A Multicenter Study of Patient Acceptability of the IBD Disk Tool and Patient-Reported Disabilities.

BACKGROUND: IBD, both Crohn's disease and ulcerative colitis, is associated with significant functional disability. Gastrointestinal symptoms alone are not the sole purpose of the interaction between patients and providers. In order to ascertain patients' disabilities, we utilized the recently developed IBD Disk to help determine their functional concerns and initiate relevant conversation. We aimed to ascertain patient acceptability and their major disabilities. PATIENTS AND METHODS: In this multicenter study, IBD patients at their outpatient visit were given the paper version of the IBD Disk. Patients were asked to score their level of disability for each item of the IBD Disk. The completed scores were then shared with their healthcare provider to act as a focus of discussion during the consultation. Patients and clinicians were also asked to provide informal qualitative feedback as to the benefits of the IBD Disk and areas for improvement. RESULTS: A total of 377 (female 60%) patients completed the questionnaires over the study period. Patient acceptability scored on a 0-10 Likert scale was excellent. All patients scored all domains of disability. Sleep, energy, and joint pain were the highest scoring domains of the IBD Disk, scoring higher than digestive symptoms. Clinicians and patients agreed that the IBD Disk allowed for ease of communication about disability symptoms and relevance to their day-to-day functioning. CONCLUSION: The IBD Disk is a novel easy-to-use tool to assess the functional disability of patients. We next plan to utilize it in the form of an electronic app internationally and in relation to treatment commencement and escalation.

Impact on healthcare resources of switch from fecal occult blood test to fecal immunochemical test within the English Bowel Cancer Screening Program: a single-center study.

BACKGROUND AND AIMS: In July 2019, the fecal immunochemistry test (FIT) replaced the fecal occult blood test (FOBT) in England as the Bowel Cancer Screening Program (BCSP) screening tool. We aimed to assess the impact of this on healthcare resources at our BCSP center. METHODS: Two 6-month periods were initially analyzed for stool sample return and positivity rates. A subsequent comparative analysis of patient screening episodes assessed utilization of specialist screening practitioner (SSP) time, endoscopy, histology, radiology, surgical, and oncology service usage. RESULTS: A total of 42,234 patients received FOBT and 42,545 patients received FIT stool kits, with FIT showing higher return (61.8% vs 58.58%, FIT vs FOBT, P < .001) and sample positivity rates (2.41% vs 1.45%, FIT vs FOBT, P < .001). Four hundred patients commenced FOBT and 616 FIT screening episodes, a 54% increase. The FIT group had of a lower mean age (67.5 vs 69.5 years, FIT vs FOBT, P = .0001) with a lower nonattendance rate (.16% vs 1.5%, FIT vs FOBT, P = .01). With higher patient numbers, the FIT group required 69% more endoscopic procedures, 58% increased SSP time, 40% more radiologic tests, and 68% higher surgical procedures. FIT also led to a 109% increase in endoscopy-derived histology samples from an increase in the proportion of patients with polyps with FIT (54.8% vs 47.2%, P = .020) and a greater number of polyps per patient in whom polyps were found (3.00 vs 2.50 polyps, P = .017). This additional service burden equated to additional financial costs of approximately $558,000 per annum. CONCLUSIONS: The implementation of FIT led to notable increases in SSP time, endoscopy procedures, radiology tests, surgical procedures, and histopathology services, resulting in considerable ongoing financial implications on the organization. Findings can be used to aid workforce and service planning in National Health Service sites delivering BCSP and countries that have already adopted or are considering FIT within their national screening programs.

The Paddington International Virtual Chromoendoscopy Score in ulcerative colitis exhibits very good inter-rater agreement after computerized module training: a multicenter study across academic and community practice (with video).

BACKGROUND AND AIMS: Electronic virtual chromoendoscopy (EVC) can demonstrate ongoing disease activity in ulcerative colitis (UC), even when Mayo subscores suggest healing. However, applicability of EVC technology outside the expert setting has yet to be determined. METHODS: Fifteen participants across 5 centers reviewed a computerized training module outlining high-definition and EVC (iScan) colonoscopy modes. Interobserver agreement was then tested (Mayo score, Ulcerative Colitis Endoscopic Index of Severity [UCEIS], and the Paddington International Virtual Chromoendoscopy Score [PICaSSO] for UC), using a colonoscopy video library (30 cases reviewed pretraining and 30 post-training). Knowledge sustainability was retested in a second round (42 cases; 9/15 participants), 6 months after training provision. RESULTS: Pretraining intraclass correlation coefficients (ICC) were good for the Mayo endoscopic subscore (ICC, .775), UCEIS scoring erosions/ulcers (ICC, .770), and UCEIS overall (ICC, .786) and for mucosal (ICC, .754) and vascular components of PICaSSO (ICC, .622). For the vascular components of UCEIS, agreement was only moderate (ICC, .429) and did not enhance post-training (ICC, .417); conversely, use of PICaSSO improved post-training (mucosal ICC, .848; vascular, .746). Histologic correlation using the New York Mt. Sinai System was strong for both PICaSSO components (Spearman's ρ for mucosal: .925; vascular, .873; P < .001 for both). Moreover, accuracy in specifically discriminating quiescent from mild histologic strata was strongest for PICaSSO (area under the receiver operating characteristic curve [AUROC] for mucosal, .781; vascular, .715) compared with Mayo (AUROC, .708) and UCEIS (AUROC for UCEIS overall, .705; vascular, .562; bleeding, .645; erosions/ulcers, .696). Inter-rater reliability for PICaSSO was sustained by round 2 participants (round 1 and 2 ICC for mucosal, .873 and .869, respectively; vascular, .715 and .783, respectively), together with histologic correlation (ρ mucosal, .934; vascular, .938; P < .001 for both). CONCLUSIONS: PICaSSO demonstrates good interobserver agreement across all levels of experience, providing excellent correlation with histology. Given the ability to discriminate subtle endoscopic features, PICaSSO may be applied to refine stratified treatment paradigms for UC patients.

Evaluation of the safety and efficacy of the fully automated active robotic system in robotic assisted total knee arthroplasty.

Background: Use of semi-active and active robotic system for performing Total Knee Arthroplasty (TKA) is increasing. The novel fully automated active robotic system performs milling of the bone surfaces with a high speed burr. The aim of the current study was to assess the safety and efficacy of the system in robotic assisted TKA (RA-TKA). Materials and methods: A single center clinical trial was conducted following 30 knees undergoing active RA-TKA for 6 months. Inclusion criteria were patients undergoing RA-TKA for end stage arthritis. Patients undergoing conventional TKA and revision TKA were excluded from the study. Sample size was estimated to be 28 patients with α error of 0.05 and ß error of 0.2 with power of study being 80. A pre-defined list of RA-TKA adverse events was employed to study the safety of the system. Efficacy was judged by comparing the planned versus achieved Implant size, alignment and limb alignment on post-operative radiographs. The post-operative clinical evaluation was done by an independent observer who was not part of the operating team. The primary safety and efficacy hypothesis was tested using a one sided Exact binomial test. The p value < 0.05 was considered significant. Results: Pre-defined adverse events did not occur in any of the 30 RA-TKA (statistically significant p value < 0.001). The implant size accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component (statistically significant, Chi-squared test, p value 0.0105 and 0.0461 respectively). The implant position and limb alignment was accurate in 100% of patients (p value < 0.001). Conclusion: Early experience of the use of fully automated active robotic system in TKA shows that it is safe and also is effective in achieving accurate implant size and implant/limb alignment.

Efficacy of the Pre-operative Three-Dimensional (3D) CT Scan Templating in Predicting Accurate Implant Size and Alignment in Robot Assisted Total Knee Arthroplasty.

Background: Nearly 20% of Total knee Arthroplasty patients remain dissatisfied. This is a major concern in twenty-first century arthroplasty practice. Accurate implant sizing is shown to improve the implant survival, knee balance and patient reported outcome. Aim of the current study is to assess the efficacy of pre-operative three-dimensional (3D) CT scan templating in a robot-assisted TKA in predicting the correct implant sizes and alignment. Materials and methods: Prospectively collected data in a single center from 30 RA-TKAs was assessed. Inclusion criterion was patients with end stage arthritis (both osteoarthritis and rheumatoid arthritis) undergoing primary TKA. Patients undergoing revision TKA and patients not willing to participate in the study were excluded. Preliminary study of ten patients had indicated almost 100% accuracy in determining the implant size and position. Sample size was estimated to be 28 for 90% reduction in implant size and position error with α error of 0.05 and beta error of 0.20 with power of study being 80. Post-operative radiographs were assessed by an independent observer with respect to implant size and position. The accuracy of femoral and tibial component sizing in the study was compared with the historic control with Chi-squared test. The p value < 0.05 was considered significant. Results: The pre-operative CT scan 3D templating accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component. The implant position and limb alignment was accurate in 100% of patients. The accuracy of femoral component and tibial component sizing is statistically significant (Chi-squared test, p value 0.0105 and 0.0461, respectively). Conclusion: The study results show the effectiveness of pre-operative 3 D CT scan planning in predicting the implant sizes and implant positioning. This may have a potential to improve the implant longevity, clinical outcomes and patient satisfaction.

Visual outcome of cataract in pediatric age group: does etiology have a role.

PURPOSE: To compare visual outcome results among traumatic and nontraumatic groups of eyes with cataract in the pediatric age group. METHOD: This is a retrospective cohort study. This study comprised a consecutive series of pediatric patients under 5 years of age with unilateral congenital, developing, or traumatic cataract who underwent surgery between January 1999 and April 2012 at Drashti Netralaya, Dahod. Records were retrieved from the medical record department. Patients were grouped as traumatic or nontraumatic and their demographics, cataract type, presenting symptoms, surgical intervention, and postoperative visual acuity follow-up refractive changes were recorded and compared. RESULTS: A total of 128 eyes of 128 children under 5 years of age were included with unilateral cataract. A total of 85 (66.4%) were traumatic and 43 (33.3%) nontraumatic. The age at surgery ranged from 1 to 60 months. Eyes were grouped by etiology: group 1- traumatic 85 (66.4%) eyes that had traumatic cataracts. Group 2 non-traumatic 43 (33.3%) eyes that had congenital, developmental or complicated cataracts. The mean follow-up time was 117 days. Finally, 22 (51.1%) group 1 patients and 40 (47.1%) group 2 patients achieved visual acuity better than 20/200 (p = 0.000). CONCLUSIONS: Surgical treatment with intraocular lens implantation for children with congenital, developmental, or traumatic cataract is an effective treatment for visual rehabilitation. Visual outcome is significantly better (p = 0.005) in case of nontraumatic cataracts than traumatic cataracts.

Maximizing the visual outcome in traumatic cataract cases: The value of a primary posterior capsulotomy and anterior vitrectomy.

Objective: The objective was to provide evidence-based care for patients with traumatic cataracts, we assessed whether a posterior capsulotomy and anterior vitrectomy, as part of the primary surgical procedure, could be a positive predictor of final visual outcome. Materials and Methods: This is a prospective randomized control trial. Patients presenting at our hospital between January 2010 and December 2012 having ocular trauma and traumatic cataracts were enrolled, according to the inclusion criteria. We enrolled two groups: Those with and without primary posterior capsulotomy and vitrectomy. Information regarding demographic and ocular trauma were collected using the World Eye Trauma Registry form at the first visit and follow-up, and specific information was collected for both the group who underwent posterior capsulectomies and vitrectomies as a part of the primary procedure, and the control group. Data were analyzed to evaluate the predictive value of primary posterior capsulectomy and anterior vitrectomy. Results: We enrolled 120 cases, 60 in each group, comprising 31 females and 89 males. When all other variables were controlled for, the visual outcome (best corrected visual acuity) differed significantly (P < 0.001) between the groups. Conclusion: Performance of posterior capsulectomy and anterior vitrectomy as part of the primary procedure improves the final visual outcome.

On increasing protein-crystallization throughput for X-ray diffraction studies.

Two recent developments, a novel screening/optimization strategy that considerably reduces the number of trials required to produce diffraction-size crystals and a simple modification that doubles the screening capacity of the Douglas Instruments ORYX 1-6 protein-crystallization robot, have been implemented into a structural genomics project. The new two-step screening/optimization strategy yields diffraction-quality crystals directly from the screening process, reducing the need for further optimization. The ORYX modification involves the addition of extensions to the sample- and oil-delivery arms and software modifications that allow two plates to be set up simultaneously.

Salvaging Pyrococcus furiosus protein targets at SECSG.

Proteins derived from the coding regions of Pyrococcus furiosus are targets for three-dimensional X-ray and NMR structure determination by the Southeast Collaboratory for Structural Genomics (SECSG). Of the 2,200 open reading frames (ORFs) in this organism, 220 protein targets were cloned and expressed in a high-throughput (HT) recombinant system for crystallographic studies. However, only 96 of the expressed proteins could be crystallized and, of these, only 15 have led to structures. To address this issue, SECSG has recently developed a two-tier approach to protein production and crystallization. In this approach, tier-1 efforts are focused on producing protein for new Pfu(italics?) targets using a high-throughput approach. Tier-2 protein production efforts support tier-1 activities by (1) producing additional protein for further crystallization trials, (2) producing modified protein (further purification, methylation, tag removal, selenium labeling, etc) as required and (3) serving as a salvaging pathway for failed tier-1 proteins. In a recent study using this two-tiered approach, nine structures were determined from a set of 50 Pfu proteins, which failed to produce crystals suitable for X-ray diffraction analysis. These results validate this approach and suggest that it has application to other HT crystal structure determination applications.

The high-throughput protein-to-structure pipeline at SECSG.

Using a high degree of automation, the crystallography core at the Southeast Collaboratory for Structural Genomics (SECSG) has developed a high-throughput protein-to-structure pipeline. Various robots and automation procedures have been adopted and integrated into a pipeline that is capable of screening 40 proteins for crystallization and solving four protein structures per week. This pipeline is composed of three major units: crystallization, structure determination/validation and crystallomics. Coupled with the protein-production cores at SECSG, the protein-to-structure pipeline provides a two-tiered approach for protein production at SECSG. In tier 1, all protein samples supplied by the protein-production cores pass through the pipeline using standard crystallization screening and optimization procedures. The protein targets that failed to yield diffraction-quality crystals (resolution better than 3.0 A) become tier 2 or salvaging targets. The goal of tier 2 target salvaging, carried out by the crystallomics core, is to produce the target proteins with increased purity and homogeneity, which would render them more likely to yield well diffracting crystals. This is performed by alternative purification procedures and/or the introduction of chemical modifications to the proteins (such as tag removal, methylation, surface mutagenesis, selenomethionine labelling etc.). Details of the various procedures in the pipeline for protein crystallization, target salvaging, data collection/processing and high-throughput structure determination/validation, as well as some examples, are described.

Protein production and crystallization at SECSG -- an overview.

Using a high degree of automation, the Southeast Collaboratory for Structural Genomics (SECSG) has developed high throughput pipelines for protein production, and crystallization using a two-tiered approach. Primary, or tier-1, protein production focuses on producing proteins for members of large Pfam families that lack a representative structure in the Protein Data Bank. Target genomes are Pyrococcus furiosus and Caenorhabditis elegans. Selected human proteins are also under study. Tier-2 protein production, or target rescue, focuses on those tier-1 proteins, which either fail to crystallize or give poorly diffracting crystals. This two tier approach is more efficient since it allows the primary protein production groups to focus on the production of new targets while the tier-2 efforts focus on providing additional sample for further studies and modified protein for structure determination. Both efforts feed the SECSG high throughput crystallization pipeline, which is capable of screening over 40 proteins per week. Details of the various pipelines in use by the SECSG for protein production and crystallization, as well as some examples of target rescue are described.

The fibronectin type 3-like repeat from the Clostridium thermocellum cellobiohydrolase CbhA promotes hydrolysis of cellulose by modifying its surface.

Fibronectin type 3 homology domains (Fn3) as found in the cellobiohydrolase CbhA of Clostridium thermocellum are common among bacterial extracellular glycohydrolases. The function of these domains is not clear. CbhA is modular and composed of an N-terminal family IV carbohydrate-binding domain (CBDIV), an immunoglobulin-like domain, a family 9 glycosyl hydrolase catalytic domain (Gh9), two Fn3-like domains (Fn3(1,2)), a family III carbohydrate-binding domain (CBDIII), and a dockerin domain. Efficiency of cellulose hydrolysis by truncated forms of CbhA increased in the following order: Gh9 (lowest efficiency), Gh9-Fn3(1,2) (more efficient), and Gh9-Fn3(1,2)-CBDIII (greatest efficiency). Thermostability of the above constructs decreased in the following order: Gh9 (most stable), Gh9-Fn3(1,2), and then Gh9-Fn3(1,2)-CBDIII (least stable). Mixing of Orpinomyces endoglucanase CelE with Fn3(1,2,) or Fn3(1,2)-CBDIII increased efficiency of hydrolysis of acid-swollen cellulose (ASC) and filter paper. Scanning electron microscopic studies of filter paper treated with Fn3(1,2), Fn3(1,2)-CBDIII, or CBDIII showed that the surface of the cellulose fibers had been loosened up and crenellated by Fn3(1,2) and Fn3(1,2)-CBDIII and to a lesser extent by CBDIII. X-ray diffraction analysis did not reveal changes in the crystallinity of the filter paper. CBDIII bound to ASC and filter paper with capacities of 2.45 and 0.73 micro moles g(-1) and relative affinities (K(r)) of 1.12 and 2.13 liters g(-1), respectively. Fn3(1,2) bound weakly to both celluloses. Fn3(1,2)-CBD bound to ASC and filter paper with capacities of 3.22 and 0.81 micro moles g(-1) and K(r)s of 1.14 and 1.98 liters g(-1), respectively. Fn3(1,2) and CBDIII contained 2 and 1 mol of calcium per mol, respectively. The results suggest that Fn3(1,2) aids the hydrolysis of cellulose by modifying its surface. This effect is enhanced by the presence of CBDIII, which increases the concentration of Fn3(1,2) on the cellulose surface.

Structural basis for the exocellulase activity of the cellobiohydrolase CbhA from Clostridium thermocellum.

Numerous bacterial and fungal organisms have evolved elaborate sets of modular glycoside hydrolases and similar enzymes aimed at the degradation of polymeric carbohydrates. Presently, on the basis of sequence similarity catalytic modules of these enzymes have been classified into 90 families. Representatives of a particular family display similar fold and catalytic mechanisms. However, within families distinctions occur with regard to enzymatic properties and type of activity against carbohydrate chains. Cellobiohydrolase CbhA from Clostridium thermocellum is a large seven-modular enzyme with a catalytic module belonging to family 9. In contrast to other representatives of that family possessing only endo- and, in few cases, endo/exo-cellulase activities, CbhA is exclusively an exocellulase. The crystal structures of the combination of the immunoglobulin-like module and the catalytic module of CbhA (Ig-GH9_CbhA) and that of an inactive mutant Ig-GH9_CbhA(E795Q) in complex with cellotetraose (CTT) are reported here. The detailed analysis of these structures reveals that, while key catalytic residues and overall fold are conserved in this enzyme and those of other family 9 glycoside hydrolases, the active site of GH9_CbhA is blocked off after the -2 subsite. This feature which is created by an extension and altered conformation of a single loop region explains the inability of the active site of CbhA to accommodate a long cellulose chain and to cut it internally. This altered loop region is responsible for the exocellulolytic activity of the enzyme.