity of the literature regarding this condition. We...     

Bendamustine in combination with thalidomide and dexamethasone is a viable salvage option in myeloma relapsed and/or refractory to bortezomib and lenalidomide

Treatment options are limited in myeloma relapsed or refractory to both bortezomib and lenalidomide (double-relapsed/refractory multiple myeloma; DRMM). Bendamustine is an antitumour agent that has efficacy in relapsed myeloma. We retrospectively analysed data from 30 DRMM patients who received a combination of bendamustine, thalidomide and dexamethasone (BTD) in 28-day treatment cycles. Bendamustine was administered with a cumulative dose of up to 200 mg/m². Thalidomide (50–150 mg) was given daily as tolerated, and dexamethasone was given at an equivalent dose of up to 160 mg per cycle. A median of 5 (2–9) treatment cycles were administered per patient. Twenty-six patients (87 %) achieved stable disease or better. At a median follow-up time of 12.1 (2.3–21.5) months, median (95 % CI) progression-free survival and overall survival were 4.0 (2.6–5.3) months and 7.2 (5.2–9.2) months, respectively. The most common grade 3–4 adverse events were haematological: anaemia (n?=?8, 34.8 %), neutropenia (n?=?16, 69.6 %) and thrombocytopenia (n?=?10, 43.5 %). Non-haematological toxicities included pain (n?=?3, 13.0 %), infection (n?=?7, 30.4 %) and sensory neuropathy (n?=?1, 4.3 %). We propose that BTD is a viable salvage treatment option for DRMM patients.     

Magnetic resonance angiographic evaluation of circle of Willis: A morphologic study in a tertiary hospital set up

Background:

Anatomy of circle of Willis (CW) shows wide variation in different individuals, population groups, and has vital clinical significance in causation and presentation of clinical disease. This study evaluates the anatomical variations, incidence of various common anomalies of CW in south Indian tertiary hospital set up, using three-dimensional time-of-flight (3D-TOF) magnetic resonance angiography (MRA).

Materials and Methods:

A total of 300 patients referred for neuroimaging study over a period of 2-year were included in the analysis. In this prospective and retrospective study, 198 men and 102 women; mean age, 55 years) underwent 3D-TOF MR angiograms of the CW using a 1.5-tesla MR scanner. Images were reviewed for anatomical configuration of the CW using maximum intensity projection (MIP) and 3D volume rendered images.

Results:

On analysis, a complete CW was seen in 50 (16.6%) of 300 subjects. An incomplete anterior and posterior CW was found in 66 (22%) The remaining 184 (61.3%) subjects had partially complete CW configuration. The most common type of CW in a single subject was anterior variant type A and posterior type variant E.

Conclusion:

We observed wide variation in CW configuration in our patients. The prevalence of complete configuration of the circle is 16.6%; slightly higher in females and younger subjects. Complete anterior circle was present in 77.3%. Most common anterior variant is type A (normal anterior configuration) with a prevalence of 66%. The most common posterior circle variant is type E (hypoplasia or absence of both PcomA) with 32.6%. Overall, CW variants are slightly more common among the women in comparison to men. Incidence of associated anomalies like aneurysm or arteriovenous malformation (AVM) was comparable to that described in literature.     

Impact of oral rehabilitation on patients with head and neck cancer: A study using the Liverpool Oral Rehabilitation Questionnaire and the Oral Health Impact Profile-14

Statement of problem

The treatment of oral cancers affects oral functions and quality of life (QOL). Dental rehabilitation is a major step toward enhancing quality of life after controlling the disease. The effects of the disease, treatment, and rehabilitation need to be evaluated to assess oral health-related QOL. The Liverpool Oral Rehabilitation Questionnaire version 3 (LORQv3) and Oral Health Impact Profile-14 (OHIP-14) are specific assessment questionnaires of oral rehabilitation.

Role of miR-155 in the Pathogenesis of Herpetic Stromal Keratitis

Ocular infection with herpes simplex virus 1 can result in a chronic immunoinflammatory stromal keratitis (SK) lesion that is a significant cause of human blindness. A key to controlling SK lesion severity is to identify cellular and molecular events responsible for tissue damage and to manipulate them therapeutically. Potential targets for therapy are miRNAs, but these are minimally explored especially in responses to infection. Here, we demonstrated that Mir155 expression was up-regulated after ocular herpes simplex virus 1 infection, with the increased Mir155 expression occurring mainly in macrophages and CD4⁺ T cells and to a lesser extent in neutrophils. In vivo studies indicated that Mir155 knockout mice were more resistant to herpes SK with marked suppression of T helper cells type 1 and 17 responses both in the ocular lesions and the lymphoid organs. The reduced SK lesion severity was reflected by increased phosphatidylinositol-3,4,5-trisphosphate 5-phosphatase 1 and interferon-γ receptor α-chain levels in activated CD4⁺ T cells in the lymph nodes. Finally, in vivo silencing of miR-155 by the provision of antagomir-155 nanoparticles to herpes simplex virus 1–infected mice led to diminished SK lesions and corneal vascularization. In conclusion, our results indicate that miR-155 contributes to the pathogenesis of SK and represents a promising target to control SK severity.Ocular infection with herpes simplex virus 1 (HSV-1) can result in a chronic tissue-damaging response in the stroma, which is considered to be largely the consequence of a host inflammatory response to the infection.¹ This concept is strongly supported by animal model studies in which lesions were shown to be mainly orchestrated by CD4⁺ T cells with neutrophils and macrophage largely responsible for the tissue damage.^2–5 Several effective control measures for stromal keratitis (SK) are suggested.⁶ These include approaches that influence cellular infiltration and activation of the proinflammatory mediators of SK.⁶ One potential means of modulating SK lesions that so far has received minimal attention is to manipulate the expression of miRNA species that affect either virus or host events during SK.A prime miRNA candidate for consideration is miR-155 because this miRNA can influence the expression of several immune events that contribute to tissue damage.^7–10 For example, animals unable to produce miR-155 because of gene knockout may develop milder lesions in some models of autoimmunity,^8,11–13 and suppressing miR-155 expression, as can be achieved by treatment with antagomirs, holds promise as a means of therapy for autoimmunity.¹³ However, the absence of miR-155 can result in higher susceptibility to some virus infections and some tumors in part because protective CD8⁺ T-cell responses are diminished.^14–17 In fact, overexpression of miRNA can result in enhanced CD8⁺ T-cell–mediated immune protection with some tumors.¹⁷Few studies have focused on the role of miR-155 in situations in which the immune response to an infectious agent may be a principal cause of tissue damage. This is the situation in ocular lesions of the cornea after HSV-1 infection. Here, we have compared the disease outcome after HSV-1 infection in miRNA-155 knockout (Mir155^−/−) mice and in mice in which miR-155 was suppressed by antagomir therapy with controls. We show that HSV-1 infection resulted in up-regulation of miR-155, which was mainly produced by the inflammatory cells and T cells in the cornea. Suppression of miR-155 production resulted in milder lesions that were associated with diminished responses of T helper cells type 1 (Th1) and type 17 (Th17) and reduced inflammatory cytokine production. We also demonstrated that miR-155 suppression resulted in increased phosphatidylinositol-3,4,5-trisphosphate 5-phosphatase 1 (Ship1) and IFN-γ receptor α-chain (IFN-γRα) levels, molecules known to be required for IFN-γ expression and Th1 differentiation.^17,18 These results indicate that miR-155 regulates differentiation and effector function of Th1 cells. Thus, our results suggest that miR-155 could be a promising therapeutic target to treat SK.     

A broadly neutralizing human monoclonal antibody is effective against H7N9

Emerging strains of influenza represent a significant public health threat with potential pandemic consequences. Of particular concern are the recently emerged H7N9 strains which cause pneumonia with acute respiratory distress syndrome. Estimates are that nearly 80% of hospitalized patients with H7N9 have received intensive care unit support. VIS410, a human antibody, targets a unique conserved epitope on influenza A. We evaluated the efficacy of VIS410 for neutralization of group 2 influenza strains, including H3N2 and H7N9 strains in vitro and in vivo. VIS410, administered at 50 mg/kg, protected DBA mice infected with A/Anhui/2013 (H7N9), resulting in significant survival benefit upon single-dose (−24 h) or double-dose (−12 h, +48 h) administration (P < 0.001). A single dose of VIS410 at 50 mg/kg (−12 h) combined with oseltamivir at 50 mg/kg (−12 h, twice daily for 7 d) in C57BL/6 mice infected with A/Shanghai 2/2013 (H7N9) resulted in significant decreased lung viral load (P = 0.002) and decreased lung cytokine responses for nine of the 11 cytokines measured. Based on these results, we find that VIS410 may be effective either as monotherapy or combined with antivirals in treating H7N9 disease, as well as disease from other influenza strains.Influenza, a zoonotic viral disease, is responsible for substantial human morbidity and mortality yearly, with periodic elevations due to emergence of novel viral strains, either through mutation or genetic reassortment in a variety of animal reservoirs, including pigs, birds, and seals. Antigenic naivety within the population, coupled with the advent of a virus strain that can effectively transmit via respiratory droplets, can lead to epidemic or pandemic outbreaks. In addition, viruses with increased virulence, such as H5N1 and H7N9, are associated with enhanced morbidity and case fatality, estimated at 30–60% despite the availability of current antiviral therapy.Patients hospitalized with H7N9 infection typically manifest a high fever and cough, hypoxemia, and opacities and/or consolidations on chest radiology, with associated findings including shock, acute kidney injury, and the development of acute respiratory distress syndrome (ARDS). The high mortality associated with H7N9 infection and development of ARDS is similar to what has been reported for H5N1. An associated cytokine storm has been described in both of these patient groups, with proinflammatory cytokines/chemokines documented in plasma and pulmonary lavage samples (1–3). The increased cytokine responses have recently been correlated with increased severity and mortality observed in patients (2–4). Elevated levels of interleukin (IL)-10, IL-6, IL-8, and macrophage inflammatory protein-1β (MIP-1β) in plasma were found to be predictive of a less favorable or fatal outcome. Furthermore, IL-1β, interferon (IFN)-γ, MIP-1α, and MIP-1β were all significantly elevated in the bronchial lavage samples at a 100- to 1,000-fold increase compared with plasma concentrations, and tumor necrosis factor (TNF)-α was only detected in the lavage samples. Mouse models for H5N1 and H7N9 infection mimic this cytokine response and the lung pathology of ARDS (2). We therefore sought to examine the role of a broadly neutralizing antibody, VIS410, in mitigating this “cytokine storm” in infected mice and lowering lung viral concentrations in this sublethal H7N9 model. Since this agent would likely be used in combination with a neuraminidase inhibitor, we investigated the effect of VIS410 compared to, and in combination with, oseltamivir.Additionally, the DBA mouse has been found to have much higher susceptibility to influenza infection than either C56BL/6 or BALB/c mice (5, 6). A variety of influenza viruses, including H5N1 and influenza B viruses, have been shown to be lethal to DBA mice without prior adaptation (7, 8). We reasoned that to complement the cytokine measurements in BALB/c mice, a lethal DBA mouse model could be used to examine the effect of VIS410 on mortality, thereby providing an appropriate model of the significant morbidity and mortality associated with H7N9 infection in humans. We therefore additionally evaluated VIS410 in a lethal model of H7N9 disease.     

Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression

The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26-87) years. Through incisions ≤4?cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop's score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p?=?0.01) and pinch grip (p?=?0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.