A population-based study of fatigue and sleep difficulties in inflammatory bowel disease

Exploring the Preference for Fatigue-avoidance Goals as a Mediator Between Pain Catastrophizing, Functional Impairment, and Walking Behavior in Women With Fibromyalgia

OBJECTIVES

Along with the symptoms of pain and fatigue, pain catastrophizing and avoidance behaviors are highly prevalent and associated with functional impairment in fibromyalgia (FM) patients. Although pain and fatigue affect patients' quality of life, research has been exclusively focused on how pain affects physical activity and exercise. The aim of this study was to analyze the role of pain catastrophizing and preference for fatigue-avoidance goals in walking behavior and functional impairment in women with FM.

MATERIALS AND METHODS

In this cross-sectional study the sample was composed of 76 participants aged 18 years and older (mean age=55.05, SD=7.70). The study evaluated pain catastrophizing, preference for fatigue-avoidance goals, functional impairment, and walking behavior along with sociodemographic variables and clinical data.

RESULTS

Pain catastrophizing was associated with preference for fatigue-avoidance goals and this preference was associated with greater functional impairment and less distance walked. Path analysis supported the mediating role of preference for fatigue-avoidance goals in the relationship between pain catastrophizing and walking behavior and between pain catastrophizing and functional impairment. Furthermore, pain catastrophizing predicted greater preference for fatigue-avoidance goals which predicted more problems in functioning and less distance walked.

DISCUSSION

The present study may help clarify the connection between the factors that stop individuals with FM from implementing beneficial behaviors such as walking, and thus, allowing for the design of psychological interventions that seek to maintain physical functioning despite experiencing fatigue.

A pilot feasibility trial of cognitive-behavioural therapy for insomnia in people with inflammatory bowel disease

OBJECTIVE

Poor sleep is common in inflammatory bowel disease (IBD), associated with worse overall disease course and predominantly attributable to insomnia. While cognitive-behavioural therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia, it is untested in IBD. It is unclear if CBT-I will be as effective in this group given the extent of night-time symptoms people with IBD experience. Thus, we evaluated the feasibility and preliminary efficacy of CBT-I in IBD.

DESIGN

We comprehensively assessed sleep in people with mild-to-moderately active IBD using questionnaires, daily diaries and actigraphy. People with significant insomnia symptoms were allocated to a single-arm, uncontrolled pilot feasibility study of gold-standard CBT-I treatment. They were then reassessed post-treatment.

RESULTS

20 participants with IBD completed a baseline assessment. 10 were experiencing insomnia and were allocated to CBT-I. All participants who were offered CBT-I elected to complete it, and all completed 5/5 sessions. Participants rated treatment acceptability highly and daily diary and actigraphy completion rates were >95%. At baseline, participants with insomnia evidenced significantly worse sleep than participants without insomnia. Following CBT-I, participants reported significant improvements in diary and actigraphy measures of sleep continuity, dysfunctional sleep-related beliefs and IBD disease activity.

CONCLUSION

CBT-I was feasible and acceptable and demonstrated a signal for efficacy in the treatment of insomnia in IBD. Importantly, the improvements in sleep continuity were consistent with the extant literature. Future fully powered randomised controlled studies should evaluate whether treatment of insomnia can improve other aspects of IBD, including pain and inflammation.

TRIAL REGISTRATION NUMBER

NCT04132024.

Promoting psycho-social wellbeing for engaging inflammatory bowel disease patients in their care: an Italian consensus statement

BACKGROUND

Inflammatory bowel diseases (IBD) are remitting and relapsing diseases that mainly interest the gastrointestinal tract. IBD is associated with a condition of psycho-social discomfort that deeply compromises the quality of life and the competence of patient to be fully engaged in their self-management. As a consequence, effective care of IBD patients should include not only medical but also psychological support in order to improve patients' wellbeing. Although this, to date there is no standardized approach to promote psychological wellbeing of IBD patients in order to improve the perception of the quality of the care. To fill this gap, a consensus conference has been organized in order to define the psychosocial needs of IBD patients and to promote their engagement in daily clinical practice. This paper describes the process implemented and illustrates the recommendations deriving from it, which focus on the importance of a multidisciplinary approach in IBD management.

RESULTS

The consensus conference has been organized in three phases: (1) literature review about life experiences, engagement, and psychosocial needs of IBD patients; (2) workshops with IBD experts and patients' representatives; (3) drafting of statements and voting. Seventy-three participants were involved in the consensus conference, and sixteen statements have been voted and approved during the consensus process.

CONCLUSIONS

The main conclusion is the necessity of the early detection of - and, in case of need, intervention on- psycho-social needs of patients in order to achieve patient involvement in IBD care.

Trajectories of Fatigue in Inflammatory Bowel Disease

BACKGROUND

Fatigue is one of the most frequently reported symptoms by patients with inflammatory bowel disease (IBD), both during active disease phases as well as during clinical remission. This study addressed whether different trajectories of fatigue over time can be identified among patients with IBD. Subsequently, we compared the demographic and clinical characteristics between trajectories.

METHODS

The current study included 849 patients with IBD diagnosed with either Crohn disease (CD; n = 511) or ulcerative colitis (UC; n = 338) who visited the University Medical Center in Groningen (the Netherlands) at least 3 times during a 9-year follow-up. We conducted latent class growth analyses to identify distinct trajectories.

RESULTS

In all patients with IBD (and in the subgroup with CD), we found 5 trajectories for fatigue. In the UC subgroup, we found 4 fatigue trajectories. One trajectory present in both patients with CD (11.45%) and patients with UC (4.75%) was characterized by chronic elevated levels of fatigue across time. Women and parents were more prevalent in trajectories with higher fatigue severity. We also found significant associations among the fatigue trajectories with disease activity and psychological well-being.

CONCLUSIONS

The results clearly showed the existence of distinct fatigue paths over time in patients with IBD. Those reporting more chronic elevated levels of fatigue also reported greater disease activity and reduced well-being. Therefore, reducing disease activity may be important for the treatment of fatigue. In addition, given the significant association with well-being, it is possible that reducing fatigue may improve self-reported well-being.

The association of the quality of sleep with proinflammatory cytokine profile in inflammatory bowel disease patients

BACKGROUND

The role of circadian rhythm abnormalities in patients with inflammatory bowel disease (IBD) remains relatively unknown. The aim of this study was to identify the inflammatory cytokine profile in the IBD patients and its relationship with the quality of sleep.

METHODS

Prospective, single-center observational cohort study was performed. In all enrolled adult IBD patients, the disease activity was assessed using Crohn's Disease Activity Index (CDAI) for Crohn's disease (CD) and Partial Mayo Score for ulcerative colitis (UC), respectively. To assess the quality of sleep, all patients were asked to respond to a questionnaire to define Pittsburgh Quality Sleep Index (PSQI). From all enrolled patients, 15 ml venous blood was taken to determine serum inflammatory cytokine levels and perform standard laboratory tests.

RESULTS

Fifty-two IBD patients were enrolled in the study: 32 with CD and 20 with UC. The poor sleep was noted in 69.4% of patients with clinically active and in 6.3% of patients with inactive disease. In the group of IBD patients with poor sleep, the significantly higher level of serum IL-6, IL-17, and IL-23 were observed. In IBD patients with exacerbation, the significantly higher level of serum IL-6, IL-17, and IL-23 were recorded.

CONCLUSIONS

The relationship between quality of sleep and proinflammatory cytokine profile may show us a predisposition for the development of inflammatory intestinal lesions in IBD patients with sleep disturbances. This knowledge may allow the pharmacological and behavioral therapies of circadian rhythm abnormalities to become new significant targets in IBD patients.

Antifatigue effects of Hechong (Tylorrhynchus heterochaetus) through modulation of Nrf2/ARE- mediated antioxidant signaling pathway

This study was to evaluate the antifatigue effect of T. heterochaetus and explore the underlying mechanism of action. T. heterochaetus extract was treated to mice for 28 days. On the 28th day, after weight loaded swimming test. The levels of antioxidant enzymes and levels of pro- and anti-inflammatory cytokines in the liver and muscles of exercised mice were evaluated. mRNA and protein expression levels of Nrf2, SOD, HO-1, and Keap-1 were evaluated using RT-PCR and western blot analysis. The low (2.70 mg/0.5 ml/20 g) and medium (5.41 mg/0.5 ml/20 g) dose enhanced the activities of antioxidant enzymes like SOD, CAT and GPx in the liver and skeletal muscle thereby enhancing the antifatigue effect. The low and medium doses showed good anti-inflammatory effects by evaluating the levels of pro and anti-inflammatory cytokines such as TNF-α, IL-1β, IL-6, and IL-10 both in the liver and skeletal muscle. Furthermore, RT-PCR and western blot analysis showed increased expression of HO-1, SOD, Nrf2, and decreased expression of Keap-1 gene and proteins in liver and skeletal muscle of T. heterochaetus treated group mice. The current results indicate that T. heterochaetus exert the antifatigue effect through attenuating oxidative stress injury and inflammatory responses through the Nrf2/ARE-mediated signaling pathway.

Evaluation of the Unidimensional Fatigue Impact Scale (U-FIS) in Crohn's Disease: The Importance of Local Item Dependency

BACKGROUND AND PURPOSE

The Unidimensional Fatigue Impact Scale (U-FIS) was developed for use in a multiple sclerosis population. The aim was to determine whether the U-FIS is a valid tool for measuring the impact of fatigue in Crohn's disease (CD).

METHOD

CD patients completed the U-FIS as part of a validation study of the Crohn's Life Impact Questionnaire (CLIQ). Data were analyzed according to Rasch measurement theory (RMT).

RESULTS

Two hundred sixty-one completed U-FIS questionnaires were available for analysis. After rescoring the items to resolve disordered thresholds, all 22 items showed acceptable RMT fit. However, there was considerable local item dependency (LID).

CONCLUSION

The U-FIS did not provide unidimensional measurement in a sample of CD patients due to high levels of LID. Combining the three FIS outcomes into a single measure was not justified.

Prevalence of Fatigue and Unrecognized Depression in Patients with Inflammatory Bowel Disease in Remission under Immunosuppressants and Biologicals

Background: Although highly prevalent among inflammatory bowel disease (IBD) patients, fatigue remains an unmet clinical need. The aim was to describe the prevalence of fatigue in an IBD population in remission and identify factors associated with fatigue. Methods: IBD patients in clinical and biochemical remission under treatment with immunomodulators or biologicals were included. Fatigue, physical tiredness and depression were assessed using the fatigue Visual Analogue Scale (fVAS), the Shortened Fatigue Questionnaire (SFQ) and the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR), respectively. Relevant clinical and biochemical parameters were included in regression analyses to identify factors associated with physical fatigue. Results: In total, 157 IBD patients were included. Up to 45.9% of patients reported fatigue, physical tiredness was observed in 51% and depression in 10.8%. The majority of patients with subclinical depression were fatigued. Female sex (OR = 4.17 [1.55–6.78], p = 0.002) was independently associated with physical fatigue. Transferrin saturation (OR = −0.11 [−0.22–−0.007], p = 0.037) and treatment with adalimumab (compared to infliximab, OR = −3.65 [−7.21–−0.08], p = 0.045) entailed a lower risk of fatigue. Conclusion: Fatigue is observed in about half of IBD patients in remission and can be a symptom of underlying undetected depression. Sex, transferrin saturation and medication were identified as independent risk factors.

Quality of Life in Newly Diagnosed Moderate-to-Severe Ulcerative Colitis: Changes in the MOSAIK Cohort Over 1 Year

Background/Aims

Improving quality of life has been gaining importance in ulcerative colitis (UC) management. The aim of this study was to investigate changes in health-related quality of life (HRQL) and related factors in patients with moderate-to-severe UC.

Methods

A multicenter, hospital-based, prospective study was performed using a Moderate-to-Severe Ulcerative Colitis Cohort in Korea (the MOSAIK). Changes in HRQL, evaluated using the 12-Item Short Form Health Survey (SF-12) and Inflammatory Bowel Disease Questionnaire (IBDQ), were analyzed at the time of diagnosis and 1 year later.

Results

In a sample of 276 patients, the mean age was 38.4 years, and the majority of patients were male (59.8%). HRQL tended to increase in both the IBDQ and SF-12 1 year after diagnosis. A higher partial Mayo score was significantly related to poorer HRQL on the IBDQ and SF-12 in a linear mixed model (p<0.01). Inflammatory markers such as C-reactive protein (CRP) or erythrocyte sedimentation rate also showed a negative correlation on HRQL (p<0.05). Patients whose IBDQ score improved by 16 or more (71.2%) in 1 year were younger, tended to be nonsmokers, and had a lower partial Mayo score and CRP than those whose IBDQ score did not. There was no significant association between HRQL and disease extent, treatments at diagnosis, or the highest treatment step during the 1-year period.

Conclusions

Optimally controlled disease status improves HRQL in patients with moderate-to-severe UC. The partial Mayo score and inflammatory markers may be potential indicators reflecting the influence of UC on patient`s daily lives.

A systematic review of psychological treatments to manage fatigue in patients with inflammatory bowel disease

OBJECTIVE

Fatigue is highly prevalent, debilitating and associated with poor mental health in people with inflammatory bowel disease (IBD). However, little is known about the efficacy of psychological interventions to manage IBD fatigue. This systematic review aimed to establish the efficacy of psychological interventions to manage IBD fatigue.

METHODS

Studies were identified by systematically searching MEDLINE, PsychINFO, CINAHL, EMBASE, Cochrane CENTRAL, Google Scholar and Open Grey. Included studies needed to employ a randomised control trial (RCT) design with a psychological intervention targeted at reducing fatigue in patients with IBD and include a measure of fatigue. All screening, as well as data extraction and quality appraisals, were conducted by two researchers independently.

RESULTS

Four RCTs were included in this systematic review. Psychological interventions including psychoeducation, cognitive behaviour therapy and solution-based approach showed preliminary efficacy for fatigue, however the studies were small and largely underpowered. CBT was the most efficacious psychotherapy trialled, with a greater reduction in fatigue severity (g = 0.91, CI 95% [- 0.30, 2.11]) and impact (g = 0.87, CI 95% [- 0.22, 2.07]) seen in the intervention group between baseline and 12-months follow-up when compared to the control group using the IBD-F scale. However, while these effect sizes are strong, they were non-significant due to being underpowered.

CONCLUSION

While the evidence is scant and low quality, psychological interventions show promise in improving IBD fatigue. Future studies should examine larger samples and employ longer follow-up to better determine efficacy of psychological interventions for fatigue in people with IBD.

Mental Health Factors Associated With Fatigue in Mexican Patients With Inflammatory Bowel Disease

GOALS

The aim of this study was to describe mental health factors associated with the development of fatigue in inflammatory bowel disease (IBD) patients.

BACKGROUND

IBD includes ulcerative colitis and Crohn's disease. Patients with chronic diseases can present fatigue differently and qualitatively more severely than those typically represented by healthy populations.

STUDY

This was a cross-sectional study in which 200 Mexican patients were attending the Inflammatory Bowel Disease Clinic at the National Institute of Medical Sciences and Nutrition. All patients answered 3 instruments: the first IBD-fatigue, HADS (Hospital Anxiety and Depression Scale), and PSQI (Pittsburgh Sleep Quality Index). The statistical analysis was carried out in the statistical program SPSS v 24.

RESULTS

The percentage of fatigue in our patients was 55.5% (n=111) for mild-moderate fatigue, 31.5% (n=63) for severe fatigue, and only 13% (n=26) had no fatigue. Sleep disturbance and sleep latency were the most important predictors of fatigue in IBD patients.

CONCLUSIONS

Sleep quality and depression have an impact on fatigue in Mexican patients with IBD. It is important for multidisciplinary management to reduce these symptoms and improve the quality of life of patients with IBD.

Review article: The aetiology of fatigue in inflammatory bowel disease and potential therapeutic management strategies

BACKGROUND

Fatigue is the inability to achieve or maintain an expected work output resulting from central or peripheral mechanisms. The prevalence of inflammatory bowel disease (IBD) fatigue can reach 86% in active disease, persisting in 50%-52% of patients with mild to inactive disease. Fatigue is the commonest reason for work absence in IBD, and patients often report fatigue burden to be greater than that of primary disease symptoms. Relatively few evidence-based treatment options exist, and the aetiology is poorly understood.

AIM

To review the available data and suggest a possible aetiology of IBD fatigue and to consider the efficacy of existing management strategies and highlight potential future interventions.

METHODS

We reviewed fatigue-related literature in IBD using PubMed database.

RESULTS

Disease related factors such as inflammation and pharmacological treatments negatively impact skeletal muscle and brain physiology, likely contributing to fatigue symptoms. Secondary factors such as malnutrition, anaemia, sleep disturbance and psychological comorbidity are potential determinants. Immune profile, faecal microbiota composition and physical fitness differ significantly between fatigued and non-fatigued patients, suggesting these may be aetiological factors. Solution-focused therapy, high-dosage thiamine supplementation and biological therapy may reduce fatigue perception in IBD. The effect of physical activity interventions is inconclusive.

CONCLUSIONS

A multimodal approach is likely required to treat IBD fatigue. Established reversible factors like anaemia, micronutrient deficiencies and active disease should initially be resolved. Psychosocial intervention shows potential efficacy in reducing fatigue perception in quiescent disease. Restoring physical deconditioning by exercise training intervention may further improve fatigue burden.

Contextualizing goal preferences in fear-avoidance models. Looking at fatigue as a disabling symptom in fibromyalgia patients

The fear-avoidance model provides an explanation for the development of chronic pain, including the role of perception (i.e. pain catastrophism) as an explanatory variable. Recent research has shown that the relationship between pain catastrophism and avoidance is influenced in turn by different psychological and contextual variables, highlighting the affective-motivational ones. From this perspective, the Goal Pursuit Questionnaire (GPQ) was developed to measure the preference for hedonic goals (mood-management or pain-avoidance goals) over achievement goals in musculoskeletal pain patients. Recently, the Spanish version of the GPQ in fibromyalgia patients has been validated. Our aim has been to adapt the Spanish version of GPQ from pain to fatigue symptoms and to validate this new questionnaire (GPQ-F) in fibromyalgia. Despite the recognition of fibromyalgia as a complex disorder and the need for a differential study of its symptoms, fatigue, despite its high prevalence and limiting nature, remains the forgotten symptom. We conducted a cross-sectional study with 231 women with fibromyalgia. Previously, we adapted the Spanish GPQ for fatigue symptoms with three sub-studies (group structured interview, self-administration questionnaire and thinking-aloud; n = 15–27 patients). We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Exploratory factor analysis showed two factors: ‘Fatigue-avoidance goal’ and ‘Mood-management goal’ (39.3% and 13.9% of explained variance, respectively). The activity avoidance pattern fully mediated the relation between both catastrophizing and fatigue-avoidance goals with fatigue. The study shows initial findings about the usefulness of the GPQ-F as a tool to analyze goal preferences related to fatigue in fibromyalgia. The results supported the mediational role of activity avoidance patterns in the relationship between preference for fatigue-avoidance goals and fatigue.

A meta-analysis on sleep quality in inflammatory bowel disease

Evidence of poor sleep quality in inflammatory bowel disease (IBD, i.e., Crohn's disease and ulcerative colitis) has been reported but never systematically reviewed or meta-analysed. We conducted a systematic review and meta-analysis of pairwise comparisons that included 1) IBD patients/controls, 2) Crohn's disease/ulcerative colitis, 3) active/inactive IBD on standardised measures of sleep quality. PubMed, Medline, PsycINFO, Scopus, and CINAHL were searched up to March 2021. Forty-two studies met the inclusion criteria. Results showed poorer subjective sleep quality in IBD patients than in controls, with moderate effect sizes (g = .49, [95% CI = .32 - .66], p < .001). No differences within IBD subtypes were found (g = -.07, [95% CI = -.17-.05], p = .208). Individuals with an active IBD reported poorer sleep quality than those in remission, with a large effect size (g = .66, [95% CI = .35 - .98], p < .001). Results on objectively recorded sleep were mixed, with no clear evidence of objective sleep impairments in individuals with IBD. Results support the view of subjective poor sleep quality as a relevant comorbidity in IBD. As a potential factor affecting immune and inflammatory responses as well as patients' quality of life, sleep quality should be taken into account in the treatment of IBD.

A Review of Inflammatory Bowel Disease: A Model of Microbial, Immune and Neuropsychological Integration

Objective: Inflammatory bowel diseases (IBDs) are complex chronic inflammatory disorders of the gastro-intestinal (GI) tract with uncertain etiology. IBDs comprise two idiopathic disorders: Crohn's disease (CD) and ulcerative colitis (UC). The aetiology, severity and progression of such disorders are still poorly understood but thought to be influenced by multiple factors (including genetic, environmental, immunological, physiological, psychological factors and gut microbiome) and their interactions. The overarching aim of this review is to evaluate the extent and nature of the interrelationship between these factors with the disease course. A broader conceptual and longitudinal framework of possible neuro-visceral integration, core microbiome analysis and immune modulation assessment may be useful in accurately documenting and characterizing the nature and temporal continuity of crosstalk between these factors and the role of their interaction (s) in IBD disease activity. Characterization of these interactions holds the promise of identifying novel diagnostic, interventions, and therapeutic strategies. Material and Methods: A search of published literature was conducted by exploring PubMed, EMBASE, MEDLINE, Medline Plus, CDSR library databases. Following search terms relating to key question were set for the search included: "Inflammatory bowel diseases," "gut microbiota," "psychological distress and IBD," "autonomic reactivity and IBD," "immune modulation," "chronic inflammation," "gut inflammation," "enteric nervous system," "gut nervous system," "Crohn's disease," "Ulcerative colitis", "depression and IBD", "anxiety and IBD", "quality of life in IBD patients," "relapse in IBDs," "remission in IBDs," "IBD disease activity," "brain-gut-axis," "microbial signature in IBD," "validated questionnaires in IBD," "IBD activity indices," "IBD aetiology," "IBDs and stress," "epidemiology of IBDs", "autonomic nervous system and gut inflammation", "IBD and environment," "genetics of IBDs," "pathways of immune response in IBDs," "sleep disturbances in IBD," "hypothalamic-pituitary-adrenal axis (HPA)," "sympatho-adrenal axis," "CNS and its control of gut function" "mucosal immune response," "commensal and pathogenic bacteria in the gut," "innate and adaptive immunity." Studies evaluating any possible associations between gut microbiome, psychological state, immune modulation, and autonomic function with IBDs were identified. Commonly cited published literatures with high quality research methodology/results and additional articles from bibliographies of recovered papers were examined and included where relevant. Results: Although there is a substantial literature identifying major contributing factors with IBD, there has been little attempt to integrate some factors over time and assess their interplay and relationship with IBD disease activity. Such contributing factors include genetic and environmental factors, gut microbiota composition and function, physiological factors, psychological state and gut immune response. Interdependences are evident across psychological and biological factors and IBD disease activity. Although from the available evidence, it is implausible that a single explanatory model could elucidate the interplay between such factors and the disease course as well as the sequence of the effect during the pathophysiology of IBD. Conclusion: Longitudinal monitoring of IBD patients and integrating data related to the contributing/risk factors including psychological state, physiological conditions, inflammatory/immune modulations, and microbiome composition/function, could help to explain how major factors associate and interrelate leading to exacerbation of symptoms and disease activity. Identifying the temporal trajectory of biological and psychosocial disturbances may also help to assess their effects and interdependence on individuals' disease status. Moreover, this allows greater insight into understanding the temporal progressions of subclinical events as potential ground for disease severity in IBD. Furthermore, understanding the interaction between these risk factors may help better interventions in controlling the disease, reducing the costs related to disease management, further implications for clinical practice and research approaches in addition to improving patients' mental health and quality of life.

Fatigue in patients with inflammatory bowel disease in Eastern China

BACKGROUND

Fatigue is a very common but relatively neglected problem in patients with inflammatory bowel disease (IBD). The prevalence rate of IBD in China is the highest in Asia, but there is little research on fatigue in patients with IBD. Neither the relationship between fatigue and quality of life (QoL) nor the relationship between fatigue and work productivity (WP) in Chinese IBD patients has been reported.

AIM

To investigate the prevalence of fatigue related to IBD in Eastern China, to identify the risk factors associated with fatigue, to assess the impact of fatigue on QoL, and to evaluate the relationship between fatigue and WP.

METHODS

A cross-sectional study was conducted in a Regional Tertiary IBD Diagnostic and Treatment Center in Eastern China. Clinical data of patients were collected, and disease activity was evaluated. Blood samples were analyzed to assess anemia, albumin, and inflammation. Fatigue was assessed using the multidimensional fatigue inventory. QoL and WP were measured using the short inflammatory bowel disease questionnaire and the work productivity and activity impairment general health questionnaire, respectively. The patients also completed assessments of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder 7-item Scale).

RESULTS

A total of 311 IBD patients, comprising 168 Crohn's disease patients and 143 ulcerative colitis patients, were enrolled. The prevalence of fatigue in patients with IBD was 60.77%. In a univariate logistic regression analysis, factors such as disease activity, depression, anxiety, anemia, and IBD-related surgery were individually related to a significantly increased risk of fatigue in IBD patients. Multivariate logistic regression analysis indicated that depression [odds ratio (OR) = 8.078, 95% confidence interval (CI): 4.113-15.865], anxiety (OR = 2.373, 95%CI: 1.100-5.119), anemia (OR = 2.498, 95%CI: 1.290-4.834), and IBD-related surgery (OR = 2.035, 95%CI: 1.084-3.819) were related to fatigue in IBD patients. There was a negative correlation between fatigue and QoL (r = -0.831; P < 0.0001) but a positive correlation between fatigue and WP loss.

CONCLUSION

The prevalence of fatigue in IBD patients in Eastern China is remarkably high even in clinical remission. Factors such as depression, anxiety, anemia, and IBD-related surgery are major risk factors for fatigue in IBD patients. In addition, fatigue has a negative impact on QoL and is positively correlated with WP loss.

Circadian Clock Disruption Suppresses PDL1+ Intraepithelial B Cells in Experimental Colitis and Colitis-Associated Colorectal Cancer

BACKGROUND & AIMS

The circadian clock is crucial for physiological homeostasis including gut homeostasis. Disorder of the circadian clock may contribute to many diseases including inflammatory bowel disease (IBD). However, the role and the mechanisms of circadian clock involvement in IBD still are unclear.

METHODS

Disorder of the circadian clock including chronic social jet lag and circadian clock gene deficiency mice (Bmal1-/-, and Per1-/-Per2-/-) were established. Dextran sulfate sodium (DSS) and/or azoxymethane were used to induce mouse models of colitis and its associated colorectal cancer. Flow cytometry, immunohistochemistry, immunofluorescence, Western blot, and reverse-transcription quantitative polymerase chain reaction were used to analyze the characteristics of immune cells and their related molecules.

RESULTS

Mice with disorders of the circadian clock including chronic social jet lag and circadian clock gene deficiency were susceptible to colitis. Functionally, regulatory B (Breg) cells highly expressing Programmed cell death 1 ligand 1 (PDL1) in intestinal intraepithelial lymphocytes (IELs) helped to alleviate the severity of colitis after DSS treatment and was dysregulated in DSS-treated Bmal1-/- mice. Notably, interleukin 33 in the intestinal microenvironment was key for Bmal1-regulated PDL1+ Breg cells and interleukin 33 was a target of Bmal1 transcriptionally. Dysregulated PDL1+ B cells induced cell death of activated CD4+ T cells in DSS-treated Bmal1-/- mice. Consequently, circadian clock disorder was characterized as decreased numbers of Breg+ PDL1+ cells in IELs and dysfunction of CD4+ T cells promoted colitis-associated colorectal cancer (CRC) in mice. In clinical samples from CRC patients, low expression of Bmal1 gene in paracancerous tissues and center area of tumor was associated closely with a poorer prognosis of CRC patients.

CONCLUSIONS

Our study uncovers the importance of the circadian clock regulating PDL1+ Breg+ cells of IELs in IBD and IBD-associated CRC.

Psychological Comorbidity and Intervention in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with significant psychological comorbidities, with associated impacts on patient quality of life, disease course, and health care costs. The present article reviews the latest evidence on the etiology of psychological comorbidities in IBD, with a focus on shared inflammatory pathways. The current state of practice in managing and understanding psychological comorbidities from the perspective of both gastroenterology practice and psychological treatment is reviewed, with a focus on evidence-based treatments shown to be effective in managing depression, anxiety, stress, and improving IBD-related health outcomes.

Sleep Characteristics and Rest-Activity Rhythms Are Associated with Gastrointestinal Symptoms Among Adults with Inflammatory Bowel Disease

BACKGROUND

Sleep disturbance is common in inflammatory bowel disease (IBD) and is associated with poorer quality of life and increased disease activity; however, sleep is a multidimensional process, and little is known about specific sleep characteristics and rest-activity rhythms (RARs) in this population.

AIMS

The purposes were to (1) describe sleep characteristics and RARs; (2) compare sleep characteristics and RARs and GI symptoms by disease activity; and (3) describe associations between sleep characteristics, RARs, and GI symptoms among adults with IBD.

METHODS

We conducted a cross-sectional study of adults with IBD. We measured sleep characteristics and RARs (continuous wrist actigraphy); GI symptoms (PROMIS-GI); and disease activity (physicians' global assessment). We conducted cosinor and nonparametric analyses to compute RAR variables and bivariate analyses to address the aims.

RESULTS

The sample included 37 participants [age M = 38 years (SD = 13.8) and 21 (56.8%) female], of whom 23 (60.6%) were in remission. Sleep efficiency [M = 82.91% (SD 5.35)] and wake after sleep onset (WASO) [M = 42.26 min (SD 18.57)] were not associated with disease activity. Inter-daily stability of the RAR was associated with heartburn/reflux (r = - .491, p = .005) and gas/bloating (r = - .469, p = .008). Intra-daily variability of the RAR was associated with heartburn/reflux (r = .421, p = .018).

CONCLUSIONS

People with IBD may have disrupted RARs, which are associated with GI symptoms. Research is needed to improve understanding of these associations and to develop interventions to improve these characteristics in adults with IBD.

Prevalence and factors associated with poor sleep quality in inflammatory bowel disease outpatients

INTRODUCTION

sleep disorders are common in the general population and have obvious repercussions on quality of life. Poor sleep quality is associated to inflammatory activity and fatigue in inflammatory bowel disease (IBD) patients. This study aimed to analyze the prevalence of poor sleep quality and the factors associated with it, in IBD outpatients.

METHODS

an observational and prospective study was performed in which epidemiological, clinical and laboratory data were collected from clinical records and patients who consecutively attended an outpatient clinic. Pittsburgh Sleep Quality index (PSQI), Hospital Anxiety and Depression Scale (HADS) and International Physical Activity Questionnaire (IPAQ) were used to measure sleep quality, anxiety, depression and physical activity, respectively. Treatment optimizations, hospital admissions or surgery were prospectively verified three months after the baseline visit.

RESULTS

one hundred and two patients were included and 54.9 % had poor sleep quality (PSQI score > 5). No association was found between poor sleep quality and IBD-related variables such as type of disease, ulcerative colitis (UC) extent, Crohn's disease (CD) location or behavior, time from diagnosis, treatment, prior admissions or surgery and laboratory values. Rotating night shift job (OR 6.116, 95 % CI: 1.312-28.514), HAD score for depression (OR 1.125, 95 % CI: 1.062-1.490) and frequency (days per week) of vigorous physical activity (OR 0.783, 95 % CI: 0.619-0.991) were independent predictors of poor sleep quality. A Pittsburgh questionnaire score higher than 5 was not significantly associated to treatment optimization in the total patient cohort (15.2 % vs 18.2 %, p = 0.451), in UC patients (18.2 % vs 10.7 %, p = 0.362) or CD patients (12.5 % vs 25.9 %, p = 0.198).

CONCLUSIONS

poor sleep quality is present in more than half of IBD patients. Aspects not directly related to IBD are associated to poor sleep quality.

Polysomnography shows sleep fragmentation in patients with inactive inflammatory bowel disease

Background

Inflammatory bowel disease (IBD), classified as Crohn’s disease or ulcerative colitis, is a chronic inflammatory condition that affects the gastrointestinal tract. Fatigue is a common symptom of IBD, even in periods of inactive disease; however, the cause of this fatigue is unknown. Studies have suggested that altered sleep patterns may be associated with the fatigue experienced by IBD patients. The aim of our study was to assess the sleep quality of patients with inactive IBD who report fatigue.

Methods

We conducted a prospective observational pilot study that examined IBD outpatients with inactive disease who had complaints of fatigue. Upon enrolment, patients underwent Level 1 diagnostic polysomnography for one night to measure objective sleep parameters. Patients were also asked to complete 3 validated questionnaires to assess fatigue, depression levels, and subjective sleep quality.

Results

Fifteen patients (7 with CD, 8 with UC) were enrolled in the study; their mean age was 38.6±11.6 years. IBD patients had a mean spontaneous arousal index of 20.0±9.7 arousals /h. Patients spent an average of 6.6%, 60.4%, 15.2%, and 17.9% of their total sleep time in stages N1, N2, N3 and rapid-eye-movement sleep, respectively. Four (26.7%) patients had obstructive sleep apnea, and 7 (46.7%) patients experienced periodic limb movements of sleep.

Conclusions

Patients with IBD experienced altered sleep patterns and high rates of sleep fragmentation. Further research is needed to determine how poor sleep quality can be treated in patients with IBD.

Non-pharmacological interventions to manage fatigue in adults with inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

The prevalence of fatigue is higher in adults with inflammatory bowel disease (IBD). There is limited information on the effectiveness of non-pharmacological interventions to manage fatigue. The purposes of this review is to evaluate the effectiveness of these interventions to manage fatigue in adults with IBD.

MATERIALS AND METHODS

A systematic review was conducted based on the PRISMA guidelines. Comprehensive Meta-Analysis software was used to compute metaanalysis.

RESULTS

Eleven studies were included in the review. The interventions to manage fatigue included problem-solving therapy, solution-focused therapy, cognitive behavioral therapy, psychoeducational intervention, exercise advice with omega-3 supplements, electro-acupuncture, and AndoSan. The pooled evidence from the metaanalysis demonstrated that non-pharmacological interventions could decrease IBDFatigue (SMD = 0.33, 95% CI [0.10, 0.55], p = 0.005).

CONCLUSION

The pooled data indicate that non-pharmacological interventions are helpful in managing IBD-Fatigue. Additionally, the non-pharmacological interventions reviewed could be utilized to promote self-management in IBD.

A Global, Prospective, Observational Study Measuring Disease Burden and Suffering in Patients with Ulcerative Colitis Using the Pictorial Representation of Illness and Self-Measure Tool

BACKGROUND

The understanding the Impact of ulcerative COlitis aNd Its assoCiated disease burden on patients study [ICONIC] was a 2-year, global, prospective, observational study evaluating the cumulative burden of ulcerative colitis [UC] using the Pictorial Representation of Illness and Self-Measure [PRISM] tool that is validated to measure suffering, but not previously used in UC.

METHODS

ICONIC enrolled unselected outpatient clinic attenders with recent-onset UC. Patient- and physician-reported outcomes including PRISM, the Short Inflammatory Bowel Disease Questionnaire [SIBDQ], the Patient Health Questionnaire [PHQ-9], and the Simple Clinical Colitis Activity Indexes [patient: P-SCCAI; physician: SCCAI] were collected at baseline and follow-up visits every 6 months. Correlations between these measures were assessed using Spearman's rank correlation coefficient.

RESULTS

Overall, 1804 evaluable patients had ≥1 follow-up visit. Over 24 months, mean [SD] disease severity measured by P-SCCAI/SCCAI reduced significantly from 4.2 [3.6]/3.0 [3.0] to 2.4 [2.7]/1.3 [2.1] [p<0.0001]. Patient-/physician-assessed suffering, quantified by PRISM, reduced significantly over 24 months [p<0.0001]. SCCAI/P-SCCAI, and patient-/physician-assessed PRISM, showed strong pairwise correlations [rho ≥0.60, p<0.0001], although physicians consistently underestimated these disease severity and suffering measures compared with patients. Patient-assessed PRISM moderately correlated with other outcome measures, including SIBDQ, PHQ-9, P-SCCAI, and SCCAI (rho = ≤-0.38 [negative correlations] or ≥0.50 [positive correlations], p<0.0001).

CONCLUSION

Over 2 years, disease burden and suffering, quantified by PRISM, improved in patients with relatively early UC. Physicians underestimated burden and suffering compared with patients. PRISM correlated with other measures of illness perception in patients with UC, supporting its use as an endpoint reflecting patient suffering.

The Reality of Patient-Reported Outcomes of Health-Related Quality of Life in an Italian Cohort of Patients with Inflammatory Bowel Disease: Results from a Cross-Sectional Study

Inflammatory bowel disease (IBD) has a negative impact on patients’ physical and psychological well-being, social performance, and working capacity, thereby worsening their health-related quality of life (HRQoL). Clinicians should take care of the patients’ global health, including the psychological, social, and emotional spheres. We aimed to investigate the reality of patient-reported outcomes of HRQoL in a series of IBD patients. Consecutive Crohn´s disease (CD) and ulcerative colitis (UC) patients in clinical remission were recruited. The survey consisted of the Short Inflammatory Bowel Disease Questionnaire (S-IBDQ), the Hospital Anxiety and Depression Scale (HADS), the Brief Illness Perception Questionnaire (B-IPQ), and a questionnaire dealing with impact of IBD on patients’ lives. Demographic and clinical characteristics were recorded. Of 202 participants (29% CD and 71% UC; 54% male; median age 48 years; mean disease duration 14 ± 11 years), 52% had poor HRQoL, 45% anxiety/depression, and 35% sleep disturbance and a high perception of disease (mean score 42.8 ± 14.3). In the multivariate analysis, a low HRQoL was rather associated with UC than CD (p = 0.037), IBD surgery (p = 0.010), disease duration (p = 0.01), sleep disturbance (p = 0.014), anxiety/depression (p = 0.042), and high illness perception (p = 0.006). IBD affected working performance and social activities in 62% and 74% of patients, respectively. Satisfaction regarding quality of care, biologics, and surgery approach were claimed in 73%, 69%, and 76% of patients, respectively. Although 84% of patients trusted their gastroenterologist, only 66% of them discussed IBD impact on HRQoL during visit. In a series of IBD patients in remission, the low HRQoL was significantly associated with surgery, disease duration, sleep disturbance, anxiety/depression, and high illness perception. Even though patients were satisfied with the quality of their care, it appears that clinicians should pay more attention to patients’ emotional status.

Sleep Impairment and Psychological Distress among Patients with Inflammatory Bowel Disease-beyond the Obvious

BACKGROUND

A healthy sleep-wake cycle is fundamental for regulating immune function. Sleepiness and fatigue are often manifestations of chronic inflammatory disorders, such as inflammatory bowel disease (IBD), potentially influencing the course of the disease. Our aim was to characterize sleep impairment in patients with IBD and to identify potential associated factors.

METHODS

We conducted a single-center prospective case control study including IBD patients and healthy controls. We evaluated clinical and biochemical parameters, sleep impairment through Pittsburgh Sleep Quality Index (PSQI) and anxiety and depression through Hospital Anxiety and Depression Scale (HADS) questionnaires.

RESULTS

In total, 110 patients with IBD and 66 healthy controls were included. Patients with IBD had a significantly altered sleep quality compared to the control group (p < 0.001), with sleep impairment also occurring for patients in remission (median PSQI = 7), but without significant differences between ulcerative colitis and Crohn's disease. However, PSQI was correlated with disease activity scores only for ulcerative colitis and not for Crohn's disease. Among patients with increased PSQI, only 30.19% used sleep medication. Sleep impairment was significantly correlated with altered psychological status (p < 0.01) and the presence of extraintestinal manifestations (p = 0.0172).

CONCLUSIONS

Sleep impairment is frequent among patients with IBD, is associated with psychological distress and several disease-related parameters and should be routinely evaluated, at least in several IBD patient subgroups, to improve disease management.

Poor Sleep Quality in Crohn's Disease Is Associated With Disease Activity and Risk for Hospitalization or Surgery

BACKGROUND AND AIMS

Poor sleep quality in Crohn's disease (CD) is associated with histologic activity and clinical relapse. We sought to characterize sleep dysfunction and determine the effect of poor sleep quality on risk for hospitalization and surgery.

METHODS

Clinical data were collected for CD subjects including the Pittsburgh Sleep Quality Index (PSQI) and Harvey-Bradshaw index (HBI). The PSQI score and a brief medical history were obtained for control subjects. The PSQI and HBI correlation was tested at an initial clinic visit and at follow-up. Crohn's disease subjects with and without poor sleep were compared for risk of hospitalization or surgery by Kaplan-Meier and Cox proportional hazards.

RESULTS

Ninety-two CD and 82 control subjects were included. Crohn's disease and control subjects shared similar baseline characteristics and PSQI (8.3 vs 7.8, P = 0.31), and 77% of the CD population had PSQI >5. Crohn's disease subjects with PSQI >5 more often had inflammatory phenotypes and reported increased benzodiazepine and psychiatric medication use. Crohn's disease subjects with PSQI >5 also reported more night awakenings due to pain and bathroom use. The PSQI correlated with HBI (r = 0.256, P = 0.014), and ΔPSQI on follow-up correlated with ΔHBI (r = 0.47, P = 0.002). Cox proportional hazards model for hospitalization or surgery showed that PSQI >8 was predictive of surgery or hospitalization (hazards ratio 5.37; 95% confidence interval, 1.39-27.54).

CONCLUSION

There is a high burden of poor sleep quality in CD, which is associated with risk for adverse outcomes. Sleep quality may identify CD patients at risk for complications and have prognostic value in CD.

Fatigue in inflammatory bowel disease: a problematic ailment

PURPOSE OF REVIEW

Fatigue, a protean complaint encompassing both physical, mental exhaustion but also demotivation, has shown to effect quality of life in patients with inflammatory bowel disease (IBD). Here we present a review of the literature as it relates to IBD-associated fatigue. Moreover, we present the common causes attributed to fatigue and present an algorithmic approach to the assessment of fatigue. Finally, we report data regarding potential management strategies for IBD-associated fatigue.

RECENT FINDINGS

Unfortunately, owing to its multidimensional nature and multifactorial causes, patients with IBD may continue to report fatigue despite optimization of disease management, replenishment of nutritional deficiencies, or management of coexistent disorders. Management likely requires a multidisciplinary approach.

SUMMARY

The majority of patients with IBD report fatigue symptoms both in setting of active disease but also during the course of remission. Fatigue is a multidimensional complaints, and management likely requires a multidisciplinary approach. Herein, we present a framework for the management and assessment of fatigue in IBD.

Cognitive Behavioral Therapy for Insomnia: A Promising Treatment for Insomnia, Pain, and Depression in Patients With IBD

Over 75% of people with active inflammatory bowel diseases (IBDs) report sleep disturbances, which heighten risk for IBD relapse and flares. Despite mounting evidence for sleep disturbances in IBD, discussion of treatment is severely limited. The most common sleep disturbance, insomnia, occurs in over 50% of adults with chronic health conditions. Herein we describe the gold standard treatment for insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I). Although yet to be studied in IBD, CBT-I reduces a number of IBD-related comorbidities, including chronic pain, depression, and systemic inflammation. We describe treatment with CBT-I, the impact of CBT-I on these comorbidities, and recommendations for providers.

The Feasibility of Measuring Sleep and Circadian Characteristics in Adults with Inflammatory Bowel Disease

Interest in sleep and circadian research in inflammatory bowel disease (IBD) (Crohn's disease and ulcerative colitis) is growing; however, few studies have objectively measured sleep or circadian rhythms in people with these conditions. The purpose was to determine the feasibility of the use of wrist actigraphy, electronic sleep/activity diaries, and participant-collected saliva among adults with both active and inactive IBD. We conducted a 10-day feasibility study of adults aged 18 years to 60 years with IBD. We measured sleep and rest-activity rhythms with wrist actigraphy, self-reported sleep/activity using electronic diaries, and participant-collected saliva to compute salivary dim light melatonin onset. All 37 (100%) participants wore the wrist actigraphs, 91.8% (N = 34) participants completed at least 15 of the 18 electronic diaries, and 34 (91.9%) completed the saliva collection. It is feasible to use wrist actigraphy and electronic sleep/activity diaries in adult participants with inflammatory bowel disease.

Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases

Various lifestyle factors including physical activity and obesity, stress, sleep, and smoking may modify the risk of developing inflammatory bowel diseases (IBDs). In patients with established IBD, these lifestyle factors may significantly impact the natural history and clinical outcomes. Recreational exercise decreases the risk of flare and fatigue in patients with IBD. In contrast, obesity increases the risk of relapse and is associated with higher anxiety, depression, fatigue, and pain and higher health care utilization. Obesity also modifies pharmacokinetics of biologic agents unfavorably and is associated with a higher risk of treatment failure. Sleep disturbance is highly prevalent in patients with IBD, independent of disease activity, and increases the risk of relapse and chronic fatigue. Similarly, stress, particularly perceived stress rather than major life events, may trigger symptomatic flare in patients with IBD, although its impact on inflammation is unclear. Cigarette smoking is associated with unfavorable outcomes including the risk of corticosteroid dependence, surgery, and disease progression in patients with Crohn's disease; in contrast, smoking does not significantly impact outcomes in patients with ulcerative colitis, although some studies suggest that it may be associated with a lower risk of flare. The effect of alcohol and cannabis use in patients with IBD is inconsistent, with some studies suggesting that cannabis may decrease chronic pain in patients with IBD, without a significant effect of biological remission. Although these lifestyle factors are potentially modifiable, only a few interventional studies have been conducted. Trials of structured exercise and psychological therapy including mindfulness-based therapies such as meditation and yoga and gut-directed hypnotherapy have not consistently demonstrated benefit in clinical and/or endoscopic disease activity in IBD, although may improve overall quality of life.

The immune-sleep crosstalk in inflammatory bowel disease

Sleep disorders are progressively common and sometimes are associated with aberrant regulation of the adaptive and innate immune responses. Sleep interruption can increase the inflammatory burden by enhancing the pro-inflammatory cytokines particularly in patients with chronic diseases such as inflammatory bowel disease (IBD). IBD is a chronic inflammatory disease characterized by immune dysregulation, dysbiosis of gut microbiome, and poor-quality life. Therefore, this review highlights the crosstalk between sleep and immune responses during the progression of IBD.

Interventions for fatigue in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is an umbrella term used to describe a group of chronic, progressive inflammatory disorders of the digestive tract. Crohn's disease and ulcerative colitis are the two main types. Fatigue is a common, debilitating and burdensome symptom experienced by individuals with IBD. The subjective, complex nature of fatigue can often hamper its management. The efficacy and safety of pharmacological or non-pharmacological treatments for fatigue in IBD is not yet established through systematic review of studies.

OBJECTIVES

To assess the efficacy and safety of pharmacological and non-pharmacological interventions for managing fatigue in IBD compared to no treatment, placebo or active comparator.

SEARCH METHODS

A systematic search of the databases Embase, MEDLINE, Cochrane Library, CINAHL, PsycINFO was undertaken from inception to July 2018. A top-up search was run in October 2019. We also searched the Cochrane IBD Group Specialized Register, the Cochrane Central Register of Controlled Trials, ongoing trials and research registers, conference abstracts and reference lists for potentially eligible studies.

SELECTION CRITERIA

Randomised controlled trials of pharmacological and non-pharmacological interventions in children or adults with IBD, where fatigue was assessed as a primary or secondary outcome using a generic or disease-specific fatigue measure, a subscale of a larger quality of life scale or as a single-item measure, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results and four authors extracted and assessed bias independently using the Cochrane 'Risk of bias' tool. The primary outcome was fatigue and the secondary outcomes included quality of life, adverse events (AEs), serious AEs and withdrawal due to AEs. Standard methodological procedures were used.

MAIN RESULTS

We included 14 studies (3741 participants): nine trials of pharmacological interventions and five trials of non-pharmacological interventions. Thirty ongoing studies were identified, and five studies are awaiting classification. Data on fatigue were available from nine trials (1344 participants). In only four trials was managing fatigue the primary intention of the intervention (electroacupuncture, physical activity advice, cognitive behavioural therapy and solution-focused therapy). Electroacupuncture Fatigue was measured with Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) (scores range from 0 to 52). The FACIT-F score at week eight was 8.00 points higher (better) in participants receiving electroacupuncture compared with no treatment (mean difference (MD) 8.00, 95% CI 6.45 to 9.55; 1 RCT; 27 participants; low-certainty evidence). Results at week 16 could not be calculated. FACIT-F scores were also higher with electroacupuncture compared to sham electroacupuncture at week eight (MD 5.10, 95% CI 3.49 to 6.71; 1 RCT; 30 participants; low-certainty evidence) but not at week 16 (MD 2.60, 95% CI 0.74 to 4.46; 1 RCT; 30 participants; low-certainty evidence). No adverse events were reported, except for one adverse event in the sham electroacupuncture group. Cognitive behavioural therapy (CBT) and solution-focused therapy Compared with a fatigue information leaflet, the effects of CBT on fatigue are very uncertain (Inflammatory Bowel Disease-Fatigue (IBD-F) section I: MD -2.16, 95% CI -6.13 to 1.81; IBD-F section II: MD -21.62, 95% CI -45.02 to 1.78; 1 RCT, 18 participants, very low-certainty evidence). The efficacy of solution-focused therapy on fatigue is also very uncertain, because standard summary data were not reported (1 RCT, 98 participants). Physical activity advice One 2 x 2 factorial trial (45 participants) found physical activity advice may reduce fatigue but the evidence is very uncertain. At week 12, compared to a control group receiving no physical activity advice plus omega 3 capsules, FACIT-F scores were higher (better) in the physical activity advice plus omega 3 group (FACIT-F MD 6.40, 95% CI -1.80 to 14.60, very low-certainty evidence) and the physical activity advice plus placebo group (FACIT-F MD 9.00, 95% CI 1.64 to 16.36, very low-certainty evidence). Adverse events were predominantly gastrointestinal and similar across physical activity groups, although more adverse events were reported in the no physical activity advice plus omega 3 group. Pharmacological interventions Compared with placebo, adalimumab 40 mg, administered every other week ('eow') (only for those known to respond to adalimumab induction therapy), may reduce fatigue in patients with moderately-to-severely active Crohn's disease, but the evidence is very uncertain (FACIT-F MD 4.30, 95% CI 1.75 to 6.85; very low-certainty evidence). The adalimumab 40 mg eow group was less likely to experience serious adverse events (OR 0.56, 95% CI 0.33 to 0.96; 521 participants; moderate-certainty evidence) and withdrawal due to adverse events (OR 0.48, 95%CI 0.26 to 0.87; 521 participants; moderate-certainty evidence). Ferric maltol may result in a slight increase in fatigue, with better SF-36 vitality scores reported in the placebo group compared to the treatment group following 12 weeks of treatment (MD -9.31, 95% CI -17.15 to -1.47; 118 participants; low-certainty evidence). There may be little or no difference in adverse events (OR 0.55, 95% CI 0.26 to 1.18; 120 participants; low-certainty evidence) AUTHORS' CONCLUSIONS: The effects of interventions for the management of fatigue in IBD are uncertain. No firm conclusions regarding the efficacy and safety of interventions can be drawn. Further high-quality studies, with a larger number of participants, are required to assess the potential benefits and harms of therapies. Future studies should assess interventions specifically designed for fatigue management, targeted at selected IBD populations, and measure fatigue as the primary outcome.

Fatigue, Physical Activity, and Mental Health in People Living With Inflammatory Bowel Disease, Fibromyalgia, and in Healthy Controls: A Comparative Cross-Sectional Survey

This study aimed to identify biopsychosocial factors associated with fatigue, physical activity, and perceived benefits of and barriers to exercise in adults with inflammatory bowel disease and to compare them with those with fibromyalgia and healthy controls. A cross-sectional online survey was conducted. Hierarchical linear regressions were used to examine correlates of fatigue and physical activity. Analysis of variance and Kruskal-Wallis tests were used to compare levels of fatigue and physical activity between the groups. Overall, 387 participants completed the study (inflammatory bowel disease: n = 232; fibromyalgia: n = 102; healthy controls: n = 53). Significant correlates of fatigue included pain catastrophizing (p = .006), sleep quality (p = .003), and depressive symptoms (p < .001). Perceived barriers to exercise were associated with depressive symptoms (p = .003). Correlates of perceived benefits of exercise included anxiety (p = .036), depressive symptoms (p = .014), coping (positive reframing) (p = .018), and social support (from family) (p = .033). The fibromyalgia group had the greatest fatigue interference and the lowest score for physical activity, followed by the inflammatory bowel disease group and healthy controls (p < .05). Given the interplay between depressive symptoms, fatigue, and benefits/barriers to exercise, there is a need for more psychological interventions to be developed and tested in order to reduce fatigue and increase physical activity to better manage disease-related outcomes.

Interrogating the Gut-Brain Axis in the Context of Inflammatory Bowel Disease: A Translational Approach

This review examines preclinical and clinical studies relevant to our understanding of how the bidirectional gut-brain axis influences the natural history of inflammatory bowel disease. Preclinical studies provide proof of concept that preexisting behavioral illness, such as depression, results in increased susceptibility to inflammatory stimuli and that commonly used classes of antidepressants protect against this vulnerability. However, clinical studies suggesting behavioral illness as a risk factor for IBD and a protective role for antidepressants have relied primarily on symptom-reporting rather than objective measurements of inflammation. In terms of gut-to-brain signaling, there is emerging evidence from preclinical and clinical observation that intestinal inflammation alters brain functions, including the induction of mood disorders, alteration of circadian rhythm both centrally and peripherally, and changes in appetitive behaviors. Furthermore, preclinical studies suggest that effective treatment of intestinal inflammation improves associated behavioral impairment. Taken together, the findings of this review encourage a holistic approach to the management of patients with IBD, accommodating lifestyle issues that include the avoidance of sleep deprivation, optimized nutrition, and the monitoring and appropriate management of behavioral disorders. The review also acknowledges the need for better-designed clinical studies evaluating the impact of behavioral disorders and their treatments on the natural history of IBD, utilizing hard end points to assess changes in the inflammatory process as opposed to reliance on symptom-based assessments. The findings of the review also encourage a better understanding of changes in brain function and circadian rhythm induced by intestinal inflammation.

A Prospective Pilot Randomized Study: Electroacupuncture vs. Sham Procedure for the Treatment of Fatigue in Patients With Quiescent Inflammatory Bowel Disease

BACKGROUND

Fatigue is a common symptom in patients with inflammatory bowel disease (IBD), and it often persists despite clinical remission. Acupuncture has been shown to be effective for treating fatigue in patients with many chronic diseases. The main objective of the study was to assess the efficacy of electroacupuncture (EAc), compared with sham EAc (ShEAc) or being on a waitlist (WL), for treating fatigue in patients with quiescent IBD in a single-blind randomized trial.

METHODS

Fifty-two patients with IBD in clinical remission and fatigue were randomly assigned to 1 of 3 groups: EAc, ShEAc, or WL. Patients in the EAc and ShEAc groups received 9 sessions over 8 weeks. Fatigue was evaluated with the IBD-validated Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-FS).

RESULTS

Baseline characteristics were similar in the 3 groups. Both EAc and ShEAc presented improved Functional Assessment of Chronic Illness Therapy-Fatigue Scale scores compared with baseline: the respective improvements were 9.53 (95% confidence intervals, 6.75-12.3, P < 0.001) and 5.46 points (95% confidence intervals, 2.7-9.7, P = 0.015), respectively. No significant changes were observed in the WL group. In the comparison of treatment groups, EAc was nonsignificantly better than ShEAc (EAc, 33.27 and ShEAc, 28.13, P = 0.168); both EAc and ShEAc improved fatigue scores significantly compared to WL (24.5; P = 0.01 and 0.04, respectively).

CONCLUSIONS

Both EAc and ShEAc reduced fatigue scores in IBD patients when compared to WL. No differences were observed between EAc and ShEAc, although the study was not powered to rule out a difference. Acupuncture may offer improvements to patients with few other treatment alternatives. Clinical Trials Org Id: NCT02733276.

Influence Of Narrative Medicine-Based Health Education Combined With An Online Patient Mutual Assistance Group On The Health Of Patients With Inflammatory Bowel Disease and Arthritis

Background

Inflammatory bowel disease arthritis (IBDA) threatens patients' physical and mental health. Therefore, patients need not only physical therapy, but also adequate health education and psychological support. This study was designed to explore the effect of health education based on narrative medicine combined with an online patient mutual assistance group that was based on the physical and mental health of patients with IBDA.

Methods

A total of 120 patients with IBDA were randomly divided into four groups (30 patients per group). Patients in the control group were given routine health education on the premise of routine treatment. The three treatment groups were given health education based on narrative medicine, online patient mutual assistance group intervention, or combined intervention. Depression, sleep, arthralgia, irritable bowel syndrome (IBS) symptoms, and inflammatory factors were measured and compared before and 1 month after the intervention.

Results

Before the intervention, no significant differences were observed in baseline data between the four groups. However, after the intervention, the physical and mental health of patients who received health education based on narrative medicine or online patient mutual assistance groups was improved. Our data showed that patients in the combined intervention group experienced a better outcome.

Conclusion

Narrative medicine-based health education combined with an online patient mutual assistance group is beneficial to the physical and mental health of IBDA patients. Taken together, this model needs to be further deepened and popularized in clinical practice.

Self-reported sleep disturbance in Crohn's disease is not confirmed by objective sleep measures

Sleep disturbance and fatigue are commonly reported among patients with Crohn’s disease (CD). In this prospective study, we aimed to define sleep quality in CD patients at various disease activity states and compare to healthy controls using objective and subjective measures. A prospective observational cohort study of CD patients seen at a tertiary academic inflammatory bowel diseases (IBD) clinic was compared to healthy volunteers. CD activity was assessed using the Harvey-Bradshaw Index (HBI). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) and objectively over 1-week using actigraphy (motion-based) and morning urinary melatonin metabolite. 121 subjects (CD patients N = 61; controls N = 60) completed the study. 34 had active CD (HBI > 4). Sleep disturbance was more frequently reported by CD subjects than controls (PSQI: 57% vs. 35%, p = 0.02) and in patients with active CD versus in remission state (PSQI 75.8% vs. 33.3%, p < 0.01; ESS: 45.5% vs. 19%, p = 0.03). Sleep parameters as measured by actigraphy and urine melatonin metabolite did not vary by group. Crohn’s patients report significantly more disturbed sleep than controls. However, poor sleep was not confirmed by objective measures of sleep quality. Excessive daytime sleepiness in CD patients may be driven by factors beyond objectively measured poor sleep.

Sleep and Fatigue in IBD: an Unrecognized but Important Extra-intestinal Manifestation

PURPOSE OF REVIEW

The bidirectional relationship between sleep disorders and inflammatory bowel disease (IBD) has gained considerable attention in recent years. It has been suggested that poor sleep and fatigue are extra-intestinal manifestations of IBD. This review reports recent studies exploring subjective and objective assessments of sleep in the adult IBD population.

RECENT FINDINGS

In ulcerative colitis patients, poor sleep has been independently linked to depression and poorer IBD-related quality of life. Using home polysomnography, IBD patients were shown to have less rapid eye movement sleep and Crohn's patient had increased lighter sleep. A study utilizing surveys assessing circadian rhythms described circadian misalignment in IBD patients and reported that circadian misalignment in Crohn's disease was associated with a more aggressive disease phenotype. The use of biologics may improve sleep disturbances in patients with IBD. Translational and clinical studies have reported that disturbances in sleep quality are linked to intestinal inflammation and a heighted systemic immune response. IBD patients appear to have disturbed sleep. Poor sleep is also suggested as a marker for subclinical disease activity. Recent studies have suggested circadian misalignment in IBD patients, and future studies are needed to assess these clinical implications.

Gastrointestinal Symptoms of and Psychosocial Changes in Inflammatory Bowel Disease: A Nursing-Led Cross-Sectional Study of Patients in Clinical Remission

Background and Objectives: Nursing management in Inflammatory Bowel Disease (IBD) is focused on global patient care. Starting from basic knowledge of diagnostic and therapeutic management, nurses can assess the impact of IBD on patients’ quality of life not only at the physical level, but also at the psychological, social, and emotional levels. The aim of this study was to evaluate the impact of gastrointestinal symptoms on psychosocial changes in IBD patients in remission through nursing-led Patient-Reported Outcomes. Materials and Methods: We performed a cross-sectional study of 109 IBD patients in clinical and endoscopic remission. Specialist nurses invited patients to complete questionnaires on gastrointestinal symptoms and quality of life through the Patient-Reported Outcomes Measurement Information System (PROMIS). Results: We found that the gastrointestinal symptoms that the patients reported had a significant impact on the analyzed aspects of health. More specifically, belly pain, diarrhea, and bloating were associated with depressive symptoms (p < 0.001), anxiety (p < 0.001), fatigue (p < 0.001), and sleep disturbances (p < 0.001). Moreover, these symptoms also significantly affected patients’ social dimension in terms of satisfaction with participation in social roles (p < 0.001, p < 0.05, and p < 0.001 for belly pain, diarrhea, and bloating, respectively) and physical functions (p < 0.001). The results were virtually the same in a multivariable analysis adjusted by age, gender, body mass index (BMI), and disease duration. Conclusions: Even during remission, gastrointestinal symptoms are the main factors that influence quality of life in IBD patients. This exploratory study highlights the need to adopt validated questionnaires in clinical practice, and demonstrates that PROMIS is a valid, objective, and standardized instrument that can help nursing staff to better define the consequences of the disease in a patient’s daily life.

Sleep Characteristics and Influencing Factors of Sleep Quality in Patients With Inflammatory Bowel Disease-Peripheral Arthritis

Background: Patients with inflammatory bowel disease-peripheral arthritis (IBD-PA) often accompany by sleep problems, but few studies have used polysomnography to investigate the objective sleep characteristics of IBD-PA.

Methods: Patients in IBD-PA group, inflammatory bowel disease (IBD) group, healthy control (HC) group were examined by polysomnography (PSG) and the sleep characteristics were compared. PSG and Pittsburgh Sleep Quality Scale (PSQI) indices were compared between active and remission IBD-PA patients. The correlation between disease activity and sleep quality in IBD-PA patients was analyzed. The influencing factors of sleep efficiency of IBD-PA patients were analyzed.

Results: The total sleep time (TST), rapid-eye-movement sleep (REM) time, slow wave sleep (S3 + S4) and sleep efficiency (SE) in the IBD-PA group were significantly less than those in the HC group and IBD group (P < 0.05), while the number and time of wake after sleep onset (WASO) and sleep latency (SL) were significantly longer than those in the HC group and IBD group (P < 0.05). To IBD-PA patients, the disease activity was negatively related to sleep quality. There was a significant difference in SE, the number of WASO, S1, S3+S4 of PSG, as well as the PSQI total score between active and remission patients. Abdominal pain, joint pain, depression, and C-reactive protein were the influencing factors of sleep efficiency.

Conclusions: The sleep quality of patients with IBD was poor than the control group, and that of patients with IBD-PA was even worse. Therefore, sleep management should be included in IBD management.

The Impact of Spondyloarthritis and Joint Symptoms on Health-Related Quality of Life and Fatigue in IBD Patients. Results From a Population-Based Inception Cohort (20-Year Follow-up in the Ibsen Study)

BACKGROUND

Patients with inflammatory bowel disease (IBD) often suffer from musculoskeletal manifestations. Health-related quality of life (HRQoL) and fatigue are known to be associated with IBD activity and musculoskeletal complaints. The aim of this study was to determine the association between spondyloarthritis, arthralgia, or back pain and the patient-reported outcomes of HRQoL and fatigue in IBD patients 20 years after their diagnosis.

METHODS

The IBSEN cohort was followed prospectively for 20 years. At the 20-year follow-up, the patients answered detailed questionnaires regarding rheumatological manifestations, intestinal symptoms, HRQoL, and fatigue. Multiple regression analyses were used to evaluate associations between spondyloarthritis or joint symptoms and HRQoL or fatigue. Sex, IBD diagnosis, and age were included in all the multiple regression models, in addition to other clinically relevant confounders.

RESULTS

In total, 441 patients (94%) completed the questionnaires at the 20-year follow-up. The criteria for spondyloarthritis (axial or peripheral) were fulfilled in 158 patients (36%), current back pain during the previous 3 months was reported by 79 patients (18%), and current arthralgia was reported by 178 patients (40%). Current back pain and arthralgia were independently associated with lower HRQoL, higher levels of fatigue, and chronic fatigue. A diagnosis of spondyloarthritis was not associated with reduced HRQoL or fatigue when adjusted for possible confounders.

CONCLUSIONS

Current joint symptoms in IBD patients 20 years after diagnosis were associated with poorer HRQoL, higher levels of fatigue, and chronic fatigue, whereas spondyloarthritis did not impact HRQoL or fatigue negatively in this cohort.

Fatigue in Inflammatory Bowel Diseases: Etiologies and Management

Fatigue is a burdensome, multidimensional, and multifactorial symptom that is associated with a wide array of chronic illnesses, specifically occurring in nearly 50% of patients with inflammatory bowel disease (IBD). Although common, given its subjective nature, physicians often under-recognize and undertreat this debilitating symptom. There are multiple etiologies that can contribute to fatigue in patients with IBD, including disease activity, anemia, medications, psychosomatic symptoms, and alterations to the gut–brain axis. The management of fatigue in IBD can be challenging, as it is often times multifaceted. In this review, we summarize the available tools for the diagnosis and measurement of fatigue, discuss etiologies, and make recommendations for their management. We identify knowledge gaps for the workup and treatment of fatigue and propose an algorithm to aid physicians in the evaluation and management of fatigue in this unique population. However, future research is needed to address several areas of knowledge deficits and improve the management of fatigue in IBD.

Risk Factors for Ulcerative Colitis in Shahrekord, Iran: A Case-Control Study

Background and aims: Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) which involves the rectum and colonic mucosa, and is often constantly expanding. Few data are available on risk factors in Chaharmahal and Bakhtiari province. Therefore, the aim of this study was to investigate the association between potential risk factors and UC in Shahrekord. Methods: A case-control study was conducted on patients diagnosed with UC. Overall, 27 new cases of UC and 54 healthy controls in the age range of 20–80 years were studied. Participants were recruited from Pathologic Centers in Shahrekord in 2018. Chi-square test and t test and were used. Logistic regression model was employed to analyze the association between risk factors and UC disease. Results: The mean age at diagnosis was 41.74 years (SD: 7.16 years) and 44.94 years (SD: 6.67 years) for case and control subjects, respectively. Moreover, univariate and multiple odds ratio (OR) showed that there was no significant association between UC and any of the risk factors including gender, marital status, education, diastolic blood pressure, history of diabetes, history of hypertension, permanent use of piped water, night shift work, history of thyroid diseases, depression, history of fatty liver disease, history of kidney stones, and sleep time and wake-up time in the morning. Conclusion: Generally, no significant association was observed between UC and the variables in the present study. Thus, further studies with larger sample size are necessary to better understand the other risk factors and environmental determinants of UC.

The relationship between the symptom of fatigue and the functioning of patients with inflammatory bowel diseases after surgery

INTRODUCTION

The occurrence of fatigue in patients suffering from inflammatory bowel diseases (IBD) is influenced by pain, frequent bowel movements, stress associated with symptoms and time of their occurrence reaction of surroundings, fear for their own health, sleep disturbances, side effects of pharmacological treatment, physical and mental exhaustion, hindered social contacts and difficulties at work.

AIM

To evaluate the fatigue and the assessment of functioning of patients with IBD, who were treated surgically.

MATERIAL AND METHODS

To evaluate the functioning of patients, a Polish version of the Inflammatory Bowel Disease Questionnaire was used. To evaluate the occurrence of fatigue in studied subjects, a Polish version of the Functional Assessment of Chronic Illness Therapy - Fatigue Scale was used. The activity of disease was evaluated with the use of the Crohn's Disease Activity Index for patients with Crohn's disease (CD) and the Clinical Activity Index for patients with ulcerative colitis (UC).

RESULTS

Before surgery, there was no significant difference between CD and UC patients, with regard to the mean FACIT-F (28.76 for CD and 28.76 for UC, p = 0.72). Also, after surgery, there was no significant difference between CD and UC patients, with regard to the mean FACIT-F (14.8 for CD and 16.0 for UC, p = 0.71). The IBD patients who underwent surgery for CD and UC had significantly lower FACIT-F scores compared to the patients before the surgery (p = 0.001 and p = 0.0001, respectively). IBD patients who underwent surgery for CD and UC had significantly better functioning and higher IBDQ total scores compared to the patients before the surgery.

CONCLUSIONS

Surgical treatment significantly reduces the fatigue symptom in patients with IBD. The severity of fatigue correlates with disease activity and functioning in the respective areas.

Cognitive-behavioural therapy for the management of inflammatory bowel disease-fatigue: a feasibility randomised controlled trial

Background

Fatigue is the third most prevalent symptom for patients with inflammatory bowel disease (IBD), yet optimal strategies for its management are unclear. Treatment protocols for fatigue in other conditions have been based on cognitive-behavioural models. Targeting cognitions, emotions and behaviour related to fatigue through cognitive-behavioural therapy (CBT) may be a viable option to improve fatigue and quality of life (QoL) in IBD.

Methods

This single centre, two-arm, feasibility randomised controlled trial (RCT) aimed to assess the feasibility and initial estimates of potential efficacy of a CBT intervention for the management of IBD-fatigue. Feasibility, acceptability and initial estimates of potential efficacy outcomes were collected through self-report measures and semi-structured interviews. Participants were recruited from one tertiary referral centre. Intervention Group 1 received a CBT manual for fatigue, one 60-min and seven 30-min telephone sessions with a therapist over 8-weeks. Control Group 2 received a fatigue information sheet without therapist support. A nested qualitative study evaluated patients’ and therapists’ experiences, and IBD-healthcare professionals’ (HCPs) perceptions of the intervention.

Results

Eighty-nine participants were assessed for eligibility. Of these, 31 of the 70 eligible participants consented to participate (recruitment rate of 44%). Of the 15 participants randomised to the intervention group, 13 (87%) started it and 10 (77% of those who started) completed all 8 sessions. Follow-up questionnaires were completed by 22 (71%) participants at 3 months, 14 (45%) at 6 months and 12 (39%) at 12 months’ follow-up. The intervention was acceptable to participants and feasible for therapists to deliver. HCPs reported that the intervention would be applicable, but time, finance and training constraints limit its implementation. Initial estimates of potential efficacy with complete case analysis showed a reduction in fatigue and an increase in QoL at 3, 6 and 12 months post-randomisation.

Conclusions

A full-scale effectiveness RCT testing CBT for IBD-fatigue is feasible and is potentially worthwhile with some changes to the protocol. However, given the small numbers, further pilot work is warranted before a full-scale RCT.

Trial registration

Registration Trial ISRCTN 17917944, Registered 2 September 2016

Sleep Disturbances in the Elderly Patient with Inflammatory Bowel Disease

PURPOSE OF REVIEW

Studies have suggested that sleep and inflammatory bowel disease (IBD) appear to have an important bi-directional relationship, where active disease promotes sleep disruption and poor sleep promotes ongoing and worsening inflammation. In the geriatric population, poor sleep has been linked to increasing morbidity and mortality. The etiologies of poor sleep in the elderly are multifactorial and are understood to be a part of the geriatric syndromes, conditions in the elderly associated with poorer mortality and morbidity. We review the current literature regarding the common sources of sleep disturbances in the geriatric population and, by extension, the growing population of elderly patients with IBD.

RECENT FINDINGS

There is a high prevalence of sleep dysfunction in patients with inflammatory bowel disease, not only in patients in disease remission but also in patients with active disease. Poor sleep has been suggested a potential marker of ongoing subclinical inflammation, and sleep disturbances are linked to poorer outcomes in patients with IBD. Management of inflammation appears to improve fatigue symptoms but is not linked with the elimination of symptoms. Thus, alternative etiologies of poor sleep, especially in the geriatric population, include chronic medical conditions with polypharmacy, co-morbid mood disorders, and primary disorders of sleep. Sleep disturbances in the elderly patient with IBD are related to multiple etiologies. Poor sleep is linked to both worse disease-specific outcomes and higher morbidity and mortality. Coordination of care with geriatricians, mental health professionals, and sleep specialists is often required to target the appropriate cause. We provide an etiological framework in the assessment of poor sleep in the elderly patient with IBD.