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Inflammatory bowel disease (IBD) and pregnancy both impact health-related quality of life (HRQoL). However, little is known about IBD-related HRQoL around pregnancy.To assess the trajectory and predictors of HRQoL in preconception and pregnant patients with Crohn's disease (CD) and ulcerative colitis (UC).Preconception and pregnant patients with IBD were followed prospectively from preconception to twelve months postpartum at a tertiary referral centre. Participants completed the Short IBD Questionnaire (SIBDQ) and were assessed for clinical disease activity (modified Harvey Bradshaw Index or partial Mayo score) and objective disease activity (C-reactive protein [CRP], fecal calprotectin [FCP]).A total of 61 patients with IBD (25 CD, 36 UC) were included. During preconception, patients with UC had higher SIBDQ bowel and social sub-scores than those with CD, but this reversed during postpartum. Patients with CD but not UC developed a significant, sustained improvement in SIBDQ upon becoming pregnant, which persisted into 12 months postpartum. In a multivariable linear regression model, clinical disease activity negatively predicted SIBDQ at every pregnancy timepoint and up to 12 months postpartum. SIBDQ was significantly lower in patients with CRP ≥ 8.0 mg/L during trimester 1 (T1), but not later in pregnancy. SIBDQ bowel sub-scores were significantly lower in patients with FCP ≥ 250 mg/kg at T2, T3, and 6 months postpartum.Clinical disease activity is a consistent negative predictor of HRQoL from conception to 12 months postpartum. Patients with UC experience better preconception HRQoL but suffer worse postpartum HRQoL than those with CD.

Objective Poor inflammatory bowel disease (IBD)-specific reproductive knowledge is associated with concerns and medication noncompliance. Having shown an educational portal can improve knowledge, we evaluated its effectiveness for addressing IBD patients’ reproductive and medication concerns. Methods Adult IBD participants (aged 18 to 45 years) were invited to access an e-health portal providing information on heritability, fertility, surgery, pregnancy outcomes, delivery, postpartum, and breastfeeding in the context of IBD and IBD medications. At pre-, post-, and 6+-month postintervention, participants completed a questionnaire on IBD-specific pregnancy concerns, medication concerns from the Beliefs About Medicines Questionnaire (BMQ), and medication adherence via the Medication Adherence Rating Scale (MARS). The Wilcoxon signed-rank test was used to compare median differences between scores (95% confidence). Results Demographics for 78 (70.3%) participants completing postintervention questionnaires: median age 29.3 (interquartile range: 25.6 to 32.9) years; 54 (69.2%) Crohn’s disease; 21 (26.9%) ulcerative colitis; 63 (80.3%) females, 5 (7.9%) pregnant; and 19 (30.2%) previously pregnant. Postintervention, the median number of reproductive concerns decreased from 3 to 1, and remained stable 6+ months later (P < 0.001*). The median BMQ score decreased from 28 to 25, and remained stable 6+ months later (P = 0.032*). Participants adherent to medications increased from 82.4% to 87.8% postintervention (P = 0.099). Conclusion Using an e-health portal may potentially reduce IBD-specific reproductive and medications concerns. An e-health portal is feasible as one component of managing IBD patient’s reproductive and medication concerns during preconception and pregnancy.

Background Standardizing care through pathways has the potential to reduce emergency department (ED) utilization. We developed and evaluated inflammatory bowel disease (IBD) care pathways for that purpose. Methods Over 2014–2016, IBD patients were retrospectively stratified into those managed and not managed by pathways. Patient data were extracted, and negative binomial regression used to predict the annual number of ED visits. Results There was a difference of 30.7 ED visits/100 patients between managed and nonmanaged at 12 months (P < 0.001). The incidence rate ratio of total ED visits occurring annually was 0.750 (P = 0.008). Conclusions Management with IBD care pathways reduces ED utilization.

Computerized clinical decision support systems, or CDSS, represent a paradigm shift in healthcare today. CDSS are used to augment clinicians in their complex decision-making processes. Since their first use in the 1980s, CDSS have seen a rapid evolution. They are now commonly administered through electronic medical records and other computerized clinical workflows, which has been facilitated by increasing global adoption of electronic medical records with advanced capabilities. Despite these advances, there remain unknowns regarding the effect CDSS have on the providers who use them, patient outcomes, and costs. There have been numerous published examples in the past decade(s) of CDSS success stories, but notable setbacks have also shown us that CDSS are not without risks. In this paper, we provide a state-of-the-art overview on the use of clinical decision support systems in medicine, including the different types, current use cases with proven efficacy, common pitfalls, and potential harms. We conclude with evidence-based recommendations for minimizing risk in CDSS design, implementation, evaluation, and maintenance.

AIM To understand the effects of delivery mode on the immune cells frequency and function in cord blood and placenta. METHODS We evaluated immunological differences in cord blood and placental tissues for a case of twins one of which delivered vaginally while the other delivered by caesarian section (C-section). Cord blood mononuclear cells were isolated and placenta tissues were processed for cell isolation. Immune phenotyping was performed by flow cytometry methods following staining for T cells, natural killer (NK) cells, monocytes, neutrophils and CD71+ erythroid cells in both cord blood and placenta tissues. In addition, fetal calprotectin of twins was measured 12 wk after birth. RESULTS We found lower percentages of immune cells (e.g. T cells, monocytes and neutrophils) in the cord blood of C-section delivered compared to vaginally delivered newborn. In contrast, percentages of monocytes and neutrophils were > 2 folds higher in the placental tissues of C-section delivered newborn. More importantly, we observed lower percentages of CD71+ erythroid cells in both cord blood and placental tissues of C-section delivered case. Lower CD71+ erythroid cells were associated with a more pro-inflammatory milieu at the fetomaternal interface reflected by higher expression of inhibitory receptors on CD4+ T cells, higher frequency of monocytes and neutrophils. Furthermore, type of delivery impacted the gene expression profile in CD71+ erythroid cells. Finally, we found that C-section delivered child had > 20-fold higher FCP in his fecal sample at 12 wk of age. CONCLUSION Mode of delivery impacted immune cells profile in cord blood/placenta. In particular frequency of immunosuppressive CD71+ erythroid cells was reduced in C-section delivered newborn.

BackgroundMany Crohn’s disease (CD) patients will undergo surgery over the course of their life. It is thought that with the introduction of disease-modifying agents like anti-TNF therapy, there would be a population-level decrease in the need for surgery. This time-trend study aimed to assess the changes in surgical rates following the induction of anti-TNF therapy.MethodsAdult CD patients who underwent abdominal surgery (identified by administrative coding) between January of 1996 and December of 2013 at 1 of the 4 Edmonton-area hospitals were included. Patient charts were manually reviewed to confirm diagnosis and gather demographic and disease-related data. Population-adjusted annual incidence rates for IBD surgery were calculated by dividing the number of surgeries by estimates for total population of CD patients in Edmonton. Time-trend analysis was conducted to identify change points, calculate annual percent change (APC), and associated 95% confidence intervals (CIs).ResultsA total of 1410 patients with Crohn’s disease underwent surgery for their disease. The surgical rate decreased by 8.4% each year (95% CI, −9.6% to −7.3%). There was a 36.2% increase in the use of anti-TNF therapy per year (95% CI, 31.3% to 41.5%). Changes in modifiable risk factors for surgery were also seen, including the proportion of active smokers decreasing by 2.2% per year (95% CI, −3.7% to −0.6%).ConclusionsAlthough anti-TNF therapy seems to play a role, the decrease in surgical trends is likely multifactorial, owing to a decline in smoking trends, earlier diagnosis, earlier treatment, improved patient education, and changes in clinical practice.

BACKGROUND: Physicians use therapeutic drug monitoring of adalimumab (ADA) as an optimization tool to guide patient therapy with inflammatory bowel disease (IBD). IBD consists primarily of Crohn’s disease (CD) and ulcerative colitis (UC). Presently, the literature on ADA therapeutic boundaries recommend a broad 5–20μg/mL range. Due to limited treatment options for moderate-to-severe IBD and the high loss of response risk with biologics, optimization to sustain clinical and biological remission is imperative. Clinical indices, including the Harvey-Bradshaw index (HBI) for CD and partial Mayo (PM) for UC, are used to assess clinical disease activity. Fecal calprotectin (FCP) is a biomarker that is used to assess intestinal inflammation. An FCP99.5μg/g. This is comparable to the currently accepted FCP level of 100μg/g as a cut-off for biological remission. The AUC for DLs to predict an FCP12μg/mL. Figure 1 illustrates the ROC curves for (A) FCP to predict clinical disease activity, and (B) DLs to predict an FCP

BACKGROUND: Induction and maintenance of remission is a primary treatment goal for inflammatory bowel disease (IBD). Known gaps exist in adherence of practitioners to international guidelines for IBD care and, in other specialties, it has been shown to take up to 17 years for evidence to be translated into clinical practice. One problem; guidelines themselves are not actionable because they largely describe ‘what’ but not ‘how’. As a solution, our group developed a clinical decision support (CDS) tool for IBD in line with current guidelines. This was embedded into the Clinical Information System (CIS), EpicCare Ambulatory, as automated alerts, call-to-actions, and electronic order sets. Although similar tools have been built in other Epic systems and used for disease management, there is limited data on impact. AIMS: We aim to assess the effect of our CDS tool on IBD specialists’ adherence to guidelines, as well as system satisfaction. METHODS: A pragmatic, pre- and post-implementation design with a two-phase interrupted time-series. The interruption is activation of the CDS tool, accompanied by user training and a memo with instructions for use. Each data point will correspond to one month of individual patient visits, with a total of 18 months of data, 9 pre- and 9 post-interruption. A questionnaire including the Workflow Integration Survey (WIS) was administered to all users pre-interruption to collect demographic and baseline use data. The STARE-HI guidelines for health informatics evaluations were used in study design and assessment of appropriateness. RESULTS: The CDS tool was activated in October 2018. Ten IBD specialist users have completed the baseline questionnaire. Demographics; median of 7.0 (IQR: 6.0 to 7.0) years in practice, 5.0 (IQR: 4.0 to 6.0) years using any EMR, and 3.0 (IQR: 3.0 to 4.0) years using EpicCare. Users were asked to what extent they felt EpicCare was being fully utilized (Likert scale); 5 (50%) selected ‘neutral’, 5 (50%) selected ‘to a good extent’ (none selected ‘to the full extent’). Results from the WIS; mean of 4.0 (SD: 0.69) for navigation, 3.37 (SD: 0.93) for functionality, 3.50 (SD: 0.86) for ease of use, 3.30 (SD: 0.75) for workload. The Likert scores from individual WIS items are shown in Figure 1. CONCLUSIONS: At baseline, users are relatively satisfied with the different domains of the pre-existing system. About half of users feel that duplicate information is entered during patient encounters, and some feel that the system is not fully utilized. We will finish collecting adherence and application data and re-administer the WIS score again post-study. We hope to improve or at least do no harm to the current user experience, while improving guideline adherence and quality of care. [Image: see text] FUNDING AGENCIES: CCC, CIHRUniversity of Alberta

Background and aims For women with inflammatory bowel disease [IBD], it is not very well known how IBD or IBD treatment affects their breast milk components. We aimed to investigate whether breast milk composition differs in healthy control [HC] versus IBD mothers in terms of antibodies, cytokines, and metabolite,s to identify potential impact of IBD breast milk on neonatal immune system. Methods Breast milk specimens from HC [n = 17] and IBD [n = 31 for Crohn's disease [CD]; and n = 41 for ulcerative colitis [UC]; were collected at 3 and 6 months postpartum [PP3] and [PP6], respectively. Faecal samples were also collected. Cytokines and immunoglobulins [IgA/IgG/IgE] were analysed by multiplex Meso Scale Discovery [MSD] and commercial kits. Moreover, breast milk metabolites were analysed by 1H nuclear magnetic resonance [NMR]. Results We found that breast milk from IBD mothers showed significantly lower levels of IgA, sugar metabolite [lactose], and 2-aminobutyrate. In contrast, we observed that breast milk from mothers with IBD had increased levels of pro-inflammatory cytokines and higher energy metabolites [lactate and succinate] than milk from healthy mothers. In addition, we noticed that the type of treatment [5-aminosalicylic acid versus biologics] influenced the milk cytokines and metabolites profile. Conclusions The reduction in immunoprotective components of IBD breast milk such as sIgA and lactose theoretically may modulate the potential protective effects of breastfeeding. On the other hand, presence of higher levels of pro-inflammatory cytokines, lactate, and succinate may predispose the offspring to an inflammatory condition or impact on the gut microbiome. Better understanding of the role of succinate in infants and its potential effects on microbiome or mucosal immunity merits further investigations.

BACKGROUND AND AIMS: CD71(+) erythroid cells are enriched during pregnancy with immuno suppressive properties. We investigated the frequency and functionality of CD71(+) erythroid cells in peripheral blood, cord blood, and placenta of inflammatory bowel disease [IBD] patients versus healthy controls [HCs]. We aimed to determine their role in IBD pathogenesis during pregnancy. METHODS: Peripheral blood was collected at preconception, the first, second and third trimesters, and postpartum. Cord blood and placental tissues were collected at the time of birth. Cells from different specimens were subjected to immune-phenotyping and functional assays. CD71(+) erythroid cells were purified for quantitative polymerase chain reaction [qPCR] analysis. Using an allogeneic mouse model of pregnancy, the effects of CD71(+) erythroid cells depletion on intestinal homeostasis and dysbiosis was studied. RESULTS: IBD patients had lower CD71(+) erythroid cells during pregnancy compared with HCs. Placenta and cord blood CD71(+) erythroid cells from IBD patients exhibited impaired functionality and expressed lower inhibitory molecules including VISTA, TGF-β, and reactive oxygen species [ROS]. Lower CD71(+) erythroid cells were correlated with reduced regulatory T cells and increased immune-activation in IBD patients. Depletion of CD71(+) erythroid cells in an allogeneic pregnancy model resulted in upregulation of TLRs, IL-6, and CXCL-1, and enhanced production of TNF-α, in intestinal tissues. In contrast, TGF-β gene expression was reduced. Excessive inflammatory response in the gut [e.g. TNF-α] affects intestinal integrity and CD71(+) erythroid cells impact on the gut’s bacterial composition. CONCLUSIONS: Reduced frequency and/or impaired functionality of CD71(+) erythroid cells during pregnancy may predispose IBD patients to a more pro-inflammatory milieu in their gastrointestinal tract, characterised by lower Tregs, higher IL-6, and TNF-α, and dysbiosis.

BACKGROUND: Women with Inflammatory Bowel Disease (IBD) are at risk of flaring during pregnancy, and are associated with adverse maternal and neonatal outcomes. In addition, active IBD has been associated with poor health related quality of life (HRQoL). However, whether pregnancy-related changes also influence HRQoL of life is still unknown. AIMS: To assess the impact of pregnancy on the health related quality of life (HRQoL) among women with IBD and the impact of IBD disease activity on HRQoL in pregnant women with IBD. METHODS: Adult (≧18years) women with Crohn’s disease (CD) or ulcerative colitis (UC), and healthy volunteers who were either preconception or pregnant participated in a quality of life research study, and followed until delivery. Participants completed disease activity indices, such as Harvey Bradshaw Index (HBI) for CD or partial Mayo score (pMayo) for UC. Clinically active disease was defined as mHBI ≧5 or pMayo ≧2; whereas c-reactive protein ≧8.0mg/L and fecal calprotectin ≧250mg/kg indicated objectively active disease. Short IBD quality of life (SIBDQ) survey was administered at each time point (preconception, trimester 1, trimester 2, and trimester 3) and compared between groups for diagnosis and disease activity. SIBDQ scores in each time point were compared using independent samples median t-test and differences between categorical variables were analyzed using chi-square test. Statistically significant results were considered to have p

Background Inflammatory bowel disease (IBD) is often diagnosed in early adulthood, affecting patients through their reproductive years. Many patients, lacking knowledge about IBD and reproduction, make uninformed decisions. Although patients have turned to the Internet for information, it remains unclear if online resources are effective for improving and retaining IBD-specific reproductive knowledge. We aimed to elucidate if a multimedia vs text-only online educational intervention could improve IBD-specific reproductive knowledge for more than 6 months. Methods We developed a website covering genetics, fertility, surgery, pregnancy, medications, delivery, and postpartum in the context of IBD. Adult IBD patients were randomized into study groups (multimedia or text-only) and provided 60-day access. Participants completed pre-, post-, and 6+ month-postintervention pregnancy knowledge (CCPKnow) questionnaires. Results were compared using nonparametric tests. Results Of 111 registered participants, 78 (70.3%) completed pre- and postintervention questionnaires, and 37 (47.4%) subsequently completed the 6+ month questionnaire. Demographics were as follows: median age (interquartile range [IQR]) 29.3 (25.6-32.9) years, Crohn's disease n = 54 (69.2%), females n = 63 (80.3%), of which n = 5 (7.9%) were pregnant and n = 19 (30.2%) had previously been pregnant. The median CCPKnow scores (/17) (IQR) were 8.0 (3.0-10.0) pre-intervention, 16.0 (13.00-17.00) postintervention, and 14.0 (12.0-15.0) 6+ months postintervention. The median within-subject increase in score was 6.5 pre- to postintervention, and 4.0 pre- to 6+ months postintervention (both P < 0.001). The median increase in score (pre- to post-) was 8.0 for the multimedia group and 6.0 for the text-only group (P = 0.216). Conclusions An evidence-based, online educational portal can significantly improve and maintain IBD-specific reproductive patient knowledge for more than 6 months.

BACKGROUND: The impact of a mother’s chronic disease on fetal development makes dealing with inflammatory bowel disease (IBD) during pregnancy complicated. Almost 50% of women with IBD have poor reproductive knowledge; this has been associated with unsubstantiated concerns toward pregnancy, and towards IBD medications. With the help of Pixel Designs Company, we developed an educational web portal to address these concerns. AIMS: To evaluate the educational web portal for effectiveness at improving pregnancy and medication concerns in IBD patients. METHODS: IBD patients aged 18–45 years were invited to participate in a study to evaluate the effectiveness of an educational web portal covering the topics of heritability, fertility, surgery, pregnancy outcomes, delivery, postpartum, and breastfeeding in the context of IBD and IBD medications. Patients completed pre- and post-study questionnaires about seven IBD-specific pregnancy concerns, and identified Likert scores for nine medication concerns from the Beliefs About Medicines Questionnaire (BMQ).The non-parametric McNemar’s test was used to determine if the proportion of patients who had each pregnancy concern decreased post-intervention. For medication concerns, the Wilcoxon signed-rank test was used to compare median differences between Likert scores. 95% confidence intervals and SPSS Version 23 were used for all analysis. RESULTS: Seventy-eight of 111 patients (70.3%) completed pre and post-study questionnaires. Demographics for the 78 are as follows: median age 29.3 (IQR 25.6 - 32.9) years; 54 (69.2%) Crohn’s disease; 21 (26.9%) ulcerative colitis; 63 (80.3%) females, 5 (7.9%) currently pregnant and 19 (30.2%) previously pregnant. Medication history: 10 (12.8%) sulfasalazine, 67 (85.9%) mesalamine/5-ASAs, 17 (21.8%) budesonide, 63 (80.8%) steroids, 12 (15.4%) methotrexate, 55 (70.5%) azathioprine/mercaptopurine, 42 (53.8%) biologics, and 38 (48.7%) antibiotics. The intervention significantly decreased the proportion of patients who reported reproductive concerns regarding: fertility, added stress of raising a child affecting IBD, birth defects from IBD, pregnancy causing a flare-up, and inability to breastfeed due to IBD or medications. The BMQ Likert scores significantly decreased post intervention for concerns about having to take IBD medication, becoming too dependent on IBD medication, and the long-term effects of IBD medication. CONCLUSIONS: The educational web portal effectively reduced the proportion of patients who reported certain concerns about pregnancy in IBD, in addition to concerns regarding their IBD medications. FUNDING AGENCIES: AIHS

Background Fecal calprotectin (FCP) is a useful biomarker for monitoring inflammatory bowel disease, showing good correlation to endoscopic disease activity. Currently used lab tests take 2–4 weeks to return a result, limiting their usefulness. Recently, lateral flow-based rapid tests have been combined with smartphone applications to allow patients to complete FCP testing at home, with their physician receiving the result the same day.

BACKGROUND: Individuals with inflammatory bowel diseases (IBD) often live remote to specialized tertiary care centers. In traditional practices, this impedes the close surveillance of symptoms, objective markers of disease (C-reactive protein (CRP), fecal calprotectin (FCP), and optimization of therapies recommended to achieve the best health outcomes. Emerging self-management and e-Health strategies have improved medication adherence and reduced duration and severity of disease flares. Our center developed an innovative eHealth platform, the “IBD Dashboard”, a secure, online portal where patients can upload their self-collected data at regular intervals to provide a cross-sectional and longitudinal assessment of disease state. The IBD clinician can modify therapy accordingly in near real-time to prevent disease relapse. AIMS: To test the feasibility and impact of the IBD Dashboard for providing optimized care in a virtual environment to IBD patients based upon patient self-reported data. METHODS: Physicians across Alberta invited their adult IBD patients to enroll into the study. Patients were instructed to submit clinical scores every month on the IBD dashboard, and complete a home FCP (Buhlmann IBDoc FCP test) at baseline, 3 and 6 months. Those who had elevated FCP repeated FCP 1 and 2 months later. Feasibility questions included ease of use, impact on management decisions of the physician, patient medication adherence, and patient acceptance. RESULTS: A total of 29 patients have consented to the study thus far, including 12 (41.4%) females and 14 (48.3%) with Crohn’s disease. The median age is 37.0 years (IQR: 32.0 to 50.0). Medication snapshot: 9 (31.0%) on 5-ASA, 2 (6.9%) on steroids, 6 (20.7%) on immunomodulators, 19 (65.5%) on biologics, and 4 (13.8%) taking no medications. A total of 21 (65.5%) have completed baseline FCP. The median FCP was 276.0 mcg/g (IQR: 64.0 to 956.0), with 11 (52.4%) having an FCP ≥250 mcg/g. Of these patients with elevated FCP, 5 (45.5%) self-report symptoms consistent with disease remission (