Sleep disturbance and risk of active disease in patients with Crohn's disease and ulcerative colitis

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.

The relation between sleep quality, sleep quantity, and gastrointestinal problems among colorectal cancer survivors: result from the PROFILES registry

Purpose

Common residual symptoms among survivors of colorectal cancer (CRC) are sleep difficulties and gastrointestinal symptoms. Among patients with various gastrointestinal (inflammatory) diseases, sleep quality has been related to gastrointestinal symptoms. For CRC survivors, this relation is unclear; therefore, we examined the association between sleep quality and quantity with gastrointestinal symptoms among CRC survivors.

Methods

CRC survivors registered in the Netherlands Cancer Registry—Southern Region diagnosed between 2000 and 2009 received a survey on sleep quality and quantity (Pittsburgh Sleep Quality Index) and gastrointestinal symptoms (European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Colorectal 38, EORTC QLQ-CR38) in 2014 (≥ 4 years after diagnosis). Secondary cross-sectional data analyses related sleep quality and quantity separately with gastrointestinal symptoms by means of logistic regression analyses.

Results

In total, 1233 CRC survivors were included, of which 15% reported poor sleep quality. The least often reported gastrointestinal symptom was pain in the buttocks (15.1%) and most often reported was bloating (29.2%). CRC survivors with poor sleep quality were more likely to report gastrointestinal symptoms (p’s < 0.01). Survivors who slept < 6 h were more likely to report symptoms of bloating or flatulence, whereas survivors who slept 6–7 h reported more problems with indigestion.

Conclusions

Worse sleep quality and short sleep duration were associated with higher occurrence of gastrointestinal symptoms.

Implications for cancer survivors

Understanding the interplay between sleep quality and gastrointestinal symptoms and underlying mechanisms adds to better aftercare and perhaps reduction of residual gastrointestinal symptoms in CRC survivors by improving sleep quality.

The Impact of Human Herpesviruses in Clinical Practice of Inflammatory Bowel Disease in the Era of COVID-19

Human herpesviruses (HHVs): herpes simplex virus (HSV) types 1 (HSV-1) and 2 (HSV-2), varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), HHV-6, HHV-7, and HHV-8, are known to be part of a family of DNA viruses that cause several diseases in humans. In clinical practice of inflammatory bowel disease (IBD), the complication of CMV enterocolitis, which is caused by CMV reactivation under disruption of intestinal barrier function, inflammation, or strong immunosuppressive therapy, is well known to affect the prognosis of disease. However, the relationship between other HHVs and IBD remains unclear. In the transplantation field, reactivation of other viruses, such as HHV-6, could cause colitis under immunosuppressed condition. Recent research revealed that combined infection of some HHVs could be a risk factor for colectomy in patients with ulcerative colitis. This suggests that it would be important to clarify HHV behavior in the treatment for patients with IBD, especially in those under immunosuppressive therapies. Looking at the relationship with recently emerged novel coronaviruses (SARS-CoV-2), there are reports describe that SARS-CoV-2 might induce reactivation of HSV-1, EBV, VZV (herpes zoster), and HHV-6/7. If SARS-CoV-2 infection becomes common, vigilance against HHV reactivation may become more crucial. In this review, we discuss the impact of HHVs in clinical practice of inflammatory bowel diseases, especially during the SARS-CoV-2 pandemic.

Wearable Respiratory Monitoring and Feedback for Chronic Pain in Adult Survivors of Childhood Cancer: A Feasibility Randomized Controlled Trial From the Childhood Cancer Survivor Study

PURPOSE

Approximately 40% of childhood cancer survivors experience chronic pain, with many also reporting pain-related disability. Given associations established in the general population among respiration, anxiety, and pain, continuous tracking and feedback of respiration may help survivors manage pain.

METHODS

A feasibility, nonblinded, randomized controlled trial (RCT) comparing wearable respiratory monitoring with a control group examined feasibility, acceptability, and preliminary efficacy among survivors of childhood cancer with chronic pain who were ≥ 18 years of age, able to speak and read English, lived in the United States, and had access to a smartphone and the Internet. The primary outcomes were pain interference, pain severity, anxiety, negative affect, and perceived stress. The intervention group (n = 32) received a wearable respiratory monitor, used the device, and completed an in-application breathing exercise daily for 30 days. The control group (n = 33) received psychoeducation after completion of the study.

RESULTS

Almost all participants in the intervention group (n = 31 of 32) and control group (n = 32 of 33) completed the study. Of those who completed the intervention, 90.3% wore the device for ≥ 50% of the trial. Posttreatment improvement for negative affect (Cohen d = 0.59; 95% CI, 0.09 to 1.10) was significantly greater in the intervention group compared with the control group. A follow-up study (n = 24) examined acceptability and feasibility of a second-generation device among those who completed the RCT. Most survivors (81.0%) wore the device daily during the trial and 85.7% reported satisfaction with the device and the application.

CONCLUSION

The results of this pilot study support the acceptability and feasibility of wearable respiratory monitoring among survivors of childhood cancer. Larger randomized trials are needed to assess efficacy and maintenance of this intervention for chronic pain.

Persistent sleep disturbance after spine surgery is associated with failure to achieve meaningful improvements in pain and health-related quality of life

BACKGROUND CONTEXT

Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery.

PURPOSE

To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018.

OUTCOME MEASURES

Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery.

METHODS

Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05.

RESULTS

Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80).

CONCLUSION

One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery.

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.

Anxiety and Depressive Symptoms Are Not Associated With Future Pediatric Crohn's Disease Activity

BACKGROUND

Studies of adults with Crohn's disease (CD) suggest that poor mental health precedes worsening disease activity. We evaluated whether depression and/or anxiety forecast worsening pediatric CD disease activity.

METHODS

Through the Inflammatory Bowel Disease Partners Kids & Teens internet-based cohort, children with CD age 9 to 17 completed Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric measures and the short Crohn's disease activity index (sCDAI). Using general linear models, we examined how baseline PROMIS Pediatric anxiety and depressive symptom scores independently associate with subsequent sCDAI scores (average survey interval 6.4 months). Models included baseline PROMIS Pediatric anxiety and depressive symptoms scores, baseline sCDAI, sex, age, parental education, race/ethnicity, and prior IBD-related surgery. We performed a post hoc subanalysis of children in baseline remission (sCDAI <150) with otherwise identical models.

RESULTS

We analyzed 159 children with CD (mean age 14 years, 45% female, 84% in baseline remission). We found no association between baseline PROMIS Pediatric anxiety score and subsequent sCDAI (change in sCDAI for 3-point change in PROMIS Pediatric -0.89; 95% CI -4.81 to 3.03). Baseline PROMIS Pediatric depressive symptoms score was not associated with future sCDAI (change in sCDAI for 3-point change in PROMIS Pediatric <0.01; 95% CI -4.54 to 4.53). In a subanalysis of patients in remission at baseline, the lack of association remained.

CONCLUSION

We found that neither anxiety nor depressive symptoms associate with subsequent disease activity in pediatric CD. These findings contrast with adult IBD studies, thus underschoring the unique pathophysiology, natural history, and outcomes of pediatric CD.

Short sleep duration and physical and psychological health outcomes among adult survivors of childhood cancer

BACKGROUND

To examine associations between phenotypes of short sleep duration and clinically assessed health conditions in long-term survivors of childhood cancer.

METHODS

Survivors recruited from the St. Jude Lifetime Cohort (n = 911; 52% female; mean age 34 years; 26 years postdiagnosis) completed behavioral health surveys and underwent comprehensive physical examinations. Sleep was assessed with the Pittsburgh Sleep Quality Index. Short sleep was defined as ≤6 h per night with phenotypes of short sleep including poor sleep efficiency (<85%), prolonged sleep onset latency (SOL; ≥30 min), and wake after sleep onset (≥3 times per week). Covariates included childhood cancer treatment exposures, demographics, body mass index, and physical inactivity. Separate modified Poisson regression models were computed for each health category to estimate relative risks (RR) and 95% confidence intervals (CI). Multinomial logistic regression models examined associations between sleep and an aggregated burden of chronic health conditions.

RESULTS

Short sleep duration was reported among 44% (95% CI 41%-47%) of survivors. In multivariable models, short sleep duration alone was associated with pulmonary (RR = 1.35, 95% CI 1.08-1.69), endocrine (RR = 1.22, 95% CI 1.06-1.39) and gastrointestinal/hepatic conditions (RR = 1.46, 95% CI 1.18-1.79), and anxiety (RR 3.24, 95% CI 1.64-6.41) and depression (RR = 2.33, 95% CI 1.27-4.27). Short sleep with prolonged SOL was associated with a high/severe burden of health conditions (OR = 2.35, 95% CI 1.12-4.94).

CONCLUSIONS

Short sleep duration was associated with multiple clinically ascertained adverse health conditions. Although the temporality of these associations cannot be determined in this cross-sectional study, sleep is modifiable and improving sleep may improve long-term health in survivors.

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.

Brain-derived neurotrophic factor is elevated in the blood serum of Crohn's disease patients, but is not influenced by anti-TNF-α treatment-A pilot study

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is associated with depression, pain, or sleep disorders, factors that are thought to be involved in the pathogenesis and clinical course of Crohn's disease (CD). Therefore, the study aimed at assessing the BDNF serum level in patients with CD and evaluates the effect of anti-TNF-α therapy on the BDNF level and its impact on sleep, mood, and pain parameters.

METHODS

Fifty-eight CD patients and 26 healthy controls (HC) were included in the study. The severity of insomnia symptoms was assessed by the Athens Insomnia Scale (AIS). Subjective pain intensity was estimated by the Visual Analogue Scale (VAS) and Laitinen Pain Scale. Mood level was measured using the Beck Depression Inventory (BDI). Seventeen patients were treated with anti-TNF-α therapy for 14 weeks and were re-examined after treatment.

KEY RESULTS

CD patients had a higher serum BDNF level than HC (P = .010). No correlation between clinical severity and BDNF was found. There were positive correlations between the BDNF level and the results of AIS (r = 0.253, P = .020), the severity of pain measured using the VAS (r = 0.251, P = .021) and the Laitinen Pain Scale (r = 0.218, P = .047), but not BDI. No differences were observed in the BDNF level before and after 14 weeks of anti-TNF-α therapy.

CONCLUSIONS AND INFERENCES

Increased BDNF level in CD patients suggests that it may be involved in the pathogenesis and clinical course of the disease. Further research into BDNF might contribute to a better understanding of the effects of sleep and pain on the course of CD.

Environmental factors associated with biological use and surgery in inflammatory bowel disease

BACKGROUND AND AIM

While major efforts were made studying the complex etiology of inflammatory bowel disease (IBD) including environmental factors, less is known about underlying causes leading to the heterogeneous and highly variable course of disease. As cigarette smoking cessation is the best-known environmental factor with beneficial effect in Crohn's disease (CD), more exposome factors are likely involved. Further insights into the role of the exposome in heterogeneity of disease might not only further knowledge of underlying pathways, but also allow for better risk stratification.

METHODS

Seven hundred twenty-eight IBD patients completed the validated Groningen IBD Environmental Questionnaire, collecting exposome data for 93 exposome factors. Associations with disease course, that is, for need for surgery or biological therapy, were evaluated using univariate and multivariate-adjusted logistic regression modeling.

RESULTS

No significant associations were seen after Bonferroni correction. However, 11 novel exposome factors were identified with P < 0.05. Two factors were associated with course of CD and ulcerative colitis (UC): beer (CD OR0.3/UC OR0.3) and cannabis (0.5/2.2). While in CD, carpet flooring (0.5) was associated with biological use, and four factors were associated with surgery: working shifts (1.8), appendectomy (2.4), frequent tooth brushing (2.8), and large household size (0.1). For UC, migrants more often required biologicals (10.2). Childhood underweight (3.4), amphetamine use (6.2), and cocaine use (4.8) were associated with surgery. Five factors were replicated.

CONCLUSIONS

We identified 16 environmental factors nominally associated with biological use and surgery in established IBD. These new insights form an important stepping stone to guide research on biological pathways involved, risk stratification, tailor-made interventions, and preventive strategies in IBD.

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.

Disparities in Objective Sleep Quality as Assessed Through Wrist Actigraphy in Minority Patients With Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with a reduced quality of life. Minority patients with IBD specifically report more impairing symptoms compared with nonminority patients. Sleep quality, a key component of quality of life, is significantly compromised in minority patients compared with nonminority patients. Nevertheless, subjective and objective sleep assessments in minority patients with IBD have not explicitly been assessed. The purpose of this prospective cohort study is to assess and compare objective sleep parameters utilizing wrist actigraphy between minority and nonminority IBD patients.

METHODS

In this institutional review board approved study, 74 patients with IBD were recruited and stratified into 2 cohorts by self-identification: white nonminority patients and minority patients. Patients in the minority cohort included black and Hispanic individuals (black and nonblack). Exclusion criteria included significant comorbidity, a history of an underlying sleep disorder, or patients who did not self-identify into categorized cohorts. Sleep was measured not only through wrist-based actigraphy but also with sleep surveys. Sleep parameters were compared between minority and nonminority cohorts. Regression analyses were performed to assess for factors independently associated with parameters of poor sleep quality.

RESULTS

Sixty-four patients (86.4%) were included in the final analysis. Thirty-one individuals (48.4%) were categorized into the nonminority cohort, and 33 (51.6%) patients were in the minority cohort. A significantly higher number of minority patients had poorer sleep efficiency and fragmented sleep compared with nonminority patients (90.9% vs 67.7%; P = 0.03 and 87.8% vs 61.3%; P = 0.02). In the adjusted analysis, minority status was independently associated with poor sleep efficiency (odds ratio = 6.41; 95% confidence interval, 1.48-28.17; P = 0.0139) and fragmented sleep (odds ratio = 4.98; 95% confidence interval, 1.09-22.89; P = 0.0389).

CONCLUSIONS

Minority patients with IBD were shown to have poorer objective measures of sleep as assessed through wrist actigraphy compared to nonminority patients. Cultural competency in the care of minority patients with IBD, specifically focusing on the management of psychosocial issues, is needed to address these disparities in sleep. The inclusion of minority patients with IBD in studies investigating sleep and other psychosocial issues are warranted not only to assess potential disparities in disease course but also to determine the etiologies of poor sleep in minority patients with IBD.

Sleep Disturbance in Inflammatory Bowel Disease Is Associated with Disease Activity and Adverse Outcome

BACKGROUND

There is growing evidence about the relationship between sleep quality (SQ) and disease activity in inflammatory bowel disease (IBD). This study aimed to identify the prevalence of sleep disturbance in IBD and its predictive factors and to assess its association with worse outcome.

METHODS

IBD patients were prospectively enrolled. Clinical activity, inflammatory activity (high C-reactive protein or fecal calprotectin), and SQ (assessed using the Pittsburgh Sleep Quality Index) were evaluated, and logistic regression was used to identify predictors of poor SQ at baseline. The development of disability or disease progression at 6 months (surgery, hospitalization, development of stenosis, penetrating or perianal disease, steroid dependency, or start/change immunosuppression) was compared between patients with and without poor SQ.

RESULTS

Two hundred and five patients were enrolled, with 44.9% (n = 92) reporting poor SQ. On multivariate analysis, current smoking (OR 2.80), extraintestinal manifestations (OR 2.68), clinical activity (OR 3.31), and inflammatory activity (OR 4.62) were predictive factors of poor SQ. Cox proportional hazards model showed that poor SQ was predictive of worse prognosis at 6 months (HR 2.470).

CONCLUSION

There is a high prevalence of poor SQ in IBD patients, highlighting the importance of its inclusion in patient-reported outcomes. Sleep disturbance seems to have prognostic value in IBD.

The Brain-Gut Axis: Psychological Functioning and Inflammatory Bowel Diseases

The brain-gut axis represents a complex bi-directional system comprising multiple interconnections between the neuroendocrine pathways, the autonomous nervous system and the gastrointestinal tract. Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic, relapsing-remitting inflammatory disorder of the gastrointestinal tract with a multifactorial etiology. Depression and anxiety are prevalent among patients with chronic disorders characterized by a strong immune component, such as diabetes mellitus, cancer, multiple sclerosis, rheumatoid arthritis and IBD. Although psychological problems are an important aspect of morbidity and of impaired quality of life in patients with IBD, depression and anxiety continue to be under-diagnosed. There is lack of evidence regarding the exact mechanisms by which depression, anxiety and cognitive dysfunction may occur in these patients, and whether psychological disorders are the result of disease activity or determinants of the IBD occurrence. In this comprehensive review, we summarize the role of the brain-gut axis in the psychological functioning of patients with IBD, and discuss current preclinical and clinical data on the topic and therapeutic strategies potentially useful for the clinical management of these patients. Personalized pathways of psychological supports are needed to improve the quality of life in patients with IBD.

Symptoms of anxiety/depression is associated with more aggressive inflammatory bowel disease

Studies have demonstrated that inflammatory bowel disease (IBD) patients are at an increased risk of developing anxiety and/or depression. IBD patients with depression/anxiety have higher rates of hospitalization and increased disease severity than those without. So far, there is a paucity of data concerning the impact of anxiety/depression on Chinese IBD patients. The aim of this study was to find out the prevalence of symptoms of anxiety/depression in Chinese IBD population and its impact on IBD-related features. This is a cross-sectional study from the southwest China IBD referral center. Eligible participants were divided into those with symptoms of anxiety/depression and those without based on the Hospital Anxiety and Depression Scale (HADS). Demographic data and disease duration, IBD-related surgery, tobacco use, extra-intestinal manifestations, disease activity scores, endoscopic evaluation, laboratory data and current medication use were compared between two groups. A total of 341 IBD patients [221 Crohn’s disease (CD) and 120 ulcerative colitis (UC)] were included. The prevalence of symptoms of anxiety/depression in IBD was 33.1%. CD patients with symptoms of anxiety/depression tended to have higher scores of simple endoscopic scores for Crohn’s disease (SES-CD) (p = 0.0005). UC patients with symptoms of anxiety/depression had a significantly higher Mayo score (p = 0.0017) and ulcerative colitis endoscopic index of severity (UCEIS) (p < 0.0001) than their non-anxiety/depression counterparts. CD-related surgery (p = 0.012) and Crohn's disease activity index (CDAI) (p < 0.0001) were identified as independent risk factors for symptoms of anxiety/depression in CD, while corticosteroid use (p = 0.036) as an independent risk factor for symptoms of anxiety/depression in UC. This study helps our understanding of the prevalence of symptoms of anxiety/depression in IBD patients and its impact on IBD course and reminds us to pay more attention on IBD management with anxiety/depression.

Disrupted Circadian Rest-Activity Cycles in Inflammatory Bowel Disease Are Associated With Aggressive Disease Phenotype, Subclinical Inflammation, and Dysbiosis

Patients with inflammatory bowel disease (IBD)-Crohn's disease (CD), and ulcerative colitis (UC), have poor sleep quality. Sleep and multiple immunologic and gastrointestinal processes in the body are orchestrated by the circadian clock, and we recently reported that a later category or chronotype of the circadian clock was associated with worse IBD specific outcomes. The goal of this study was to determine if circadian misalignment by rest-activity cycles is associated with markers of aggressive disease, subclinical inflammation, and dysbiosis in IBD. A total of 42 patients with inactive but biopsy-proven CD or UC and 10 healthy controls participated in this prospective cohort study. Subjects were defined as having an aggressive IBD disease history (steroid dependence, use of biologic or immunomodulator, and/or surgery) or non-aggressive history. All participants did two weeks of wrist actigraphy, followed by measurement of intestinal permeability and stool microbiota. Wrist actigraphy was used to calculate circadian markers of rest-activity- interdaily stability (IS), intradaily variability (IV), and relative amplitude (RA). Aggressive IBD history was associated with decrease rest-activity stability (IS) and increased fragmentation compared to non-aggressive IBD and health controls at 0.39 ±.15 vs. 0.51 ± 0.10 vs. 0.55 ± 0.09 (P < 0.05) and 0.83 ± 0.20 vs. 0.72 ± 0.14 (P < 0.05) but not HC at 0.72 ± 0.14 (P = 0.08); respectively. There was not a significant difference in RA by IBD disease history. Increased intestinal permeability and increased TNF-α levels correlated with an increased rest activity fragmentation (IV) at R = 0.35, P < 0.05 and R = 0.37, P < 0.05, respectively; and decreased rest-activity amplitude (RA) was associated with increased stool calprotectin at R = 0.40, P < 0.05. Analysis of intestinal microbiota showed a significant decrease in commensal butyrate producing taxa and increased pro-inflammatory bacteria with disrupted rest-activity cycles. In this study, different components of circadian misalignment by rest-activity cycles were associated with a more aggressive IBD disease history, increased intestinal permeability, stool calprotectin, increased pro-inflammatory cytokines, and dysbiosis. Wrist activity allows for an easy non-invasive assessment of circadian activity which may be an important biomarker of inflammation in IB.

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.

Longitudinal Trajectory of Fatigue in Patients With Inflammatory Bowel Disease: A Prospective Study

BACKGROUND

Fatigue is a disabling symptom in patients with inflammatory bowel disease (IBD). Its prevalence, mechanism, and impact remain poorly understood. We determined changes in fatigue status over time and identified predictors of incident or resolving fatigue.

METHODS

This was a prospective study nested within the IBD Partners cohort. Participants prospectively completed the Multidimensional Fatigue Inventory and the Functional Assessment of Chronic Illness Therapy-Fatigue at baseline, 6 months, and 12 months. A Functional Assessment of Chronic Illness Therapy-Fatigue score ≤43 defined significant fatigue. Multivariable regression models using baseline covariates were used to identify risk factors for incident fatigue at 6 months and to predict the resolution of fatigue.

RESULTS

A total of 2429 patients (1605 with Crohn disease, 824 with ulcerative colitis) completed a baseline assessment, and 1057 completed a second assessment at 6 months. Persistent fatigue (at baseline and at 6 months) was the most common pattern, affecting two-thirds (65.8%) of patients. One-sixth (15.7%) of patients had fatigue at 1 timepoint, whereas fewer than one-fifth (18.5%) of patients never reported fatigue. Among patients not fatigued at baseline, 26% developed fatigue at 6 months. The strongest predictor of incident fatigue was sleep disturbance at baseline (odds ratio, 2.91; 95% confidence interval, 1.48-5.72). In contrast, only 12.3% of those with fatigue at baseline had symptom resolution by month 6. Resolution was more likely in patients with a diagnosis of ulcerative colitis, quiescent disease, and an absence of significant psychological comorbidity.

CONCLUSIONS

Fatigue is common in patients with IBD. However, only a few fatigued patients experience symptom resolution at 6 or 12 months, suggesting the need for novel interventions to ameliorate its impact.

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.

Determinants of Sleep Quality in Inflammatory Bowel Diseases

The causes of disordered sleep, frequently reported by patients with inflammatory bowel diseases (IBD), are poorly understood. The study aimed to evaluate sleep quality in IBD patients and to identify factors affecting their sleep. IBD patients (n = 133) and healthy controls (HC; n = 57) were included in the study and completed sleep questionnaires (Pittsburgh Sleep Quality Index (PSQI), Athens insomnia scale (AIS), and Epworth sleepiness scale (ESS)), Beck Depression Inventory (BDI), and pain scales (Visual Analogue Scale and Laitinen Pain Scale). IBD patients attained higher scores in all sleep questionnaires compared to HC: PSQI, AIS, and ESS (all p < 0.001). They also had prolonged sleep latency (p < 0.001) with reduced sleep efficiency (p < 0.001). Patients in exacerbation of IBD had higher scores in PSQI (p = 0.008), ESS (p = 0.009), but not in AIS, compared to those in remission. Participants with comorbid chronic diseases had higher scores in PSQI and AIS, but not in ESS, compared to others. Multiple regression revealed that the sleep questionnaire results were significantly affected by mood level (BDI), but not by the aforementioned pain scales. Sleep impairment in IBD patients is a common problem that deserves attention in everyday clinical practice and mood level seems to be the main factor affecting the quality of sleep in IBD patients.

Diurnal Rhythmicity Programs of Microbiota and Transcriptional Oscillation of Circadian Regulator, NFIL3

Circadian rhythms are a very exquisite mechanism to influence on transcriptional levels and physiological activities of various molecules that affect cell metabolic pathways. Long-term alteration of circadian rhythms increases the risk of cardiovascular diseases, hypertension, hypertriglyceridemia, and metabolic syndrome. A drastic change in dietary patterns can affect synchronizing the circadian clock within the metabolic system. Therefore, the interaction between the host and the bacterial community colonizing the mammalian gastrointestinal tract has a great impact on the circadian clock in diurnal programs. Here, we propose that the microbiota regulates body composition through the transcriptional oscillation of circadian regulators. The transcriptional regulator, NFIL3 (also called E4BP4) is a good example. Compositional change of the commensal bacteria influences the rhythmic expression of NFIL3 in the epithelium, which subsequently controls obesity and insulin resistance. Therefore, control of circadian regulators would be a promising therapeutic target for metabolic diseases.

A pilot study of a mind-body stress management program for student veterans

BACKGROUND

Student veterans are an at-risk population given the challenges of military experience, reintegration to civilian life, and attending college. Therefore, there is a need for innovative programs to support student veterans. The present study sought to determine the acceptability and effectiveness of a 10-week mind-body stress reduction intervention for student veterans, or Resilient Student Warrior.

MATERIALS AND METHODS

Eighty-six student veterans took part in the 10-week mind-body stress reduction course, Resilient Student Warrior.

RESULTS

Results showed a significant improvement in reports of stress reactivity, mindfulness, sleep disturbance and coping skills for stress (p < 0.05), but not self-efficacy, perceived stress, depressive or post-traumatic stress disorder symptoms. The intervention was reported as helpful by 96% of participants, with 95% of participants stating they would recommend the course to others.

CONCLUSION

Future studies should further assess the effectiveness of mind-body interventions among the student veteran population.

Multi-"-Omics" Profiling in Patients With Quiescent Inflammatory Bowel Disease Identifies Biomarkers Predicting Relapse

BACKGROUND

Inflammatory bowel diseases (IBD) are characterized by intermittent relapses, and their course is heterogeneous and unpredictable. Our aim was to determine the ability of protein, metabolite, or microbial biomarkers to predict relapse in patients with quiescent disease.

METHODS

This prospective study enrolled patients with quiescent Crohn disease and ulcerative colitis, defined as the absence of clinical symptoms (Harvey-Bradshaw Index ≤ 4, Simple Clinical Colitis Activity Index ≤ 2) and endoscopic remission within the prior year. The primary outcome was relapse within 2 years, defined as symptomatic worsening accompanied by elevated inflammatory markers resulting in a change in therapy or IBD-related hospitalization or surgery. Biomarkers were tested in a derivation cohort, and their performance was examined in an independent validation cohort.

RESULTS

Our prospective cohort study included 164 patients with IBD (108 with Crohn disease, 56 with ulcerative colitis). Upon follow-up for a median of 1 year, 22 patients (13.4%) experienced a relapse. Three protein biomarkers (interleukin-10, glial cell line-derived neurotrophic factor, and T-cell surface glycoprotein CD8 alpha chain) and 4 metabolomic markers (propionyl-L-carnitine, carnitine, sarcosine, and sorbitol) were associated with relapse in multivariable models. Proteomic and metabolomic risk scores independently predicted relapse with a combined area under the curve of 0.83. A high proteomic risk score (odds ratio = 9.11; 95% confidence interval, 1.90-43.61) or metabolomic risk score (odds ratio = 5.79; 95% confidence interval, 1.24-27.11) independently predicted a higher risk of relapse over 2 years. Fecal metagenomics showed an increased abundance of Proteobacteria (P = 0.0019, q = 0.019) and Fusobacteria (P = 0.0040, q = 0.020) and at the species level Lachnospiraceae_bacterium_2_1_58FAA (P = 0.000008, q = 0.0009) among the relapses.

CONCLUSIONS

Proteomic, metabolomic, and microbial biomarkers identify a proinflammatory state in quiescent IBD that predisposes to clinical relapse.

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.

Do specific types of sleep disturbances represent risk factors for poorer health-related quality of life in inflammatory bowel disease? A longitudinal cohort study

OBJECTIVES

Poor global sleep quality is commonly reported in people with inflammatory bowel disease (IBD) and is linked to poorer health-related quality of life (HRQoL). However, understanding is currently limited by a lack of: (1) longitudinal research and (2) research investigating the impact of specific types of problems sleeping on IBD-related outcomes, particularly on HRQoL.

DESIGN

Observational longitudinal cohort study.

METHODS

N = 276 participants with IBD completed measures at baseline (T1) and 4 weeks later at T2. Four specific sleep disturbances associated with IBD including sleep apnoea, insomnia, restless legs, and nightmares were measured alongside depression, anxiety and stress, and HRQoL.

RESULTS

After controlling for participant demographics and clinical characteristics, T1 depression, anxiety, stress, and T1 HRQoL, more severe symptom severity of sleep apnoea (B = -0.30, p < .05) and insomnia symptoms (B = -0.23, p < .05) at T1 significantly predicted poorer HRQoL at T2. However, the experience of restless legs (B = -0.03, p > .87) and nightmares (B = -0.14, p > .11) at T1 did not predict HRQoL.

CONCLUSION

Symptoms synonymous with sleep apnoea and insomnia might represent modifiable risk factors that provide independent contributions to HRQoL over time in those with IBD. These findings suggest that interventions designed to improve sleep apnoea and insomnia could confer benefits to HRQoL in those with IBD. However, more longitudinal research is needed to understand the contribution of sleep disturbances over the longer term, as well as more randomized controlled trials testing the effect of improving sleep on IBD-related outcomes.

Pharmacodynamic and Metabolomics Studies on the Effect of Kouyanqing Granule in the Treatment of Phenol-Induced Oral Ulcer Worsened by Sleep Deprivation

Oral ulcers are the most prevalent oral mucosal diseases globally, and no specific treatment schemes are currently available due to the complexity of oral ulcer diseases. Sleep deprivation increases the risk of a deterioration in oral health. Kouyanqing Granule (KYQG) has been used for decades in China to treat inflammatory diseases of the mouth and throat associated with the hyperactivity of fire due to yin deficiency syndrome. However, the mechanisms underlying the effects of KYQG in the treatment of oral ulcers are still unclear. The aims of this study were to investigate whether KYQG treatment could attenuate the symptoms of oral ulcers worsened by sleep deprivation and identify the involved metabolic pathways. First, we conducted chemical profiling of KYQG via UPLC–MS analysis. We then combined pharmacological and metabolomics approaches in a phenol-induced rat model of oral ulcers worsened by sleep deprivation. A total of 79 compounds were initially identified. Our observations showed that KYQG treatment induced a significantly higher healing rate in oral ulcers worsened by sleep deprivation. KYQG significantly reduced the levels of 5-HT and GABA in serum, and only decreased the 5-HT level in brain tissue after phenol injury followed by sleep deprivation. Moreover, KYQG administration significantly suppressed systemic inflammation by inhibiting TNF-α, IL-1β, IL-6, IL-18, and MCP-1. Immunohistochemical analysis further revealed that KYQG inhibited IL-6 expression in buccal mucosa tissues. KYQG treatment also significantly decreased the serum levels of ACTH, CORT, IgM, and 8-OHdG. Serum metabolomics analysis showed that a total of 30 metabolites showed significant differential abundances under KYQG intervention, while metabolic pathway analysis suggested that the altered metabolites were associated with the dysregulation of eight metabolic pathways. Taken together, our results indicated that KYQG attenuates the symptoms of oral ulcers worsened by sleep deprivation probably through the regulation of the neuroimmunoendocrine system, oxidative stress levels, and tryptophan metabolism. This study also provides a novel approach for addressing the increased health risks resulting from sleep deficiency using an herbal medicine formula.

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.

Psychologic stress and disease activity in patients with inflammatory bowel disease: A multicenter cross-sectional study

Background and aims

Psychologic stress can affect the pathogenesis of inflammatory bowel disease (IBD), but the precise contribution of psychologic stress to IBD remains unclear. We investigated the association of psychologic stress with disease activity in patients with IBD, especially in terms of mental state and sleep condition.

Methods

This was a multi-center observational study comprising 20 institutions. Data were collected using survey forms for doctors and questionnaires for patients, and the association of psychologic stress with clinical parameters was investigated. Mental state was evaluated using the Center for Epidemiologic Studies Depression (CES-D) scale, and sleep condition was evaluated by querying patients about the severity of insomnia symptoms.

Results

A total of 1078 IBD patients were enrolled, including 303 patients with Crohn’s disease and 775 patients with ulcerative colitis. Seventy-five percent of IBD patients believed that psychologic stress triggered an exacerbation of their disease (PSTE group) and 25% did not (non-PSTE group). The CES-D scores were significantly higher for patients with clinically active disease than for those in remission in the PSTE group (median (interquartile range) = 7 (4–9.5) vs. 5 (3–7), p < .0001), but not in the non-PSTE group (5 (2–8) vs. 4 (3–7), p = 0.78). Female sex and disease exacerbation by factors other than psychologic stress were independent factors of psychologic stress-triggered disease exacerbation. Also, patients with insomnia had higher disease activity than those without insomnia, especially in the PSTE group.

Conclusions

A worsened mental state correlates with disease activity in IBD patients, especially those who believe that their disease is exacerbated by psychologic stress.

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.

Revisiting Inflammatory Bowel Disease: Pathology, Treatments, Challenges and Emerging Therapeutics Including Drug Leads from Natural Products

Inflammatory bowel disease (IBD) is a chronic and life-long disease characterized by gastrointestinal tract inflammation. It is caused by the interplay of the host's genetic predisposition and immune responses, and various environmental factors. Despite many treatment options, there is no cure for IBD. The increasing incidence and prevalence of IBD and lack of effective long-term treatment options have resulted in a substantial economic burden to the healthcare system worldwide. Biologics targeting inflammatory cytokines initiated a shift from symptomatic control towards objective treatment goals such as mucosal healing. There are seven monoclonal antibody therapies excluding their biosimilars approved by the US Food and Drug Administration for induction and maintenance of clinical remission in IBD. Adverse side effects associated with almost all currently available drugs, especially biologics, is the main challenge in IBD management. Natural products have significant potential as therapeutic agents with an increasing role in health care. Given that natural products display great structural diversity and are relatively easy to modify chemically, they represent ideal scaffolds upon which to generate novel therapeutics. This review focuses on the pathology, currently available treatment options for IBD and associated challenges, and the roles played by natural products in health care. It discusses these natural products within the current biodiscovery research agenda, including the applications of drug discovery techniques and the search for next-generation drugs to treat a plethora of inflammatory diseases, with a major focus on IBD.

Antidepressants in inflammatory bowel disease

Gut-brain dysregulation has been recognized by the scientific community as being crucial to the understanding of chronic gastrointestinal conditions, and this has translated into the practice of a newly established discipline, psychogastroenterology. Along with psychotherapy, antidepressants (a subtype of central neuromodulators) have been proposed as treatments for gut-brain disorders that might benefit both psychological and gastrointestinal health. Antidepressants have been found to be effective for the treatment of comorbid anxiety and depression, pain and impaired sleep. Although the efficacy of antidepressants is well established in disorders of gut-brain interaction (DGBI), evidence is only now emerging in IBD. This Perspective discusses the use of antidepressants in DGBI and IBD, focusing on how what we have learnt about the role of antidepressants in DGBI could be applied to help optimize the management of IBD.

Circadian rhythm abnormalities in patients with inflammatory bowel disease - association with adipokine profile

Background: The role of sleep disturbances in patients with inflammatory bowel disease (IBD) remained relatively unknown. The aim of this study was to identify the adipokine profile in the patients with IBD and its relationship with the circadian rhythm disorders.Methods: Prospective, observational cohort study was performed. In all the enrolled adult IBD patients, the disease activity was assessed by using Crohn's Disease Activity Index (CDAI) for Crohn's disease (CD) and Partial Mayo Score for ulcerative colitis (UC), respectively. All patients were also asked to respond to a questionnaire to define Pittsburgh Quality Sleep Index (PSQI). From all the enrolled patients, 15 mL venous blood was taken to determine adipokine levels and perform standard laboratory tests.Results: Sixty-five IBD patients were enrolled in our study: 30 with CD and 35 with UC. Poor sleep was noted in 69.2% patients with clinically active and in 7.7% patients with inactive disease (p = .0023). In the group of IBD patients with poor sleep, the significantly higher level of serum resistin (p = .0458), and lower level of serum adiponectin and leptin (p = .0215, p = .0201; respectively) were observed. In the IBD patients with exacerbation, the significantly higher level of serum resistin (p = .0396), significantly lower serum level of leptin (p = .0453) and tendency to lower serum level of adiponectin (p = .1214) were recorded.Conclusions: The relationship between circadian rhythm abnormalities and specific adipokine profile may show us a risk factor of developing inflammatory intestinal lesions in IBD patients. This knowledge may allow the treatment of sleep disturbances, body weight-control and dietary habits become new targets in IBD therapy.

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.

Sleep disturbance in Inflammatory Bowel Disease: prevalence and risk factors - A cross-sectional study

Inflammatory bowel diseases (IBD) are chronic relapsing disorders that have a negative impact on quality of life. They can be highly disabling and have been associated with sleep disturbance. The aim of our study was to evaluate the sleep quality of a large cohort of IBD patients to identify possible associated cofactors. We prospectively recruited consecutive patients attending the IBD Unit of "Azienda Ospedaliera" of Padua from November 2018 to May 2019 and collected demographics and clinical characteristics. The patients completed the Pittsburgh Sleep Quality Index (PSQI), the IBD questionnaire (IBDQ), the IBD-Disability Index (IBD-DI) questionnaire, and the Hospital Anxiety and Depression Scale (9-HADS). A multivariate regression model was applied to assess independent risk factors of sleep disturbance among IBD-related variables, disability, quality of life, anxiety, and depression. We investigated the sleep quality of 166 patients with IBD, finding 67.5% of them suffering from sleep disturbance. In particular, low quality of life, presence of disability and extraintestinal manifestations were identified as independent risk factors of sleep disturbance. We discovered that all depressed patients were also affected by sleep disturbance, while we found no difference in sleep disturbance between patients with or without anxiety state. However, a positive correlation was reported between both anxiety and depression scores and PSQI score (Spearman correlation: r = 0.31 and r = 0.38 respectively). Our study showed that sleep quality is not directly associated with an active or inactive IBD state or with the ongoing treatment, but it is mostly correlated with the patients' mood state, disability, and quality of life. Gastroenterologists and psychologists should join forces during clinical outpatients' visits to evaluate emotional states for a better IBD management.

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.

Clock Gene Disruption Is an Initial Manifestation of Inflammatory Bowel Diseases

BACKGROUND & AIMS

Sleep disruption modifies the immune system and can trigger flares of inflammatory bowel diseases (IBD). Changes in expression of clock genes have been reported in patients with IBD. We investigated whether a change in the circadian clock is an early event in development of IBD.

METHODS

We performed a prospective study of patients younger than 21 years old who underwent diagnostic endoscopies at the pediatric and adult gastroenterology units at the Tel Aviv Sourasky Medical Center from August 2016 through August 2017. Questionnaires were completed by 32 patients with IBD (8-21 years old) and 18 healthy individuals (controls) that provided data on demographics, sleep, disease activity scores. We also obtained data on endoscopic scores, anthropometric parameters, blood level of C-reactive protein (CRP), and fecal level of calprotectin. Peripheral blood and intestinal mucosa samples were analyzed for expression levels of clock gene (CLOCK, BMAL1, CRY1, CRY2, PER1, and PER2).

RESULTS

Levels of CRP and fecal calprotectin were significantly higher in patients with IBD compared with controls (P<.05). Expression levels of clock genes (CLOCK, CRY1, CRY2, PER1, and PER2) were significantly lower in inflamed intestinal mucosa from patients compared with intestinal mucosa from controls (P<.05). Expression levels of all clock genes except for PER2, were also significantly lower in non-inflamed intestinal mucosal tissues from patients compared with controls (P<.05). Expression levels of clock genes (CLOCK, BMAL1, CRY1, CRY2, PER1 and PER2) were lower in white blood cells from patients with IBD compared with controls. This reduction was greater in white blood cells from patients with ulcerative colitis than in patients with Crohn's disease.

CONCLUSION

Young, newly diagnosed, untreated patients with IBD have reduced expression of clock genes in inflamed and non-inflamed intestinal mucosal samples, and also in blood cells, compared with healthy individuals. Alterations in expression of clock genes might be an early event in IBD pathogenesis. ClinicalTrials.gov Identifier: NCT03662646.

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.

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.

Circadian Rhythm Disruption Aggravates DSS-Induced Colitis in Mice with Fecal Calprotectin as a Marker of Colitis Severity

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic immunologically mediated pathology that remains a major health burden. Circadian rhythm disruption leads to a deregulation in the immune system which is a major risk factor for IBD.

AIMS

Since fecal calprotectin (FC) has been a useful tool for monitoring IBD, we aimed to evaluate the effect of circadian rhythm alteration on gut inflammation status and whether FC is associated with the severity of colitis.

METHODS

C57BL/6J mice were exposed to circadian shifts for 3 months, and then colitis was induced by 2% dextran sulfate sodium (DSS). Colitis was evaluated according to clinical symptoms and histological scoring. Plasma and intestinal inflammatory and permeability markers as well as fecal and intestinal calprotectin were assessed.

RESULTS

Circadian shifts aggravated DSS-induced colitis with increased diarrhea, flatulence, and fecal blood associated with decreased colon length. In addition, intestinal cryptic architecture was lost with the presence of increased inflammation, mucosal muscle thickening, and cryptic abscesses. Plasma tumor necrosis factor alpha, interleukin 1 beta, interleukin 6, and C-reactive protein upregulations were paralleled by the deterioration of intestinal permeability. Calprotectin expression and distribution increased in the intestines and feces of shifted animals, and levels highly correlated with the increases in intestinal inflammation and permeability.

CONCLUSIONS

Circadian rhythm disruption aggravates DSS-induced colitis, whereas fecal and intestinal calprotectin associates with the severity of disease. Calprotectin might be a useful marker and tool for assessing patients at risk of IBD due to lifestyles with disruptive sleep patterns.

Mediating Roles of Anxiety, Self-Efficacy, and Sleep Quality on the Relationship Between Patient-Reported Physician Empathy and Inflammatory Markers in Ulcerative Colitis Patients

BACKGROUND Empathy between doctor and patient has an important bearing on patient health. The purpose of this study was to assess whether anxiety, sleep quality, and self-efficacy of patients have mediating effects in the relationship of patient-reported physician empathy and inflammatory factor in ulcerative colitis (UC) patients. MATERIAL AND METHODS This study included 242 patients attended by 45 doctors. Self-reported doctors' empathy ability was measured at patient admission (T1), and patient-reported physician empathy was measured 3 months later (T2). Patient anxiety, general self-efficacy, sleep, and inflammatory factor (IL-6) were measured on T1 and T2. Pearson correlation analysis was used to assess the relationships between self-reported doctor empathy ability and patient indices on T1 and T2. The relationships between anxiety, sleep quality, self-efficacy, IL-6, and patient-reported physician empathy were measured by Pearson correlation analysis and structural equation modeling. RESULTS On T1, no significant correlation was reported between self-reported doctors' empathy ability and indices of the patients (P>0.05). On T2, self-reported doctors' empathy ability was significantly positively correlated with patient sleep and self-efficacy (P<0.01), and significantly negatively correlated with patient anxiety and IL-6 (P<0.01). Moreover, on T2, patient-reported physician empathy was negatively correlated with anxiety and IL-6 and was positively correlated with self-efficacy and sleep quality. The effect of patient-reported physician empathy on IL-6 was mediated by anxiety, sleep quality, and self-efficacy. CONCLUSIONS The anxiety, self-efficacy, and sleep quality of UC patients had mediating effects in the relationship between patient-reported physician empathy and IL-6.