Concerns of patients with inflammatory bowel disease: results from a clinical population

Symptoms and symptom clusters in patients newly diagnosed with inflammatory bowel disease: results from the IBSEN III Study

BACKGROUND

Patients with inflammatory bowel disease report multiple symptoms, but the relationships among co-occurring symptoms are poorly understood. This study aimed to examine the prevalence of symptoms and explore symptom clusters and possible associations between symptom clusters and socio-demographic and clinical variables in patients newly diagnosed with inflammatory bowel disease.

METHODS

The IBSEN III study is a prospective population-based inception cohort of patients with inflammatory bowel disease. This study used patient data from the three largest hospitals in the study catchment area. The Memorial Symptom Assessment Scale was used to assess the prevalence of symptoms. Symptom clusters were identified using principal component analysis. Possible associations between socio-demographic and clinical variables and symptom cluster membership were estimated using regression analysis.

RESULTS

Of the 573 patients (age, ≥18 years) diagnosed with inflammatory bowel disease, 350 (61.1%) completed the questionnaire (responders). Eleven symptoms were reported by >50% of the responders. The three most prevalent symptoms were bloating (84%), drowsiness (81%), and lack of energy (81%). Three symptom clusters were identified: psychological (56% of the patients), impaired energy (28%), and physical (16%) clusters. Multinomial regression analysis revealed that vitamin D deficiency was significantly associated with the impaired energy cluster (odds ratio=2.49, 95% confidence interval [1.00-6.2], p=0.05).

CONCLUSIONS

We found high symptom prevalence in patients newly diagnosed with inflammatory bowel disease. Three distinct symptom clusters were identified, and the psychological cluster includes >50% of the patients. Vitamin D deficiency is the only factor associated with cluster membership, namely the impaired energy cluster.

Do inflammatory bowel disease patient preferences from treatment outcomes differ by ethnicity and gender? A cross-sectional observational study

BACKGROUND

Inflammatory bowel disease (IBD) patients’ expectations of treatment outcomes may differ by ethnicity.

AIM

To investigate treatment preferences of Jewish and Arabs patients.

METHODS

This prospective survey ranked outcomes treatment preferences among Arab IBD patients, based on the 10 IBD-disk items compared to historical data of Jews. An anonymous questionnaire in either Arabic or Hebrew was distributed among IBD patients. Patients were required to rank 10 statements describing different aspects of IBD according to their importance to the patients as treatment goals. Answers were compared to the answers of a historical group of Jewish patients.

RESULTS

IBD-disk items of 121 Arabs were compared to 240 Jewish patients. The Jewish patients included more females, [151 (62.9%) vs 52 (43.3%); P < 0.001], higher education level (P = 0.02), more urban residence [188 (78.3%) vs 54 (45.4%); P < 0.001], less unemployment [52 (21.7%) vs 41 (33.9%); P = 0.012], higher income level (P < 0.001), and more in a partnership [162 (67.8%) vs 55 (45.4%); P < 0.001]. Expectations regarding disease symptoms: abdominal pain, energy, and regular defecation ranked highest for both groups. Arabs gave significantly lower rankings (range 4.29–6.69) than Jewish patients (range 6.25–9.03) regarding all items, except for body image. Compared to Arab women, Jewish women attached higher priority to abdominal pain, energy, education/work, sleep, and joint pain. Multivariable regression analysis revealed that higher patient preferences were associated with Jewish ethnicity (OR 4.77; 95%CI 2.36–9.61, P < 0.001) and disease activity. The more active the disease, the greater the odds ratio for higher ranking of the questionnaire items (1-2 attacks per year: OR 2.13; 95%CI 1.02–4.45, P = 0.043; and primarily active disease: OR 5.29; 95%CI 2.30–12.18, P < 0.001). Factors inversely associated with higher patient preference were male gender (OR 0.5; 95%CI 0.271-0.935, P = 0.030), UC (OR 0.444; 95%CI 0.241–0.819, P = 0.009), and above average income level (OR 0.267; 95%CI: 0.124–0.577, P = 0.001).

CONCLUSION

The highest priority for treatment outcomes was symptom relief. Patients preferences were impacted by ethnicity, gender, and socio-economic disparity. Understanding patients' priorities may improve communication and enable a personalized approach.

The impact of Inflammatory Bowel Disease related fatigue on Health-Related Quality of Life: a qualitative semi-structured interview study

Background

Fatigue is a frequently reported symptom of Inflammatory Bowel Disease (IBD), having a negative impact on Health-Related Quality of Life (HRQoL). Patients' experiences of this have not been researched in IBD.

Methods

Semi-structured interviews were conducted with adults with Crohn's Disease from out-patient clinics in the United Kingdom. Interviews were audio-recorded and transcribed verbatim, then analysed using thematic analysis.

Results

Fourteen participant interviews were conducted. Three key themes were identified: 1) 'The new normal' established through adaptation and acceptance; 2) 'Energy as a resource' describing attempts to better manage fatigue through planning and prioritising tasks; 3) 'Keeping healthy' encompasses participants' beliefs that 'good health' allows better management of fatigue.

Conclusion

Participants establish a 'new' normality, through maintaining the same or similar level of employment/education activities. However, this is often at the expense of social activities. Further research is required to explore patient led self-management interventions in IBD fatigue.

MANTA and MANTA-RAy: Rationale and Design of Trials Evaluating Effects of Filgotinib on Semen Parameters in Patients with Inflammatory Diseases

Introduction

The phase 2 MANTA and MANTA-RAy studies were developed in consultation with global regulatory authorities to investigate potential impacts of filgotinib, a Janus kinase 1 preferential inhibitor, on semen parameters in men with active inflammatory diseases. Here we describe the methods and rationale for these studies.

Methods and Rationale

The MANTA and MANTA-RAy studies included men (aged 21–65 years) with active inflammatory bowel disease (IBD) and rheumatic diseases, respectively. Participants had no history of reproductive health issues, and the following semen parameter values (≥ 5th percentile of World Health Organization reference values) at baseline: semen volume ≥ 1.5 mL, total sperm/ejaculate ≥ 39 million, sperm concentration ≥ 15 million/mL, sperm total motility ≥ 40% and normal sperm morphology ≥ 30%. Each trial included a 13-week, randomized, double-blind, placebo-controlled period (filgotinib 200 mg vs placebo, up to N = 125 per arm), for pooled analysis of the week-13 primary endpoint (proportion of participants with ≥ 50% decrease from baseline in sperm concentration). All semen assessments were based on two samples (≤ 14 days apart) to minimize effects of physiological variation; stringent standardization processes were applied across assessment sites. From week 13, MANTA and MANTA-RAy study designs deviated owing to disease-specific considerations. All subjects with a ≥ 50% decrease in sperm parameters continued the study in the monitoring phase until reversibility, or up to a maximum of 52 weeks, with standard of care as treatment. Overall conclusions from MANTA and MANTA-RAy will be based on the totality of the data, including secondary/exploratory measures (e.g. sperm motility/morphology, sex hormones, reversibility of any effects on semen parameters).

Conclusions

Despite the complexities, the MANTA and MANTA-RAy studies form a robust trial programme that is the first large-scale, placebo-controlled evaluation of potential impacts of an advanced IBD and rheumatic disease therapy on semen parameters.

Trial Registration

EudraCT numbers 2017-000402-38 and 2018-003933-14; ClinicalTrials.gov identifiers NCT03201445 and NCT03926195.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02168-4.

Filgotinib is a treatment for patients with ulcerative colitis and rheumatoid arthritis, and is being studied in other inflammatory diseases. Filgotinib works by blocking Janus kinase 1, an intracellular protein involved in inflammatory signalling processes. We designed the MANTA and MANTA-RAy trials with global health agencies to find out if filgotinib decreases the quality of semen in men with active inflammatory bowel disease (ulcerative colitis or Crohn’s disease) (MANTA) or rheumatic disease (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis or non-radiographic axial spondylitis) (MANTA-RAy). This paper describes the design of the two trials.

Patients had normal sperm measurements and could not have had previous reproductive health issues. Nearly 250 patients were included in each trial. In both MANTA and MANTA-RAy, half of the patients were treated with 200 mg of filgotinib once a day for 13 weeks, and the other half with placebo. We determined if any patients had a decrease in number of sperm cells per millilitre (sperm concentration) by at least half after 13 weeks of treatment. We then monitored any patients who had such a decrease in sperm concentration for up to 52 weeks (while they received standard of care treatment) or until the decrease was reversed.

The conclusions from the trials will be in a different paper and will be based on all the final data, including changes in sex hormones. This is the first large-scale clinical trial programme to measure the effect of a treatment on sperm in men with inflammatory bowel disease or rheumatic diseases.

Fatigue: a frequent and biologically based phenomenon in newly diagnosed celiac disease

Fatigue is increasingly recognized as a major complaint in patients with chronic inflammatory and autoimmune diseases. Although fatigue is assumed to represent a significant problem in celiac disease, existing knowledge is scarce, and opinions are conflicting. This study aimed to investigate the prevalence and severity of fatigue in patients with newly diagnosed celiac disease and compare it with healthy control subjects. Ninety patients with newly diagnosed celiac disease were compared with 90 age- and sex-matched healthy subjects. The primary endpoints were fatigue severity as measured by: the fatigue Visual Analog Scale (fVAS), the Fatigue Severity Scale (FSS), and the inverted Vitality subscale of the MOS36 (SF-36vs). Higher scores indicate more severe fatigue. Clinically relevant fatigue was determined using predefined cut-off values. Secondary endpoints were the associations between fatigue, and sex, age, depression, pain, and selected biochemical variables. The median (IQR) fVAS-scores were 43.0 (18.0–64.5) in patients, and 9.0 (2.0–16.0) in the control group (p < 0.001); and the FSS scores 3.8 (2.0–4.8) in patients, and 1.4 (1.0–1.9) in control subjects (p < 0.001). Inverted SF-36vs scores had a mean (SD) value of 58.8 (23.6) in patients, and 29.7 (14.3) in healthy subjects (p < 0.001). The presence of clinically relevant fatigue ranged from 41 to 50% in patients. Increased fatigue severity was associated with female sex, younger age, and elevated pain and depression scores, but not with levels of selected biochemical variables, including hemoglobin. Fatigue is a severe and frequent phenomenon in patients with untreated celiac disease.

Incorporating patient experience into drug development for ulcerative colitis: development of the Urgency Numeric Rating Scale, a patient-reported outcome measure to assess bowel urgency in adults

Background

Bowel urgency, the sudden or immediate need to have a bowel movement, is a common, bothersome and disruptive symptom of ulcerative colitis (UC). UC treatment goals include control of urgency; however, it is not consistently assessed in UC clinical trials. The Urgency Numeric Rating Scale (NRS) is a new patient-reported measure to assess severity of bowel urgency in adults with UC developed in accordance with Food and Drug Administration guidelines.

Methods

Qualitative interviews were used to develop Urgency NRS. The scale asks patients to report the immediacy status of their UC symptom over the past 24 h on an 11-point horizontal numeric rating scale [0 (No urgency) to 10 (Worst possible urgency)]. Higher scores indicate worse urgency severity. A 2-week diary study assessed floor and ceiling effects, test–retest reliability (intraclass correlation coefficient (ICC) (2,1) between Week 1 and 2), and construct validity (Spearman correlation using Week 1 scores). Weekly scores were calculated as mean score over each 7-day period.

Results

Qualitative interviews with 16 UC patients (mean age 37.9 ± 11.6 years; 50% female; 56% White) confirmed relevance, content, and comprehensiveness. The 2-week diary study included 41 UC patients (mean age 44.2 ± 14.6 years; 51% female; 56% White). No ceiling or floor effects were identified. Test–retest reliability was high (ICC = 0.877). Average Urgency NRS and patient global rating of severity scores were highly correlated, with a moderate correlation between average Urgency NRS and stool frequency, demonstrating construct validity.

Conclusions

Bowel urgency is a distinct symptom of UC. The Urgency NRS is a well-defined, content-valid, and reliable measurement of bowel urgency in adults with UC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00439-w.

Anemia in Crohn's Disease-The Unseen Face of Inflammatory Bowel Disease

Background and Objectives: Anemia is the most frequent complication of inflammatory bowel diseases. Clinically, anemia can affect important quality-of-life (QoL) components, such as exercise capacity, cognitive function, and the ability to carry out social activities. The disease activity has a significant impact on QoL, mainly due to clinical manifestations, which are more severe during the periods of disease activity. Our aim was to estimate the impact of anemia on QoL in patients with Crohn's disease. Material and Methods. We made a prospective study on 134 patients with Crohn's disease (CD) in a Romanian tertiary center. The CD diagnosis was established by colonoscopy and histopathological examination. In particular cases, additional examinations were required (small bowel capsule endoscopy, computed tomography enterography, and magnetic resonance enterography). Anemia was defined according to the World Health Organization's definition, the activity of the disease was assessed by Crohn's disease activity index (CDAI) score, and the QoL was evaluated by Inflammatory Bowel Disease Questionnaire 32 (IBDQ 32). Results: 44.8% patient had anemia, statistically related to the activity of the disease and corticoids use. We found a strong association between QoL and disease activity on all four sub-scores: patients with more severe activity had a significantly lower IBDQ (260.38 ± 116.96 vs. 163.85 ± 87.20, p = 0.001) and the presence of anemia (127.03 vs. 148.38, p = 0.001). In multiple regression analyses, both disease activity and anemia had an impact on the QoL. Conclusions: Anemia has high prevalence in the CD in northeastern region of Romania. Anemia was more common in female patients, in patients undergoing corticosteroid treatment, and in those with active disease. Both anemia and disease activity had a strong negative and independent impact on QoL.

Assessment of sexual dysfunction in patients with perianal Crohn's disease

AIM

Over the past 10 years, several studies have focused on sexuality in patients with Crohn's disease. Very few of them specifically focused on perianal disease (PD). This study aimed to compare the prevalence of sexual dysfunction (SD) in Crohn's disease patients with active PD versus controls without active PD.

METHOD

Patients from 14 French centres with active PD, defined by the presence of symptomatic ulceration, fistula or stenosis, were arbitrarily included. They were compared with controls from the existing SEXIA cohort. Men completed the International Index of Erectile Function (IIEF) and women the Female Sexual Function Index (FSFI). The primary end-point was SD defined by FSFI < 26.55 in women and IIEF < 42.9 in men.

RESULTS

Ninety-seven patients (64 women, 33 men) and 238 controls (131 women, 107 men) were included. SD was found in 66% of the female patients versus 50% of the controls (P = 0.04). In the male population, SD was found in 30% of the cases versus 16% of the controls (P = 0.06). Erectile dysfunction affected 46% of the male patients and 43% of the controls (P = 0.8). On multivariate analysis, the predictive factor most strongly associated with SD in women was severely active anal PD defined by a perineal disease activity index > 4 [OR = 13.05 (2.32-73.44)].

CONCLUSION

Women with active PD had an increased prevalence of SD compared with controls without active PD. In the male population, the study was unable to determine whether there was a difference as it was underpowered.

The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease

Background: There is ample evidence of the high mental health burden caused by Inflammatory Bowel Disease (IBD). Several constructs such as experiential avoidance, cognitive fusion, shame, and self-criticism have recently emerged as potential intervention targets to improve mental health in IBD. Psychotherapeutic models such as Acceptance and Commitment Therapy and compassion-based interventions are known to target these constructs. In this protocol, we aim to describe a two-arm Randomized Controlled Trial (RCT) testing the efficacy of an ACT and compassion-focused intervention named Living with Intention, Fullness, and Engagement with Inflammatory Bowel Disease (LIFEwithIBD) intervention + Treatment As Usual (TAU) vs. TAU in improving psychological distress, quality of life, work and social functioning, IBD symptom perception, illness-related shame, psychological flexibility, self-compassion, disease activity, inflammation biomarkers, and gut microbiota diversity. Methods: This trial is registered at ClinicalTrials.gov (Identifier: NCT03840707, date assigned 13/02/2019). The LIFEwithIBD intervention is an adaptation to the IBD population of the Mind programme for people with cancer, an acceptance, mindfulness, and compassion-based intervention designed to be delivered in a group format. The LIFEwithIBD intervention's structure and topics are presented in this protocol. Participants were recruited at the Gastroenterology Service of the Coimbra University Hospital between June and September 2019. Of the 355 patients screened, 61 participants were selected, randomly assigned to one of two conditions [experimental group (LIFEwithIBD + TAU) or control group (TAU)] and completed the baseline assessment. Outcome measurement took place at baseline, post-intervention, 3- and 12-month follow-ups. Discussion: Results from this RCT will support future studies testing the LIFEwithIBD intervention or other acceptance and/or compassion-based interventions for IBD.

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.

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.

Stigmatisation and resilience in inflammatory bowel disease

Inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis, is an immune-mediated, chronic relapsing disorder characterised by severe gastrointestinal symptoms that dramatically impair patients' quality of life, affecting psychological, physical, sexual, and social functions. As a consequence, patients suffering from this condition may perceive social stigmatisation, which is the identification of negative attributes that distinguish a person as different and worthy of separation from the group. Stigmatisation has been widely studied in different chronic conditions, especially in mental illnesses and HIV-infected patients. There is a growing interest also for patients with inflammatory bowel disease, in which the possibility of disease flare and surgery-related issues seem to be the most important factors determining stigmatisation. Conversely, resilience represents the quality that allows one to adopt a positive attitude and good adjustments despite adverse life events. Likewise, resilience has been studied in different populations, age groups, and chronic conditions, especially mental illnesses and cancer, but little is known about this issue in patients with inflammatory bowel disease, even if this could be an interesting area of research. Resilience can be strengthened through dedicated interventions that could potentially improve the ability to cope with the disease. In this paper, we focus on the current knowledge of stigmatisation and resilience in patients with inflammatory bowel disease.

Systematic review: the impact of inflammatory bowel disease-related fatigue on health-related quality of life

BACKGROUND

Fatigue is frequently reported in inflammatory bowel disease (IBD) and impacts on health-related quality of life (HRQoL). HRQoL has not been systematically reviewed in IBD fatigue.

AIM

To investigate what impact IBD fatigue has on HRQoL in adults with IBD.

METHODS

Systematic searches (CINAHL, EMBASE, PsychINFO, Medline) were conducted on 25 September 2018, restricted to 'human', 'adult', 'primary research' and 'English language'. Search terms encompassed concepts of 'fatigue', 'IBD' and 'HRQoL'. A 5-year time limit (2013-2018) was set to include the most relevant publications. Publications were screened, data extracted and quality appraised by two authors. A narrative synthesis was conducted.

RESULTS

Eleven studies were included, presenting data from 2823 participants. Fatigue experiences were significantly related to three HRQoL areas: symptom acceptance, psychosocial well-being and physical activity. Patients reporting high fatigue levels had low symptom acceptance. Psychosocial factors were strongly associated with both fatigue and HRQoL. Higher social support levels were associated with higher HRQoL. Physical activity was impaired by higher fatigue levels, lowering HRQoL, but it was also used as a means of reducing fatigue and improving HRQoL. Quality appraisal revealed methodological shortcomings in a number of studies. Notably, use of multiple measures, comparison without statistical adjustment and fatigue and HRQoL assessment using the same tool were some of the methodological shortcomings.

CONCLUSION

Psychosocial factors, symptom management and acceptance and physical activity levels have significant impact on HRQoL. Results support application of psychosocial or exercise interventions for fatigue management. Further exploration of HRQoL factors in IBD fatigue is required, using validated fatigue and HRQoL measures.

PROSPERO REGISTRATION NUMBER

CRD42018110005.

Sexual health and fertility for individuals with inflammatory bowel disease

The impact of a chronic disease such as inflammatory bowel disease (IBD) on sexual functioning and body image can significantly impair the quality of life of patients. This review considers the sexual and fertility aspects of IBD patients and their daily management. Modern IBD healthcare management should include appropriate communication on sexuality and consider psychological, physiological, and biological issues. Patients with IBD have less children than the general population, and voluntary childlessness is frequent. The most influential factors reported by IBD patients who experience fertility alteration are psychological and surgery-related problems. Pregnancy is a major concern for patients, and any pregnancy for IBD patients should be closely followed-up to keep the chronic disease in a quiescent state. Preconceptional consultation is of great help.

Perceptions of IBD within patient and community samples: a systematic review

Objective: Inflammatory bowel disease (IBD) is a chronic, gastrointestinal condition that involves a range of debilitating bowel symptoms. Adjustment to living with IBD can be negatively impacted by maladaptive cognitive and behavioural factors (e.g. negative illness representations and repressing emotions). Patient samples also report negative reactions from the general public and such perceptions can further negatively impact people living with IBD. Therefore, we aimed to systematically review literature investigating the illness perceptions, perceived stigmatisation, and negative emotional reactions toward IBD within patient and community samples. We also aimed to review how these factors impact those living with IBD (i.e. adjustment, psychological health). Design: A range of databases (e.g. Psych INFO, PubMed) were searched over two years. One reviewer individually screened titles and abstracts using the specified inclusion criteria, and this process was repeated by a second reviewer. Subsequently, the full text articles were screened and data were extracted for the 82 articles that satisfied the inclusion criteria. Following data extraction, a narrative synthesis was conducted.Results: The review of 82 studies suggested that negative illness perceptions are linked to poorer psychosocial outcomes, that patient samples frequently anticipate stigmatisation, fear relating to bowel accidents was the most common emotion reported, and that the general public direct little enacted stigma towards IBD.Conclusion: For people living with IBD: (i) poorer psychological adjustment was reported by those who held more negative perceptions and reactions toward their illness; and (ii) their concerns regarding public perceptions of IBD warrants further empirical attention. Results emphasise the importance of targeting perceptions, and facilitating education and adaptive responding during treatment.

Assessment of sexual dysfunction in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) represents a diverse variety of chronic inflammatory intestinal conditions. Sexuality is often disturbed in patients with IBD, more often affecting women than men. Many factors seem to contribute to intimacy concerns. The most popular questionnaires used in empirical research around the world are the Female Sexual Function Index (FSFI) for women and the International Index of Erectile Function (IIEF) for men. Sexual satisfaction was negatively correlated with depression, anxiety, sexual problems, and illness perceptions. When analysing the problem of IBD, disorders of sexual function should not be ignored. Patients should be screened for psychological diseases and sexual dysfunction, and necessary treatments should be given as soon as possible. By understanding what factors contribute to poor sexual functioning in patients with IBD, we may try to minimise adverse psychosocial events. Screening for sexual disorders should be a part of daily medical practice.

Randomized controlled trial: a pilot study of a psychoeducational intervention for fatigue in patients with quiescent inflammatory bowel disease

Introduction:

Fatigue is a frequent, debilitating symptom of inflammatory bowel disease (IBD). Despite this, studies report dissatisfaction among IBD patients regarding how little attention is given to fatigue-related issues during consultations. We performed a pilot randomized controlled trial (RCT) to assess whether a brief, structured, multidisciplinary psychological support program improved fatigue, mood and quality of life indices in patients with quiescent IBD.

Methods:

The intervention consisted of three small-group psychoeducational sessions over 6 months. Primary outcomes were effect on fatigue severity and impact scores. Secondary outcomes included effect on depression, anxiety, somatization scores, generic and disease-specific quality of life.

Results:

Twenty-three patients were enrolled, 10 in the intervention arm and 13 controls. Mean fatigue severity and impact scores improved for patients in the intervention group (by 14.5–13.1 and 49.7–45.8, respectively), and worsened in controls (by 11.5–12.6 and 33.5–35 respectively). Mean Short Form 36 (SF-36) scores for role limitations due to physical health decreased from 44.4 to 38.9 in the intervention group, but increased from 44.2 to 51.9 among controls. Energy scores in the intervention group improved from 17.8 to 26.6, but only from 31.4 to 31.7 among controls. Short IBD questionnaire scores improved in both groups, from 46.2 to 45.2 in controls compared with 44.4–40 in the intervention group.

Discussion:

In this small pilot RCT, positive effects were demonstrated on fatigue, energy levels and other quality of life outcomes. Larger, adequately powered studies with longer follow up are required.

ClincialTrials.gov identifier: NCT02709434.

Body image dissatisfaction in patients with inflammatory bowel disease: a systematic review

BACKGROUND AND AIMS

Little is known about the relationship between inflammatory bowel disease (IBD) and body image. The aim of this systematic review was to summarise the evidence on body image dissatisfaction in patients with IBD across four areas: (1) body image tools, (2) prevalence, (3) factors associated with body image dissatisfaction in IBD and (4) association between IBD and quality of life.

METHODS

Two reviewers screened, selected, quality assessed and extracted data from studies in duplicate. EMBASE, MEDLINE, PsycINFO and Cochrane CENTRAL were searched to April 2018. Study design-specific critical appraisal tools were used to assess risk of bias. Narrative analysis was undertaken due to heterogeneity.

RESULTS

Fifty-seven studies using a body image tool were included; 31 for prevalence and 16 and 8 for associated factors and association with quality of life, respectively. Studies reported mainly mean or median scores. Evidence suggested female gender, age, fatigue, disease activity and steroid use were associated with increased body image dissatisfaction, which was also associated with decreased quality of life.

CONCLUSION

This is the first systematic review on body image in patients with IBD. The evidence suggests that body image dissatisfaction can negatively impact patients, and certain factors are associated with increased body image dissatisfaction. Greater body image dissatisfaction was also associated with poorer quality of life. However, the methodological and reporting quality of studies was in some cases poor with considerable heterogeneity. Future IBD research should incorporate measurement of body image dissatisfaction using validated tools.

An Exploratory Study of Inflammatory Bowel Disease and the Psychosocial Factors Affecting Health-Related Quality of Life

Health-related quality of life (HRQoL) is a multidimensional concept that assesses an individual’s personal satisfaction with his/her daily life while coping with a medical condition and/or its consequent therapy. This study aims to determine the psychosocial needs most commonly affected among inflammatory bowel disease (IBD) patients. Psychosocial needs which were pertinent to the IBD community were assessed using a questionnaire designed by the gastrointestinal team at the Port of Spain General Hospital, Trinidad after getting ethical approval. The chi-squared test was used to assess for statistically significant associations. Of the total 115 participants who completed the survey, a majority of 73 (63%) were females and 70 (61%) were in the 18 to 40-year age group. A majority of 66 (57%) were diagnosed with ulcerative colitis and 66 (57%) were on non-biologic drug therapy. Diet was the need most prevailingly affected, with 87% of participants indicating such. Ability to maintain good hygiene was the need least affected, with 32% of participants identifying concern. We found a significant association between participant’s illness perception (IP) and each of the ten psychosocial variables. The participants’ IP was in turn strongly associated with the ability to cope with the illness while not being associated with the demographic or clinical details of the participants. The results can be used to improve the quality of care delivered to patients living with IBD.

Walking in a Patient's Shoes: An Evaluation Study of Immersive Learning Using a Digital Training Intervention

Objectives: Evidence suggests that immersive learning increases empathy and understanding of the patient experience of illness. This study evaluated a digital training intervention 'In Their Shoes' which immerses participants in the experience of living with inflammatory bowel disease (IBD), highlighting the biopsychosocial impact. The simulation program uses a mobile application to deliver time-based tasks and challenges over 36 h, supplemented with telephone role-play and 'kit' items to open and use. This study investigated changes in IBD understanding and connection to patients, empathy and perception of job value in a group of pharmaceutical employees. Additionally, it explored experiences and impact of taking part in the intervention. Methods: A mixed methods pre-post design was utilized, with an opportunity sample of employees taking part in the training. 104 participants from sites in 12 countries completed measures at baseline and 97 post-intervention. Measures included the Toronto Empathy Questionnaire, Prosocial Job Characteristics Scale, and structured questions around IBD understanding and connection to patients. Two focus groups (N = 14) were conducted regarding participants experiences of the intervention to complement an open-response question in the questionnaire (N = 75). Qualitative data was analyzed using thematic analysis. Results: Following the intervention, there were statistically significant increases in IBD understanding and connection to patients (p < 0.00025), evaluation of organizational innovation (p < 0.00025), empathy (d = 0.45) and prosocial job perceptions (d = 0.28). Qualitative analysis revealed more fully the transformative personal journey undertaken by participants which provided 'eye opening' insight into the psychosocial impact of living and working with IBD. This insight encouraged patient perspective-taking and a strong desire to promote patient advocacy and reduce stigma around chronic illness. Finally, greater organizational pride and connectivity was evident for some participants. Conclusions: An immersive training program, focussing on the lived experience of illness, led to significant increases in disease understanding and empathy. These findings align with other literature evaluating immersive learning and the potential for increasing knowledge, empathy and motivation. The present study offers opportunities to extend this outside of the body of work focussing on healthcare practitioners and explores the benefits of using this type of learning experience within an organizational setting.

Impacts of perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease

BACKGROUND

Patient reported outcomes regarding perianal disease and faecal incontinence in the community-based inflammatory bowel disease population are poorly described.

AIMS

To determine the impacts of perianal disease and faecal incontinence on quality of life and employment in inflammatory bowel disease patients.

METHODS

For this cross-sectional study, a comprehensive survey was sent out to members of the Dutch National Crohn's and Colitis patient organisation. Validated questionnaires regarding faecal incontinence and active perianal disease were used to estimate its prevalence's. The effect on the quality of life (36-Item Short Form Survey) and on employment status (multivariate binary regression analysis) was assessed in this inflammatory bowel disease population.

RESULTS

A total number of 1092 returned questionnaires (58% responders) were used for analysis; 750 respondents (69%) were female; mean age was 47 years (IQR 35-59). In 621 patients (57%) Crohn's disease, in 422 (39%) ulcerative colitis and in 49 (4%) patients unclassifiable inflammatory bowel disease was self-reported. The 114 patients (10%) with a stoma were excluded for continence related analyses. Faecal incontinence was reported in 555 patients (57%), was comparable between the different inflammatory bowel disease diagnoses and affected all 36-Item Short Form Survey subscales adversely (incontinence vs continence: Physical functioning 75 vs 84, P < 0.0001; Limitations due to physical health 49 vs 63, P < 0.0001; Limitations due to emotional problems 49 vs 64, P < 0.0001; Energy/fatigue 47 vs 53, P < 0.0001; Emotional well-being 71 vs 74, P = 0.005; Social functioning 63 vs 73, P < 0.0001; Pain 66 vs 75, P < 0.0001; General health 41 vs 48, P < 0.0001). Active perianal disease was reported in 39% Crohn's disease, 16% ulcerative colitis (84% fissures) and 20% unclassifiable inflammatory bowel disease patients. Faecal incontinence was more common in patients with perianal disease (67% vs 53%, P = 0.003). When correcting for age, disease duration, inflammatory bowel disease-related surgery and faecal incontinence, active perianal disease was independently affecting employment (OR 0.67; 95% CI 0.50-0.91; P = 0.01).

CONCLUSIONS

Faecal incontinence and perianal disease are quality of life determining factors. Faecal incontinence needs more attention among clinicians, and development of new (drug) therapies needs to be focussed on perianal disease.

Frequency of and Factors Associated With Sexual Dysfunction in Patients With Inflammatory Bowel Disease

BACKGROUND

Improvement of quality of life is a main objective in inflammatory bowel disease [IBD] management. Data on sexual dysfunction [SD] in IBD are scarce. This study compared rates of SD between IBD patients and healthy controls [HC], and searched for predictors of SD.

METHODS

All consecutive IBD patients seen in two tertiary centres during 2 months were invited to fill an anonymous validated questionnaire on their sexual function [Female Sexual Index Function and International Index of Erectile Function]. The same questionnaires were filled by HC and by patients with irritable bowel syndrome [IBS] enrolled as a second comparative group.

RESULTS

In all, 358 IBD patients filled the questionnaire [192 women]-including 238 with Crohn's disease and 120 with ulcerative colitis-and 110 HC [54 women] and 107 IBS patients [54 women]. In women, SD rates were 53.6% in IBD vs 28% in HC [p < 0.01] and 77.5% in IBS [p = 0.10] patients; in men, figures were 16.9% in IBD, 7.4% in HC [p = 0.64], and 26.4% in IBS [p = 0.60]. An erectile dysfunction [ED] was reported by 43% of IBD patients, 13% of HC [p < 0.01] and 55% of IBS patients [p = 0.60 vs IBD]. Predictors of SD and ED were social and emotional functioning, anxiety in women and depression in men. IBD activity was not associated with SD.

CONCLUSIONS

In IBD, 54% of women have an SD and 43% of men an ED. These rates are significantly higher than in HC, mostly driven by psychological factors, and independent from disease severity.

Symptom clusters in adults with inflammatory bowel disease

Symptoms (pain, fatigue, sleep disturbance, depression, and anxiety) in inflammatory bowel disease (IBD) are associated with reduced quality of life. Understanding how IBD symptoms cluster and the clinical and demographic factors associated with symptom clusters will enable focused development of symptom management interventions. The study purposes were to (i) identify symptom cluster membership among adults with IBD and (ii) examine associations between demographic (age, gender, race/ethnicity, and education) and clinical factors (smoking status, time since diagnosis, medication type, IBD type, disease activity), and membership in specific symptom cluster groups. We conducted a retrospective study of data from the Crohn's and Colitis Foundation of America's (CCFA) Partners Cohort and used Patient Reported Outcome Measurement Information System (PROMIS) measures to measure pain interference, fatigue, sleep disturbance, anxiety, and depression. The sample included 5,296 participants with IBD (mean age 44, 72% female). In latent class analysis (LCA), four groups of participants were identified based on symptoms: "low symptom burden" (26% of sample), "high symptom burden" (38%), "physical symptoms" (22%), and "psychological symptoms" (14%). In multinomial regression, female gender, smoking, corticosteroids, Crohn's disease, and active disease state were associated with membership in the high symptom burden group. Additional research is needed to test interventions that may be effective at reducing symptom burden for individuals with IBD.

The Rating Form of IBD Patient Concerns: Translation, Validation, and First Implementation of the Greek Version

Background. The rating form of IBD patients' concerns (RFIPC) provides a unique assessment of the worries and concerns of inflammatory bowel disease (IBD) patients. Our aims were primarily to validate the Greek version of RFIPC and secondarily to describe the pattern of Greek patients'concerns. Methods. After translating RFIPC, the questionnaire was given to IBD patients at baseline and after 12 weeks. The questionnaire's measuring properties were evaluated based on the consensus-based standards for the selection of health status measurement instruments (COSMIN) recommendations. Premediated factorial structures were tested for goodness of fit with confirmatory factor analysis (CFA). Results. At baseline, 200 patients (94 with Crohn's disease) completed RFIPC. After 12 weeks, the first 100 patients recompleted the questionnaire. CFA results were consistent with a slightly modified than the original factorial structure. Cronbach's α and intraclass correlation coefficients were high. RFIPC scores negatively affected the quality of life. RFIPC was sensitive to detect important changes in patients' condition and was able to discriminate between remission and active disease. Disease activity, full time employment, celibacy, and low education were associated with higher scores. Conclusion. The Greek version of RFIPC is a reliable, valid, and responsive tool to assess Greek IBD patients' concerns.

The concerns of Spanish patients with inflammatory bowel disease as measured by the RFIPC questionnaire

BACKGROUND AND OBJECTIVES

Concerns impact the quality of life for patients with inflammatory bowel disease (IBD). We attempted to identify the concerns of IBD patients in our practice, and to assess the applicability of the Rating Form of IBD Patients Concerns (RFIPC) questionnaire to Spanish patients.

PATIENTS AND METHODS

One hundred and thirty-one patients seen in our practice filled out the Spanish version of RFIPC. The questionnaire's reliability, validity, and discriminating power were analyzed.

RESULTS

The total score was 46.93, with a standard deviation (SD) of 21.475. Primary concerns included: "having an ostomy bag", "effects of medication", "developing cancer", "energy level", and "uncertain nature of disease". Female patients scored higher on total RFIPC and on most items. Cronbach's alpha was 0.924. A good correlation was seen between two consecutive answers for 37 patients; the Spearman's coefficient was 0.842 (p < 0.001), and the intraclass correlation coefficient (ICC) was 0.775 (p < 0.001). Correlation was also found between RFIPC and both the IBDQ-32 emotional domain (0.413, p < 0.001) and anxiety scale (0.543, p < 0.001).

CONCLUSIONS

The RFIPC questionnaire may be administered to Spanish patients.

Patient self-reported concerns in inflammatory bowel diseases: A gender-specific subjective quality-of-life indicator

Background

Patient-reported disease perceptions are important components to be considered within a holistic model of quality of care. Gender may have an influence on these perceptions. We aimed to explore gender-specific concerns of patients included in a national bilingual inflammatory bowel disease cohort.

Methods

Following a qualitative study, we built a questionnaire comprising 37 items of concern. Answers were collected on a visual analog scale ranging from 0 to 100. Principal axis factor analysis was used to explore concern domains. Linear multiple regressions were conducted to assess associations with patient characteristics.

Results

Of 1102 patients who replied to the survey, 54% were female and 54% had Crohn’s disease. We identified six domains of concern: socialization and stigmatization, disease-related constraints and uncertainty, symptoms and their impact on body and mind, loss of body control (including sexuality), disease transmission, and long-term impact of the disease. Cancer concerns were among the highest scored by all patients (median 61.8). Severity of symptoms was the only factor associated with concerns, unrelated to dimension and gender (p<0.015). In women, being >40 years decreased disease-related constraints and uncertainty concerns, and being at home or unemployed increased them. Treatments were associated with increased socialization and stigmatization and with increased disease-related constraints and uncertainty concerns in men. Overall, psychosomatic characteristics were highly associated with concerns for both men and women. Depending on the concern dimensions, increased levels of concern were associated with the highest signs of anxiety in women or depression in men, as well as lower health-related quality of life in men.

Conclusions

Patients have numerous concerns related to their illness that need to be reassessed regularly. Concerns differ between men and women, suggesting that information and communication about the disease should take gender differences and subjective perceptions of quality of life into consideration.

The effects of body image impairment on the quality of life of non-operated Portuguese female IBD patients

OBJECTIVES

Inflammatory bowel diseases (IBD) and their treatment are known to negatively impact on patients' body image, especially female patients. However, although there are broad evidences of body image impairment in female IBD patients, its negative impact on the quality of life (QoL) of non-operated women is not clearly and specifically studied. The aim of the current study was therefore to analyse, in a sample of non-operated female IBD patients, the factors that contribute to body image impairment and its impact on QoL.

METHODS

Ninety-six non-operated women (39.7 % with CD and 60.3 % with UC), aged between 18 and 40 years old, completed an online survey with validated self-report measures, which included the Body Image Scale and the WHO Brief Quality of Life Assessment Scale.

RESULTS

Negative body image was correlated with lower psychological and physical QoL and increased corticosteroids use, associated medical complications, body mass index (BMI), and IBD symptomatology. Regression analyses revealed that BMI and IBD symptomatology significantly predicted body image impairment. Furthermore, results from path analyses indicated that BMI and IBD symptomatology's effect on psychological and physical QoL was mediated through the negative effects of body image impairment. This model explained 31 % of psychological QoL and 41 % of physical QoL.

CONCLUSIONS

These findings suggest that non-operated female patients are subject to pervasive and harmful effects of body image impairment on psychological and physical functioning. Therefore, psychological interventions aiming to target body dissatisfaction should be implemented in the health care of IBD, independently of patients' operative status.

A systematic review of disease-related stigmatization in patients living with inflammatory bowel disease

Chronic illness stigma is a global public health issue. Most widely studied in HIV/AIDS and mental illness, stigmatization of patients living with inflammatory bowel disease (IBD), chronic autoimmune conditions affecting the digestive tract, has garnered increasing attention in recent years. In this paper, we systematically review the scientific literature on stigma as it relates to IBD across its three domains: perception, internalization, and discrimination experiences. We aim to document the current state of research, identify gaps in our knowledge, recognize unique challenges that IBD patients may face as they relate to stigmatization, and offer suggestions for future research directions. Based on the current review, patients living with IBD may encounter stigmatization and this may, in turn, impact several patient outcomes including quality of life, psychological functioning, and treatment adherence. Significant gaps exist related to the understanding of IBD stigma, providing opportunity for future studies to address this important public health issue.

Participants' perspectives on mindfulness-based cognitive therapy for inflammatory bowel disease: a qualitative study nested within a pilot randomised controlled trial

Background

Mindfulness-based interventions have shown to improve depression and anxiety symptoms as well as quality of life in patients with inflammatory bowel disease (IBD). However, little is known about the experiences of this group of patients participating in mindfulness interventions. This paper sets out to explore the perspectives of patients with IBD recruited to a pilot randomised controlled trial (RCT) of mindfulness-based cognitive therapy (MBCT) about the intervention.

Methods

In a qualitative study nested within a parallel two-arm pilot RCT of mindfulness-based cognitive therapy for patients with IBD, two focus group interviews (using the same schedule) and a free text postal survey were conducted. Data from both were analysed using thematic analysis. Data and investigator triangulation was performed to enhance confidence in the ensuing findings.

Forty-four patients with IBD were recruited to the pilot RCT from gastroenterology outpatient clinics from two Scottish NHS boards. Eighteen of these patients (ten from mindfulness intervention and eight from control group) also completed a postal survey and participated in two focus groups after completing post intervention assessments.

Results

The major themes that emerged from the data were the following: perceived benefits of MBCT for IBD, barriers to attending MBCT and expectations about MBCT. Participants identified MBCT as a therapeutic, educational and an inclusive process as key benefits of the intervention. Key barriers included time and travel constraints.

Conclusions

This qualitative study has demonstrated the acceptability of MBCT in a group of patients with IBD. Participants saw MBCT as a therapeutic and educational initiative that transformed their relationship with the illness. The inclusive process and shared experience of MBCT alleviated the sense of social isolation commonly associated with IBD. However, time commitment and travel were recognised as a barrier to MBCT which could potentially influence the degree of therapeutic gain from MBCT for some participants.

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-015-0041-z) contains supplementary material, which is available to authorized users.

Assessing fatigue in inflammatory bowel disease: comparison of three fatigue scales

BACKGROUND

Fatigue is commonly reported by patients with inflammatory bowel disease (IBD), both in quiescent and active disease. Few fatigue scales have been tested in IBD.

AIM

To assess three fatigue assessment scales in IBD and to determine correlates of fatigue.

METHODS

Potential participants (n = 2131) were randomly selected from an IBD organisation's members' database; 605 volunteered and were posted three fatigue scales: Inflammatory Bowel Disease Fatigue scale, Multidimensional Fatigue Inventory and Multidimensional Assessment Fatigue scale and questionnaires assessing anxiety, depression, quality of life (QoL) and IBD activity. The questionnaires were tested for stability over time with another group (n = 70) of invited participants. Internal consistency was measured by Cronbach's alpha and test-retest reliability by the intraclass correlation coefficient (ICC).

RESULTS

Four hundred and sixty-five of 605 (77%) questionnaires were returned; of 70 invited, 48/70 returned test (68.6%) and 41/70 (58.6%) returned retest. The three scales are highly correlated (P < 0.001). Test-retest suggests reasonable agreement with ICC values between 0.65 and 0.84. Lower age, female gender, IBD diagnosis, anxiety, depression and QoL were associated with fatigue (P < 0.001) on univariable analysis. However, on multivariable analysis only depression and low QoL were consistently associated with fatigue, while female gender was associated on most scales. IBD diagnosis, age and other factors were not consistently associated with severity or impact of fatigue once other variables were controlled for.

CONCLUSIONS

All three fatigue scales are likely to measure IBD fatigue adequately. Responsiveness to change has not been tested. Depression, poorer QoL and probably female gender are the major associations of fatigue in IBD.

Is iron deficiency in the absence of anemia associated with fatigue in inflammatory bowel disease?

OBJECTIVES

We explored whether iron deficiency in the absence of anemia is associated with fatigue in inflammatory bowel disease (IBD).

METHODS

We assessed iron deficiency and anemia in 280 participants from the population-based Manitoba IBD Cohort Study.

RESULTS

Iron deficiency was identified in 20% with Crohn's disease and 27% with ulcerative colitis. Anemia was identified overall in 50 (18%), with 230 who were nonanemic. In the nonanemic subgroup, there were no significant differences between iron-deficient and -sufficient groups in mean fatigue levels or proportions with problematic fatigue. There was no unique contribution of iron deficiency to problematic fatigue after adjustment for active disease and anemia.

CONCLUSIONS

There was no evidence of an association between iron deficiency and fatigue in the absence of anemia, suggesting that iron deficiency is not a clinically relevant contributor to fatigue in IBD.

Chronic illness and disordered eating: a discussion of the literature

This paper describes the prevalence of eating disorders and disordered eating behaviors, the reasons why these practices are endorsed, and the potential consequences in youths and young adults with selected diet-related chronic health conditions (DRCHCs) and provides recommendations for eating disorder prevention interventions and research efforts. Although it remains unclear whether the prevalence of eating disorders is higher in those with DRCHCs compared with the general population, overall findings suggest that young people with DRCHCs may be at risk of endorsing disordered eating behaviors that may lead to diagnosis of an eating disorder and other health problems over the course of their treatment. Thus, health care providers should be aware that young people with DRCHCs may be at risk of eating disorders and carefully monitor psychological changes and the use of unhealthy weight control methods. It is also important to develop and evaluate theory-based interventions and disease-specific eating disorder risk screening tools that are effective in halting the progression of eating disorders and negative health outcomes in young people with chronic health conditions.

Health-related quality of life in patients with inflammatory bowel disease: a single-center experience

BACKGROUND

Inflammatory bowel disease (IBD) has a negative impact on health-related quality of life (HRQoL). The aim of the study was to assess HRQoL of IBD patients in South-Western Greece.

METHODS

89 IBD patients [38 (42.7%) Crohn's disease (CD), 51 (57.3%) ulcerative colitis (UC)] were included. HRQoL was assessed using IBD questionnaire (IBDQ), which tests four health domains: bowel symptoms (BS), systemic symptoms (SS), emotional function (EF) and social function (SF). Total score (TS) ranges from 32 to 224. Disease activity was measured using Crohn's Disease Activity Index (CDAI) (CD), and Truelove and Witts classification (UC). The impact of epidemiological and disease-specific characteristics on IBDQ was studied.

RESULTS

No statistically significant difference was found in all IBDQ scores between UC and CD patients. No correlation was found regarding age, sex, smoking, anemia, disease duration and use of corticosteroids, 5-aminosalicylates or immunosuppressives with HRQoL. The factors found to have a major negative impact on all IBDQ scores was disease severity both in CD and UC, and education on bowel symptoms in CD. On multivariate analysis, only high disease activity had significant effects on total and dimensional scores of IBDQ in UC (TS, P=0.005; BS, P<0.001; SS, P=0.004; EF, P=0.05; SF, P=0.001), whereas in CD, only CDAI (TS, P=0.001; BS, P=0.004; SS, P=0.001; EF, P=0.003; SF, P=0.003) and education (TS, P=0.047; BS, P=0.004; SS, P=0.03) had significant effects.

CONCLUSIONS

IBD patients in remission experience better HRQoL than patients with active disease. Induction of remission should become the mainstay of care regarding improvement in HRQoL.

The experience of fatigue in people with inflammatory bowel disease: an exploratory study

AIMS

To explore fatigue, the impact it has on daily life and the strategies used to ameliorate the symptom, as described by people with inflammatory bowel disease.

BACKGROUND

Fatigue is the most troublesome symptom during remission of inflammatory bowel disease. Fatigue affects people's daily functioning, impacting on quality of life. There is limited understanding of the nature of and the ways fatigue in inflammatory bowel disease is experienced and managed in everyday adult life.

DESIGN

An epistemological interpretive approach to understand participants' self-reported experiences of disease-related fatigue.

METHODS

A convenience sample of 46 participants was recruited from the Crohn's and Colitis UK member database. Five focus group interviews (November 2008-February 2009) were conducted, audio-recorded, transcribed, and analysed using an inductive thematic framework.

FINDINGS

Five themes were identified: the experience of fatigue, causes of fatigue, managing fatigue, consequences of fatigue, and seeking support. Fatigue had a debilitating effect on the social and emotional well-being of participants and limited their employment opportunities. People used a range of strategies to cope and reported that fatigue-related issues seemed to be poorly understood by clinicians and were not addressed in medical consultations.

CONCLUSION

Fatigue was an inextricable part of daily life for some people with inflammatory bowel disease. Specialist nurses and medical colleagues need to address the personal, social, and economic consequences of fatigue, whilst further nursing research would improve understanding of the impact of fatigue and help develop appropriate intervention strategies for people with inflammatory bowel disease.

Understanding the health and social care needs of people living with IBD: a meta-synthesis of the evidence

AIM

To undertake a metasynthesis of qualitative studies to understand the health and social needs of people living with inflammatory bowel disease (IBD).

METHODS

A systematic search strategy identified qualitative studies exploring the phenomenon of living with inflammatory bowel disease. Databases included MEDLINE, PsychInfo, EMBASE, CINAHL and the British Nursing Index via the OVID platform. Qualitative search filters were adapted from Hedges database (http://www.urmc.rochester.edu/hslt/miner/digital_library/tip_sheets/Cinahl_eb_filters.pdf). Qualitative empirical studies exploring the health and social needs of people living with inflammatory bowel disease were selected. Study eligibility and data extraction were independently completed using the Critical Appraisal Skills Programme for qualitative studies. The studies were analysed and synthesised using metasynthesis methodology. The themes from the studies allowed for common translations into a new interpretation of the impact of living with inflammatory bowel disease.

RESULTS

Of 1395 studies, six published studies and one unpublished thesis fulfilled the inclusion criteria. First iteration of synthesis identified 16 themes, 2nd iteration synthesised these into three main 2nd order constructs: "detained by the disease"; "living in a world of disease" and "wrestling with life". "Detained by the disease" is the fear of incontinence, the behaviour the patients display due to the fear, and the impact this has on the individual, such as social isolation and missing out on life events. All of these serve to "pull" the patient back from normal living. "Living in a world of disease" is the long term effects of living with a long term condition and the fear of these effects. "Wrestling with life" is the continued fight to thrive, the "push" to continue normal living.

CONCLUSION

The metasynthesis provides a comprehensive representation of living with IBD. The unmistakeable burden of incontinence is exposed and its ongoing effects are demonstrated. The combined overall impact of living with IBD is the tension these patients live with: "Pushed and pulled: a compromised life", people living with IBD experience a constant conflict throughout their lives, they push to be normal but IBD pulls them back. The impact of the fear of incontinence and behaviour of the individual as a result, requires further qualitative enquiry.

A preliminary evaluation of internalized stigma and stigma resistance in inflammatory bowel disease

Illness stigmatization among inflammatory bowel diseases (IBDs) is poorly understood. We aim to characterize internalized stigma and stigma resistance in IBD patients, and evaluate their relationships to outcomes. A total of 191 IBD patients reported internalized stigma, resistance, demographic and clinical information, and several outcomes: health-related quality of life (HRQOL), psychological distress, self-esteem, and self-efficacy. Overall 36% experienced internalized stigma and 88% moderate to high stigma resistance behaviors. Internalized stigma strongly related to poorer outcomes while resistance demonstrated a weaker, opposite effect. Internalized stigma and stigma resistance are important considerations for IBD outcomes. Interventions to reduce internalized stigma and leverage resistance are warranted.

Chronic fatigue is associated with increased disease-related worries and concerns in inflammatory bowel disease

AIM: To investigate the impact of chronic fatigue on disease-related worries in inflammatory bowel disease (IBD) and the potential multicolinearity between subjective questionnaires.

METHODS: Patients in remission or with mild-to-moderate disease activity completed the fatigue questionnaire (FQ), the rating form of IBD patient concerns (RFIPC), the Short-Form 36 (SF-36), and IBD questionnaire (N-IBDQ). In addition, clinical and epidemiological data were obtained.

RESULTS: In total, 140 patients were included; of which 92 were diagnosed with ulcerative colitis and 48 with Crohn’s disease. The mean age of patients with chronic fatigue was 44.2 years (SD = 15.8) and for non-fatigued patients was 44.7 years (SD = 16.0). Chronic fatigued patients had clinically significantly increased levels of disease-related worries, as measured by Cohen’s d effect size. Worries about having an ostomy bag, loss of bowel control, and energy levels were most prominent in both chronic fatigued and non-chronic fatigued IBD patients. Variance inflation factor (VIF) and tolerance indicated that there were no problematic multicolinearity among the FQ, RFIPC, SF-36 and N-IBDQ responses (VIF < 5 and tolerance > 2).

CONCLUSION: Chronic fatigue is associated with increased levels of disease-related worries and concerns in IBD. Increased levels of worries were also associated with impaired health-related quality of life.

Worries and Concerns among Inflammatory Bowel Disease Patients Followed Prospectively over One Year

Disease-related worries are frequently reported in inflammatory bowel disease (IBD), but longitudinal assessments of these worries are scarce. In the present study, patients completed the rating form of IBD patient concerns (RFIPC) at three occasions during one year. One-way analysis of variance (ANO VA), t-tests, bivariate correlation, and linear regression analyses were used to analyse data. The validity and reliability of the Norwegian RFIPC was tested. A total of 140 patients were included (V1), ulcerative colitis (UC) n = 92, Crohn's disease (CD) n = 48, mean age 46.9 and 40.0-year old, respectively. The highest rated worries included having an ostomy bag, loss of bowel control, and reduced energy levels. Symptoms were positively associated with more worries. A pattern of IBD-related worries was consistent over a period of one year. Worries about undergoing surgery or having an ostomy bag seemed to persist even when symptoms improved. The Norwegian RFIPC is valid and reliable.

Relevance of the phenotypic characteristics of Crohn's disease in patient perception of health-related quality of life

BACKGROUND

Crohn's disease (CD) has a negative impact on patients' perception of health. Several factors, such as disease activity, influence HRQOL impairment. However, the effect of the phenotypic CD characteristics recognized in the Vienna classification on health-related quality of life (HRQoL) remains unknown.

METHODS

HRQOL was measured in CD patients using three questionnaires: the Spanish version of the Inflammatory Bowel Disease Questionnaire (IBDQ-36), the Psychological General Well-Being Index (PGWBI), and the EuroQol.

RESULTS

One hundred ninety-eight CD patients were included. Scores for the IBDQ-36, PGWBI, and EuroQol dimensions did not differ according to age at diagnosis (177 patients under 40 yr and 21 over 40 yr), disease location (53 in terminal ileum, 62 in colon, 72 in ileocolon, and 11 in upper gastrointestinal tract) or disease behavior (99 nonstricturing-nonpenetrating, 32 stricturing, and 67 penetrating). Multivariate analysis identified as significant independent variables for worse HRQoL: female sex (t: -3.70), higher number of relapses per year (t: -2.71), and worse clinical disease activity (t: -7.82). None of the three Vienna variables reached statistical significance.

CONCLUSIONS

HRQoL impairment in CD patients is independent of the clinical variables established in the Vienna classification for phenotypic type of disease.

Review article: psychosocial factors in the quality of life of patients with inflammatory bowel disease

Information on quality of life in inflammatory bowel disease is limited. Despite the clear importance of this topic to patients, quality of life measurement is seldom undertaken in day-to-day management of patients or included in clinical trials. Although previous reviews have dealt with quality of life, the area of psychosocial functioning has not been specifically addressed. The aim of this study was to review the psychosocial factors affecting quality of life in patients with inflammatory bowel disease, using an electronic search of MEDLINE, EMBASE, CINAHL and psycINFO. Of the 751 articles identified by the search, 107 were considered relevant and included in the review. A number of psychosocial factors appear to be important, including gender, socioeconomic status, ethnicity and perceived stress. To improve the quality of life in patients with inflammatory bowel disease, clinicians' attention needs to be drawn towards this subject, with an awareness of those patient groups more vulnerable to impaired quality of life. These identified variables also represent important factors, which should be adjusted for when conducting research into quality of life in these patients.

Patient-perceived usefulness of online electronic medical records: employing grounded theory in the development of information and communication technologies for use by patients living with chronic illness

OBJECTIVE

Patient use of online electronic medical records (EMR) holds the potential to improve health outcomes. The purpose of this study is to discover how patients living with chronic inflammatory bowel disease (IBD) value Internet-based patient access to electronic patient records.

DESIGN

This was a qualitative, exploratory, descriptive study using in-depth interviews and focus groups of a total of 12 patients with IBD of at least one-year duration at University Health Network, a tertiary care center in Toronto, Ontario.

RESULTS

Four themes have been elucidated that comprise a theoretical framework of patient-perceived information and communication technology usefulness: promotion of a sense of illness ownership, of patient-driven communication, of personalized support, and of mutual trust.

CONCLUSIONS

For patients with chronic IBD, simply providing access to electronic medical records has little usefulness on its own. Useful technology for patients with IBD is multifaceted, self-care promoting, and integrated into the patient's already existing health and psychosocial support infrastructure. The four identified themes can serve as focal points for the evaluation of information technology designed for patient use, thus providing a patient-centered framework for developers seeking to adapt existing EMR systems to patient access and use for the purposes of improving health care quality and health outcomes. Further studies in other populations are needed to enhance generalizability of the emergent theory.