LOOP Blog

Preparing young patients with IBD to transition from pediatric to adult care, and actively transferring care to the adult care team, is crucial to ensuring the continued effective management of IBD. Below is an informational article, originally written for a 2013 issue of CIRCLE eNewsletter by Sandy Kim, MD and Maureen Kelly, RN, MS, CPNP. In it they discuss transition from the clinician perspective, outline transition stages and goals for parents and patients, and provide answers to frequently asked transition questions.

Today in class, a guest lecturer talked about patients with chronic illness “having to get used to” their new roles as patients. Those words were not the main point of the sentence; they were the words you say trying to pad the time, but nevertheless they were there, sandwiched in between other ideas. It made me think of space-saving storage bags. My grandparents bought them years ago, in an effort to control the umpteen crocheted afghans that had begun to overtake their Florida condo.

There’s a sense of disbelief – or at least at 13 I possessed such a notion – that overtakes you when watching someone demonstrate a space-saving bag. They show you the pile of items to be stored and the nonsensically small bag that the items will supposedly all fit into. No, your reasonable brain informs you, this is impossible; it is foolish, for it seems like trying to fit the entire American population into the state of Rhode Island. But the miracle is performed; disregarding your doubt, the vacuum is hooked up to a special port in the bag, sucking air out and shrinking down the large pile until it is neatly, possibly even comfortably, squished in the teeny space-saving bag. And this is what I thought of, as the speaker lectured, about fitting into bags that can't possibly contain the whole of you - until you shrink.

There is something about being a patient that is belittling, and for the chronically ill, something that is voluntarily so. We comply and save our feelings for favorite books, comfort food, the song that always makes us smile, the memory of our first car, our first kiss, our first failure, plans to travel the world, and whatever else makes us up.  Instead we don the Johnny shirt, shrinking into our own space-saving bag. We become reduced down to our disease; a list of symptoms, a medicine cabinet of pills, a medical record number.

If there is a manual on how to deal with a chronic illness, I missed it. As far as I'm concerned there are no rules, all you can do is live (and trip) gracefully. Yes, it is important for people with chronic illnesses to learn about their illness and to adjust to what it means (read: adjust emotionally not adjust your expectations about your life's possibilities).  But it is also important to be true to yourself.  When I wake up in the morning and get ready for class, or sing along to some favorite lyrics, or tell my parents about my day, or make cupcakes for my roommates; I am not my disease. I am Jennie. I am a girl graduating from college who wishes Patrick Dempsey would marry her - and so many other things. I politely, but fervently, refuse to be put in a space-saving bag, because it’s impossible to shrink me down and after years of being reduced to a diagnosis, I will no longer allow it.

The noun ‘doctor’ comes from the Latin ‘docere’, which means ‘teach’. ‘Patient’, on the other hand, is also Latin but means ‘suffering’. Even if you can manage to overlook the double meaning of patients having to be patient, the roots of the words speak for themselves. But the best doctors are the ones who suffer alongside you, who see the pain you’re too proud to admit to, who are normal and everyday and accessible and in that way wholly incredible and wonderful. And the best patients are the ones who never pass up the opportunity to teach a doctor, a nurse, or a medical student. The relationship between a patient and a doctor is dynamic and constantly evolving, and only when we can understand and respect it as a process will we ever be able to meaningfully work together – to quote a Taylor Swift song (but of course), “two is better than one”.

So be a little rebellious (if you’re like me, you never really went through the traditional teenage rebellion phase [Mom, Dad, feel free to disagree], you’ve earned it). You don’t fit in a space-saving bag, so don’t bother trying. Be patient with yourself, but no need to be only a patient – you are a teacher, you are incredible, you are a thousand other things, and (in the words of a fellow Crohnie) you deserve a beautiful life. That, my friends, is impossible to fit in a space-saving bag.

Jennie

I'm often asked if I believe ulcerative colitis has changed me for the better.

It's a tough question. I can't go back in time and see how my high school years would have played out otherwise. There is no me, as I am now, without ulcerative colitis.

Has ulcerative colitis changed me for the better? The simple answer is no. My disease has not changed me outside of my intestines. I am the same girl with a few extra pills. The more complicated answer is yes* - with the asterisk. It's based on a technicality. No, UC has not changed me for the better, but living with UC has.

It starts with another girl: one named Tara. She was diagnosed with Crohn's Disease during her second year of medical school. A few years later, Tara had chosen to pursue a career in pediatrics and found herself on the inpatient rotation at my children's hospital in April '08 - the month of my diagnosis and subsequent hospitalization.

You can guess how this plays out.

I was the "I'm okay" kid in the hospital. I felt so good on steroids and so relieved to have a name for my disease, my answer to most everything became standardized. Did I want a visit from the art therapist? "I'm okay, thanks." Did I want another blanket? "I'm okay, thanks." It was my standard answer, so if asked if I wanted to participate in a mentoring program, I would have probably answered predictably: "I'm okay, thanks."

Tara was the mentor this "I'm okay" kid never wanted. She stayed one day after rounds to share her story. A day past diagnosis, I hadn't yet started to think about what a future with IBD meant. Thanks to Tara, I never doubted my potential. From the get-go, I knew Tara's story. If she could continue to pursue her passion with IBD, my possibilities were equally endless. Until I met Tara, I didn't realize mentoring is not an emergency measure; it's a survival skill. Her confidence inspired my confidence.

Being a good mentor is not about knowing the "right" thing to say or the "right" moment to say it. There will be moments when you don't know what to say, and there will be moments when it's best to stay quiet and just listen. Being a good mentor is not about the story; it's about the storyteller. The best storytellers - and the best mentors - realize that every story matters - and every story can change another story for the better.

Until I met Tara, I never believed a single patient voice could matter. Clearly, as I'm here blogging, I do now.

Many years ago now, I was at an IBD conference with several other patients. It was the last day of the conference, and we were sitting in a room, chatting at white-clothed tables with our suitcases at our feet. At 16, I was the youngest in the group by a couple of years - the others were a mix of guys and girls: college-students, with boyfriends and jobs and so on. The moment that is so clear in my mind all of these years later was sitting next to one girl I admired so much and bursting into tears. Alarmed (she had only known me for 48 hours, it was alarming to start sobbing!), she asked me what was wrong. Through my tears and melodrama I blubbered, “I don’t want to go home! No one else understands me like you guys do!”

Even though it sounds silly and very over the top, to my younger self, it seemed like nothing had ever been more true. I suddenly had a family of older brothers and sisters who got it, who could coach me from the sidelines and pick me up as I tripped trying to figure out adolescence with a chronic illness. And interestingly, if you asked the group why they were involved, the answer was always the same - so the younger versions of themselves would have the support and encouragement.

And it’s true - knowing someone else like you could do it means so much, it’s the I-think-I-can to the I-KNOW-I-can attitude switch, which is priceless. For me, that was the moment when I was suddenly in charge of my life again, and since then I have been fortunate enough to be that support for other people. Having mentors and people to look up to, gave me hope when things felt small and constrained, and in a lot of ways it gave me the fuel to keep going.

I am still in touch with my IBD friends from that first conference. Many of them are engaged or married, working and successful, one girl and her husband even have an adorable little boy. Yes, they are still sick, they still struggle to find the balance between patient and person, but they are living and doing an incredible job at it. Their mentorship to me is something that I will never be able to adequately thank them for, so instead I hope that by aspiring to be like them I will make them proud.

Jennie

Dr. Richard Colletti - Network Director for ImproveCareNow - announced today that an ImproveCareNow study has been accepted for oral presentation at Digestive Diseases Week in May.  This is a highly innovative study done in collaboration with the Department of Biostatistics and Epidemiology of the University of Pennsylvania.  It is a replication of the REACH study, and the first pediatric comparative effectiveness study of anti-TNF drugs.

Congratulations to Mike Kappelman, Wallace Crandall and the research team.  And congratulations and thank you to all of the centers whose data made this study possible.  More comparative effectiveness studies are planned.

Here is the abstract:

Kappelman MD, Bailey LC, Crandall WV, Zhang P, King E, Joffe M, Colletti RB, Forrest CB and the ImproveCareNow Network

Real-World Clinical and Comparative Effectiveness of Infliximab in Pediatric Crohn’s Disease

Background and Aims: Clinical trials in pediatric Crohn’s disease (CD) are difficult to recruit for, enroll highly selected subjects, and utilize standardized protocols. Thus, efficacy data from trials may not be generalizable to clinical practice. Studies of real-world clinical effectiveness are needed to fully evaluate evolving therapeutic options. We sought to use data from a multicenter clinical registry (the ImproveCareNow Network, ICN) to evaluate the clinical and comparative effectiveness of anti-TNFα biological therapy in children with moderate to severe CD.

Methods: ICN maintains a registry of medication use and clinical and laboratory data collected during pediatric gastroenterology outpatient IBD encounters (33 centers in this analysis). We identified a cohort of new users of infliximab and adalimumab with characteristics (selection criteria) similar to subjects enrolled in the REACH clinical trial. To evaluate clinical effectiveness, Pediatric Crohn’s Disease Activity Index (PCDAI) scores and corticosteroid use were evaluated at the visit closest to 10 weeks following induction. Missing data were estimated by multiple imputation. Response (PCDAI Results: 192 biologic initiators (53% male, mean age 14.9 years, mean PCDAI 39.7) were included in the analysis.  Overall, 80% experienced response, 39% remission, and 33% steroid free status at week 10. Among those on concomitant immunomodulators, 82% experienced response and 48% experienced remission (REACH clinical trial 88% and 59% respectively). In the trial simulation, 198 biologic trials were compared with 1157 non-biologic trials. Biologics were associated with increased remission (hazard ratio 1.5, 95% CI 1.1-2.0) and steroid free remission (hazard ratio 2.0, 95% CI 1.5-2.7), with corresponding number needed to treat (NNT) of 7.8 and 5.3.

Discussion: The real-world clinical effectiveness of anti-TNFα biological therapy observed in a multi-center pediatric IBD network is similar to the efficacy estimates from the REACH clinical trial. Concomitant immunomodulator use is associated with increased effectiveness. Compared with conventional care, biological therapy is more effective at achieving remission, particularly steroid-free remission. The NNT can be used to guide clinical decision making regarding risks and benefits. These findings support the use of the ICN registry for comparative effectiveness research.

[Editor's Note:  Erin Moore is "Doin' it for Drew"!  Drew has Cystic Fibrosis (CF).  CF is a life shortening genetic disease that affects the lungs and digestive system of about 30,000 children and adults in the United States (70,000 worldwide).  It is a chronic illness - meaning until a cure is found, CF is forever.  Erin is collaborating with the C3N Project; exploring the creation of a Collaborative Chronic Care Network for CF.  This post was originally featured on Erin's blog - 66 roses.]

I arrive for our clinic appointment around 7:45am. The last time we were here was 3 months ago. Usually, we are ushered back to a room within 15 minutes of arrival. A nurse greets us shortly thereafter to review our medicine list and address any issues that we've been having. Just the other day he was coughing up a storm but seems to have gotten over it. Should I talk to the dietician about his diet again? His weight is up and his stools seem "normal" but I'm always anxious about his lack of interest in food. I wonder if an RT is available to talk a little bit about his airway clearance. I don't want to be a bother but I sure do think the airway clearance he had in the hospital this summer was more effective. I wish I knew what they were doing differently! 

Next up is the doctor. She asks how things have been going. Today? Great! Last week? I was a little worried, but the cough he had seemed to go away. There was that one day that his stool was a little weird but that got better too, not sure what caused it. And frankly I can't remember back farther than that. She checks him out and wants to review his labs since we are at his anniversary visit. His vitamin D is low, his breathing still sounds a little noisy, and a note that she has from his ENT seems to indicate that he may need another sinus surgery. She feels out whether I'd be open to a bronchoscopy at the same time. Maybe another CT is a better option.  When I talked to the ENT last month it sounded like things were going well? I guess I don't mind if they do a bronchoscopy while he's under for something else, but I remember huge discussion with other CF parents on Facebook about CT scans and all the negative effects of radiation and I don't know that I want to do that? I wish I could find that conversation! I ask questions about a game plan for if he needs IV antibiotics if we grow pseudomonas again, having read online about all different methods used for eradication but not knowing which is best and why. It's hypothetical at the moment because they haven't even swabbed him yet. I just have sort of a busy life and sometimes having a plan provides a sense of comfort for me. She suggests an action plan and I am mostly on board, except for the azithromycin because I saw a presentation somewhere that seemed to show compelling evidence against its use. I wish I could find that presentation to show her! I trust his doctor and want to follow her recommendations, but I have some reservations. I don't think either of us has time to get into this as I've already taken up more than my fair share of appointment time. We agree to wait for the results of the culture to decide a course of action.

Next up is the dietician. Lucky for me, he has a "weird poop" while we are there so she can look at it and provide her thoughts. This isn't what all of his stool looks like. I don't really know how often his stool looks like this - sometimes once a day, sometimes 4 times a day, sometimes once a week. We talk for a bit about enzyme dosing and the calories he's taking in, her offering suggestions for beefing up his intake and me adding them to the "notes" section in my iPhone, hoping I can get them down elsewhere before one of my kids deletes them by accident.

The social worker pops in to address some questions about starting preschool that I had mentioned to the nurse 2 hours ago. I had met with the Psychologist about a year ago to talk about his lack of interest in food, but never followed up, mostly because of both time constraints and cost. If only she could pop in and give me a couple of quick suggestions. But I have to go, we've already been here for almost 4 hours. While waiting for my discharge paperwork, a research assistant shows up to see if I'd be interested in participating in a study about I'm not sure what because my 3yr old is clambering to get out of that office. I agree anyway, get my discharge paperwork and fly out the door.

This summer, we were visiting family in Philadelphia and my son got sick. He was admitted to Children's Hospital of Philadelphia for a pulmonary exacerbation. Not a single morsel of information about him and his history with Cystic Fibrosis was available to the doctors at CHOP. Many phone calls were made between fellows from my personal cell phone to understand his medical history and doctors asked me the same questions day after day before we trusted and understood each other and hashed out what was going on in the days leading to our admission. I know that it was in Drew's best interest that we discuss everything about him ad nauseum, but it blew my mind that in this age of technology, there was no electronic medical health record that the doctors in Philadelphia could access to understand Drew to provide the best care for him quickly.

When Drew was a baby, we kept a diary of his formula intake and the corresponding output. We set up a nice little Excel chart and shared that with our dietician on a very regular basis. I credit that chart for his gained weight and reaching the 50th percentile by the time he was 6 months old and he has been able to maintain that to today when he is almost 3. I know that all patients aren't equal, but wouldn't it be great if that data, if our "patient reported outcomes" were cataloged somewhere so that we could share what we did and how it worked for us? Sure, I could take to the CF Mom's Facebook page and ask about what high calorie snacks work for their 3 year olds and hope that some of those moms are online and eager to provide some feedback. But once that question is asked and answered, it just simply vanishes into cyberspace. I cannot tell you how many times I've said, "I know I've seen that somewhere". Image the power of cataloging that data, those conversations, those findings. It can be used by patients, by doctors, by researchers and teachers. Just thinking about the power of that is what is driving me to stay involved and insist on nothing less.

I think you're seeing my point, a point that was brought out in almost every session I sat through at the NACFC this year. The information that we currently have on patients in between visits is limited. Filling those gaps would give us a more complete picture of health. It would help doctors to intervene at appropriate times, times when patients might not call because in their mind "its just not that bad yet", but doctors are able to identify a problem or a pattern that lets them know the direction something that's "not that bad" is headed. They would be able to more easily determine if certain therapies were actually making a difference through the combine use of passive behavioral and active patient reported data, looking at a real-time view of what is going on with a patient, not what they remember to tell you when they are in clinic. The registry could be enhanced by identifying day to day trends and commonalities in patients sharing mutations. And all of this data can be used by researchers and scientists to figure out every last detail this disease and find therapies that work for every one of us. From a parent's perspective, the C3N is what we need to make life easier and improve outcomes while we wait for our cure.

In this single patient experiment, an 11-year-old patient with Crohn’s disease (and her parents) teamed up with Shehzad Saeed, MD of Cincinnati Children’s Hospital Medical Center* to test whether a change in probiotic therapy would improve the patient’s stool urgency (sudden, irresistible need to have a bowel movement).

Dieticians are often asked whether probiotics are beneficial in the treatment of Crohn’s disease and ulcerative colitis (also known as Inflammatory Bowel Disease or IBD). Before reviewing the research, let’s discuss what probiotics are.

I returned home on Tuesday evening, dropped my bag on the floor, sighed, and looked at the pile of clothes still sitting on a table beside my desk and thought, ‘Thanks for the reminder.’ I had been looking forward to attending a great IBD meeting in Montreal this past weekend - planning to, but in the end my unruly body decided that traveling was not a good idea. Consequently, I missed the conference, my friends, and had left the pile of clothes atop that table and spent the past near-week in the hospital.

I find that when I’m hospitalized, for the first few days with the nausea and upchucking and pain meds and exhaustion, I’m relatively okay with being in the hospital. Relatively. But then I reach a point, a threshold level, when I’m feeling okay enough or frustrated enough or just as though I’ve had enough and feel the inescapable need to devise my exit strategy.

Crawling into my own bed last night, I felt as though I simultaneously belonged nowhere and everywhere. There’s an ease in being transposed in hospital, academic, or home situations that is comforting but alarming. The same habits flood back to me - using my medical lingo (“No an 18 French is not acceptable, please get a 10 French, and I’ll be putting in the NG tube myself, thank you very much”), putting my disease history in chronological order (deciding, as doctors have taught me, what is relevant and what is ‘personal’), reciting my IV speech (“I’m a hard stick, go a little higher or a little lower, but try wherever you think you can get it”), and explaining my ever-faithful teddy bear companion (yes, even at 21 years old). It’s routine. But it’s also disorienting, a feeling that leaves me awake at night, blinking at the ceiling, wondering when the bruises on my arms will fade and knowing that the ones on my spirit may never quite heal. This is not intended to sound fatalistic or depressive, just honest, a feeling that sucks me back to a fetal position regardless of the 9 years of IBD, until I feel like a little girl just wanting to be hugged.

A friend, who was at the conference that I missed, was texting me today and asked me how I was doing. Throughout our conversation, he asked me if I was taking it easy and taking care of myself. I replied that I think we both do a much better job of taking care of others than taking care of ourselves. I’m the first one to hold someone’s hand, to hug them, to offer company to the hospital or an equally difficult/upsetting task, yet the last one to ask for my hair to be held back as I vomit. And luckily for me, I have friends who do not ask (because they know I’ll politely decline) and help me out anyway and I love them for it.

Similar to my reaction to the over-sized NG tube, sometimes that tantrum of “It’s just NOT FAIR” bubbles to the surface. And that’s okay, even if it feels like something I should’ve gotten over. When I’ve had it up to here, near-tears and all, the comfort of having people who ‘get it’ is immensely helpful. I don’t have to explain myself to them, and it makes me really believe that there will be more conferences, more opportunities, despite the pain and frustration that accompanies any chronic illness.

My only advice when it comes to ‘having-it-up-to-here-moments’: eat a cupcake (if tolerable), stare at a picture of PDemps for a while, listen to a favorite song, dig up your old yearbook and reread notes that make your heart warm, hug someone, and remember that there are always people in the wings waiting to catch you.

Jennie

A control chart allows us to detect when there has been a significant change—a real improvement.

This graph shows that the remission rate has been increasing steadily since February 2012, and in August 2012 the remission rate crossed the dotted line (the upper control limit), indicating that a real improvement had occurred.  It also shows that the average remission rate has increased from 60% in 2007, to 71% in 2008, to 75% in 2010, and to 77% in 2012.  The ImproveCareNow Network will continue to apply the Model for Improvement and use QI tools to improve the remission rate to 80% or more.