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

Impact of Nursing Interventions via Telephone and Email on the Quality of Life of Patients with Inflammatory Bowel Disease: Preliminary Results of a Comparative Observational Study

BACKGROUND

Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is a heterogeneous chronic condition characterized by periods of relapse and remission. Ulcerative colitis involves inflammation of the colon and rectum mucosa, while Crohn's disease causes deeper, transmural inflammation affecting all four gut layers from the mouth to the anus and can lead to complications such as fistulation. IBD significantly impacts patients' physical and psychological well-being, thus reducing their quality of life (QoL). We aimed to evaluate the effectiveness of nursing intervention facilitated through telephone and email support in improving the quality of life (QoL) of Inflammatory Bowel Disease (IBD) patients.

METHODS

A pilot comparative observational design with pre-test and post-test assessments was employed, involving 50 participants assigned to either an intervention group (Group A, n = 26) or a control group (Group B, n = 24). Group A received regular telephone consultations and prompt email responses from trained nurses; Group B received standard care. Data were collected at baseline and six months post-intervention (T1) using the Patient-Reported Outcomes Measurement Information System (PROMIS®) and Pittsburgh Sleep Quality Index.

RESULTS

Group A showed significant improvements in anxiety, depression, fatigue, and sleep quality, with p-values indicating the significance of these findings.

CONCLUSIONS

Tailored nursing support via remote communication significantly benefits IBD patients by alleviating psychological distress and enhancing their overall well-being, underscoring the importance of integrating such interventions into standard IBD care practices.

The effects of stress on gut virome: Implications on infectious disease and systemic disorders

The role of gut microbiota in health and disease is being thoroughly examined in various contexts, with a specific focus on the bacterial fraction due to its significant abundance. However, despite their lower abundance, viruses within the gut microbiota are gaining recognition for their crucial role in shaping the structure and function of the intestinal microbiota, with significant effects on the host as a whole, particularly the immune system. Similarly, environmental factors such as stress are key in modulating the host immune system, which in turn influences the composition of the gut virome and neurological functions through the bidirectional communication of the gut-brain axis. In this context, alterations in the host immune system due to stress and/or dysbiosis of the gut virome are critical factors in the development of both infectious and noninfectious diseases. The molecular mechanisms and correlation patterns between microbial species are not yet fully understood. This literature review seeks to explore the interconnected relationship between stress and the gut virome, with a focus on how this interaction is influenced by the host's immune system. We also discuss how disturbances in this finely balanced system can lead to the onset and/or progression of diseases.

Noise is a Risk Factor for Patients with Ulcerative Colitis and Anxiety

BACKGROUND

This work aimed to explore anxiety-associated risk factors in patients diagnosed with ulcerative colitis (UC).

METHODS

Clinical data from patients diagnosed with UC and hospitalized at the First Affiliated Hospital of Xi'an Jiaotong University between May 2019 and June 2022 were retrospectively analyzed. A total of 260 patients were included and divided into UC with anxiety (n = 86) and UC without anxiety (n = 174) groups according to the Self-Rating Anxiety Scale score. The quality of life and disease activity in patients with UC were assessed using the Inflammatory Bowel Disease Questionnaire and Mayo Score, respectively. Clinical data, disease characteristics, quality of life, disease activity, and noise exposure were compared between the groups, and factors contributing to anxiety in patients with UC were explored through multivariate logistic regression analysis.

RESULTS

No significant difference was found between the groups in terms of disease duration (P = 0.73), distribution of disease (P = 0.86), or medication use (P = 0.86). However, compared to UC patients without anxiety, those with anxiety were older (P < 0.05), predominantly female (P < 0.05), had lower quality of life (P < 0.05), experienced higher disease activity (P < 0.05), and had greater noise exposure (P < 0.05). The quality of life [odds ratio (OR) = 0.558, 95% confidence interval (CI) = 0.348-0.895, P = 0.02] was a protective factor for anxiety in patients with UC. Disease activity (OR = 1.680, 95% CI = 1.103-2.561, P = 0.02) and noise exposure (OR = 2.148, 95% CI = 1.084-4.106, P = 0.01) were significant risk factors for anxiety in patients with UC.

CONCLUSION

Noise exposure and disease activity were associated with an increased risk of anxiety in patients with UC, whereas higher quality of life was protective against anxiety in UC patients.

Psychological symptoms and quality of life in patients with inflammatory bowel disease in China: A multicenter study

AIMS

To investigate the current situation of mental psychology and quality of life (QoL) in patients with inflammatory bowel disease (IBD) in China, and analyze the influencing factors.

METHODS

A unified questionnaire was developed to collect clinical data on IBD patients from 42 hospitals in 22 provinces from September 2021 to May 2022. Multivariate Logistic regression analysis was conducted, and independent influencing factors were screened out to construct nomogram. The consistency index (C-index), receiver operating characteristic (ROC) curve, area under the ROC curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, accuracy, and clinical utility of the nomogram model.

RESULTS

A total of 2478 IBD patients were surveyed, including 1371 patients with ulcerative colitis (UC) and 1107 patients with Crohn's disease (CD). Among them, 25.5%, 29.7%, 60.2%, and 37.7% of IBD patients had anxiety, depression, sleep disturbance and poor QoL, respectively. The proportion of anxiety, depression, and poor QoL in UC patients was significantly higher than that in CD patients (all p < 0.05), but there was no difference in sleep disturbance between them (p = 0.737). Female, higher disease activity and the first visit were independent risk factors for anxiety, depression and sleep disturbance in IBD patients (all p < 0.05). The first visit, higher disease activity, abdominal pain and diarrhea symptoms, anxiety, depression and sleep disturbance were independent risk factors for the poor QoL of patients (all p < 0.05). The AUC value of the nomogram prediction model for predicting poor QoL was 0.773 (95% CI: 0.754-0.792). The calibration diagram of the model showed that the calibration curve fit well with the ideal curve, and DCA showed that the nomogram model could bring clinical benefits.

CONCLUSION

IBD patients have higher anxiety, depression, and sleep disturbance, which affect their QoL. The nomogram prediction model we constructed has high accuracy and performance when predicting QoL.

Illness Perceptions as a Predictor of Symptom Cluster Trajectories in Patients With Inflammatory Bowel Disease: A Latent Growth Mixture Model

The aims of this study were to (a) identify the trajectory of symptom clusters in patients with inflammatory bowel disease up to 28 weeks after initiation of infliximab therapy and (b) examine the illness perceptions associated with symptom cluster trajectories. This was a prospective study where participants completed the symptom cluster scale at baseline, 14 weeks, and 28 weeks. A latent growth mixture modeling was used to identify trajectories of symptom clusters that were predicted, using baseline covariates (Brief Illness Perception Questionnaire). A total of 206 patients were included and identified as three latent classes: moderate symptom cluster-stable decline group (C1), high symptom cluster-rapid decline group (C2), and stable symptom cluster-stable trend group (C3). C1 was predicted by cognitive illness perceptions (odds ratio [95% confidence interval]: 1.134 [1.071, 1.200], p < .001). C2 was also predicted by cognitive and emotional illness perceptions (odds ratio [95% confidence interval]: 1.169 [1.095, 1.248], p < .001; odds ratio [95% confidence interval]: 1.174 [1.038, 1.328], p = .011). Patients with inflammatory bowel disease, initiating infliximab therapy, had different symptom cluster trajectories. Illness perceptions were associated with symptom cluster classes, which underline the complexity of symptoms. Paying attention to these factors and providing necessary knowledge and psychological supporting care after infliximab therapy would effectively improve patients' symptom burden.

Defining Comprehensive Disease Control for Use as a Treatment Target for Ulcerative Colitis in Clinical Practice: International Delphi Consensus Recommendations

BACKGROUND AND AIMS

Treatment of ulcerative colitis [UC] requires a patient-centric definition of comprehensive disease control that considers improvements in aspects not typically captured by classical landmark trial endpoints. In an international initiative, we reviewed aspects of UC that affect patients and/or indicate mucosal inflammation, to achieve consensus on which aspects to combine in a definition of comprehensive disease control, using a modified Delphi process.

METHODS

The Delphi panel comprised 12 gastroenterologists and one patient advocate. Two gastroenterologists were elected as chairs and did not vote. To inform statements, we asked 18 patients and the panel members about their experiences of remission and reviewed published literature. Panel members voted on statements anonymously in three rounds, with a live discussion before Round 3. Consensus was met if ≥67% of the panel agreed. Statements without consensus in Rounds 1 and 2 were revised or discarded after Round 3.

RESULTS

The panel agreed to measure individual patient benefit using a definition of comprehensive disease control that combines aspects currently measured in trials [rectal bleeding, stool frequency, disease-related quality of life, endoscopy, histological inflammatory activity, inflammatory biomarkers, and corticosteroid use] with additional patient-reported symptoms [bowel urgency, abdominal pain, extraintestinal manifestations, fatigue, and sleep disturbance]. The panel agreed on scoring systems and thresholds for many aspects.

CONCLUSIONS

Using a robust methodology, we defined comprehensive disease control in UC. Next, we will combine the measurement and scoring of these aspects into a multicomponent tool and will adopt comprehensive disease control as a treatment target in clinical practice and trials.

Factors Affecting and Promoting Health-related Quality of Life in Patients With Liver Cirrhosis: An Underestimated Domain in Patient Care

Cirrhosis patients have poor health-related quality of life (HRQoL). To enhance medical care and therapeutic approaches, it is crucial to identify factors that alter HRQoL in patients with cirrhosis. The present study aims to identify the potential factors affecting and promoting HRQoL in patients with liver cirrhosis. Four databases were extensively searched, including PubMed, Scopus, Embase, and Google Scholar. All original articles with liver cirrhosis and factor-altering HRQoL were included. The present study showed that elderly age, female gender, low family income, low body mass index (BMI), presence of anxiety and depression, presence of cirrhosis complications including ascites, hepatic encephalopathy (HE), and abnormal endoscopic findings, high disease severity score, presence of sarcopenia, disturbed sleep pattern, muscle cramps, poor sexual health, and increased levels of bilirubin, prothrombin time, and albumin-bilirubin ratio were the significant factors associated with lower HRQoL scores. Meanwhile, physical exercise, liver transplant, stem cell therapy, mindfulness, and the use of probiotics, rifaximin, and lactulose were associated with increased HRQoL scores. The present study recommends more prospective or randomized control trials with interventions including health education, yoga, psychotherapy, and other potential factors promoting HRQoL in patients with liver cirrhosis. The present study also emphasizes that the treating physician should consider taking HRQoL into account when prescribing medical therapy.

Exploring work productivity loss in patients with inflammatory bowel disease

Aim

We aimed in this study to evaluate the impact of inflammatory bowel disease (IBD) on patients' professional life and to determine predictors of severe work productivity loss (WPL).

Materials & methods

A cross sectional study including patients with a confirmed diagnosis of IBD. Work productivity was evaluated with the work productivity and activity impairment score.

Results

Severe absenteeism and WPL were found in respectively 7 (5.1%) and 54 (39.1%) patients. In multivariate analysis, the following features were found to be independently associated with severe WPL: penetrating Crohn's disease (p: 0.001, OR: 6), anemia (p: 0.031, OR: 3.23), diarrhea (p < 0.001, OR: 11.23) and a secondary level of education (p: 0.003, OR: 1.95).

Conclusion

Our results show that IBD have a substantial effect on patients' professional life.

Systematic review: Individual-level factors and social determinants of health impacting sleep health in individuals with inflammatory bowel disease

AIM

To examine the individual-level factors and social determinants of health (SDOH) linked to sleep health among individuals with inflammatory bowel disease (IBD).

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

Four databases (PubMed, Web of Science, CINAHL and PsycINFO) were searched in February 2022.

REVIEW METHODS

Databases were searched with keywords related to IBD and sleep. The review was conducted per the PRISMA protocol. The checklist for analytical cross-sectional studies published by the Joanna Briggs Institute was used for quality appraisal. Factors were organized by individual, social and societal levels according to the social-ecological model of sleep health.

RESULTS

In the review, 45 studies were identified and synthesized. All studies examined individual-level factors with sleep, with age being the most common factor studied. Only nine studies considered a social determinant of health which included marital status, number of children, education level, annual income, employment status, work tenure, type of employment, area of residence, minority status/ethnicity and COVID-19. However, the source of information for the social determinant of health was not clearly defined for more than half of these studies.

CONCLUSION

Although IBD sleep research has explored individual-level factors (i.e. age) that impact sleep health, there is a lack of information on the SDOH that can contribute to sleep health.

IMPACT

This review provides insight into the different factors that have been examined in IBD sleep research. By determining the SDOH that impact sleep, nursing research can inform sustainable and tailored interventions that focus on changing behaviour and improving sleep of individuals of varying backgrounds and life experiences. There is a continued need for nurses in practice and research to explore the SDOH that influence health outcomes and the daily lives of those with IBD.

Gastrointestinal Symptoms Impact Psychosocial Function and Quality of Life in Patients with Rheumatoid Arthritis and Spondyloarthritis: A Cross-Sectional Study

Patients with chronic Inflammatory Arthritis (IA), such as Rheumatoid Arthritis (RA) and Spondyloarthritis (SpA) are more likely to experience psychosocial impairment. Gastrointestinal (GI) symptoms are also present, especially in Spondyloarthritis. No data are available on the relationship between gut and brain manifestations and their impact on daily activities in this setting; thus, this study aimed to assess these symptoms in an IA population and identify potential associations. IA patients and a control group were enrolled. The Patient-Reported Outcome Measurement Instrument System (PROMIS^®) questionnaire was used to evaluate GI and psychosocial domains. The study included 389 subjects (238 controls and 151 with IA); demographic and clinical data were collected for each participant. IA patients reported both higher psychosocial and GI impairment compared with controls. The logistic regression model revealed a strong association between depression and belly pain (p = 0.035), diarrhea (p = 0.017), bloating (p = 0.018), and reflux (p = 0.01); anxiety was associated with belly pain (p = 0.004), diarrhea (p = 0.019), swallowing alterations (p = 0.004), flatulence (p < 0.001) and reflux (p = 0.008). Moreover, fatigue, sleep disorders, and pain interference were associated with almost all GI symptoms, whereas high physical function scores and satisfaction in social roles decreased the odds of most GI symptoms. IA patients had more significant impairment in both dimensions compared with controls. To address reported symptoms and improve the overall quality of life in rheumatologic patients, a new holistic approach is required.

Repercussões das Doenças Inflamatórias Intestinais no Desenvolvimento Socioemocional de Pacientes Pediátricos

Este estudo descreve as repercussões dos sintomas das doenças inflamatórias intestinais (DII) nas emoções, na vida escolar e nas interações sociais de pacientes pediátricos. Participaram 20 cuidadores de crianças e adolescentes com idades entre cinco e 17 anos e diagnosticados com alguma DII. Os cuidadores, que tinham entre 26 e 54 anos, forneceram informações clínicas e sociodemográficas e responderam a um questionário sobre as repercussões dos sintomas das DII na vida das crianças e dos adolescentes. A análise das frequências absolutas e relativas e o teste de aderência revelaram que os impactos dos sintomas foram significativamente maiores nas emoções quando comparados aos impactos na vida escolar e nas interações sociais (X² = 6,14; df= 2; p= 0,04). O tratamento das DII deve incluir a construção de planos terapêuticos sensíveis às necessidades psicossociais dos pacientes pediátricos.

Inflammatory bowel disease: perceived impact on leisure-time activities

OBJECTIVE

Inflammatory bowel disease, consisting of Crohn's disease and ulcerative colitis, is known to negatively impact an individual's quality of life. Leisure-time activities are an important part of life by creating and strengthening social networks. The aim of this study was to thoroughly evaluate the perceived impact of inflammatory bowel disease on leisure-time activities by quantifying limitations in activities caused by the disease.

METHODS

A structured questionnaire, hospital records and national registers were combined to assess limitations caused by the disease in a patient's leisure-time activities. The final study sample was 561 patients.

RESULTS

More than half of the patients (52.8%) reported that IBD had caused limitations in their leisure-time activities. Women perceived that their limitations were greater when compared to the reports by men. One-third of the patients (33.3%) reported reducing and 17.6% abandoning at least one leisure-time activity due to their disease. Most often mentioned activities that were reduced and abandoned were physical activities. The IBDQ32 score had a significant correlation with all of the studied outcomes. Laboratory tests results and the patient's age or the level of income did not correlate with limitations in leisure-time activities.

CONCLUSIONS

In conclusion, this study showed that patients with inflammatory bowel disease perceived a marked limitation in their leisure-time activities due to their disease.

Measuring Mood and Anxiety Disorders by Patient Reported Outcomes in Inflammatory Bowel Disease: A Literature Review Update

Background Anxiety and depression are the most common psychological disorders found in Inflammatory Bowel Disease (IBD) patients. Accurate measuring of these disorders should be proposed for a prompt management. Patient-reported outcome measurements (PROMs) allow patients to self-report their psychological symptoms. Objective To highlight the presence of PROMs measuring anxiety and depression in IBD setting evaluating the most used psychometric tools. Methods We reviewed the literature from 2010 up to September 2021. Articles on adult IBD patients assessing depression and anxiety by PROMs in English language were included. Results Thirty-six studies, including 11 psychometric tools were found. Hospital Anxiety and Depression Scale (21 studies), Beck Depression Inventory II (5 studies), Spielberg State-Trait Anxiety Inventory (3 studies), Patient-Reported Outcomes Measurement Information System (3 studies), Symptom Checklist-90 (2 studies), Euro Quality of Life (2 studies) mostly used psychometric tools for anxiety and depression in IBD settings. Conclusion Our review analyzed psychometric tools used for PROMs evaluating anxiety and depression in IBD setting. No chronological differences have emerged, all have been used in the last ten years, highlighting a lack of specificity. The strong association between IBD and mood disorders suggests that clinicians should consider the evaluation of depression and anxiety as integral parts of IBD clinical care. It is essential to identify tools enabling these items to be detected better. A global view of IBD patients, accounting not only for physical but also for psychical symptoms with an early and feasible assessment of unrecognized psychiatric disorders, can have a strong impact on their management strategy.

Satisfaction in Social Roles and Physical Function in Immune-mediated Inflammatory Diseases: A Cross-Sectional Study

BACKGROUND

Although mood disorders have been well characterized in Immune-mediated inflammatory diseases, physical function and satisfaction in social roles have not yet been defined as independent domains.

OBJECTIVE

The study aims to assess satisfaction in social roles and physical function alterations in an Immune-mediated inflammatory diseases population and identify associated characteristics.

METHODS

Physical function and social roles satisfaction were evaluated through the Patient-Reported Outcomes Measurement System. Besides comparisons between groups, univariate and multivariable logistic regression were performed to identify independent predictors.

RESULTS

Two hundred sixty-five Immune-mediated Inflammatory Diseases patients and 206 controls were recruited. Compared with controls, Inflammatory Bowel Diseases patients had impaired physical function (p<0.001), while Inflammatory Arthritis patients reported impairment in both domains (p<0.001, each). In the univariate logistic regression, gender, high school educational level, physical activity and occupation were positively associated with physical function and social role satisfaction (p<0.001; p=0.001; p<0.001; p=0.001 and p<0.001; p=0.012; p=0.008; p=0.004, respectively). Active disease and steroids were inversely associated with physical function and social roles satisfaction (p=0.033; p=0.022 and p=0.002; p=0.038, respectively). Further associations were found between age and physical function (p=0.002); biological treatment and ESR with social roles satisfaction (p<0.001; p=0.043; respectively). In the multivariable regression, gender remained associated with physical function (p<0.001) and social roles satisfaction (p=0.003). Negatively associated factors were biological treatment for satisfaction in social roles (p<0.001) and steroids for physical function (p=0.021) and social roles satisfaction (p=0.018).

CONCLUSION

Immune-mediated Inflammatory diseases determine alterations in physical function and social life satisfaction. Gender and treatment are independent associated factors. Patient-Reported Outcomes should be considered in clinical management to define patients' real needs.

Prevalence of anxiety and depressive symptoms in ulcerative colitis patients in Jordan and its relationship to patient-reported disease activity

Inflammatory bowel disease is associated with higher rates of anxiety and depression compared to the general population. We aimed to determine the prevalence of anxiety and depressive symptoms among patients with ulcerative colitis and correlation to disease activity. In this cross-sectional study, we collected data from 70 consecutive ulcerative colitis patients over one year at our inflammatory bowel disease outpatient clinic through an interview and a questionnaire containing patient demographics and disease characteristics. Anxiety and depressive symptoms were characterized using the Generalized Anxiety Disorder-7 questionnaire and Patient Health Questionnaire-9, respectively, with ulcerative colitis disease severity assessed by the Partial Mayo scoring system. The majority of our patients were females (68.6%) and the mean age was 39.3 years. Rates of anxiety and depressive symptoms among ulcerative colitis patients were 65.7% and 58.6%, respectively. Depressive symptoms were significantly associated with patient-reported disease activity (r = 0.361; p = 0.010). Significant percentages of ulcerative colitis patients were appreciated to have anxiety and depressive symptoms, and there was a correlation between patient-reported disease activity and depressive symptoms. At this high rate of prevalence, it is justified to screen patients for the presence of psychiatric comorbidities.

Fatigue and Associated Factors in an Immune-Mediated Inflammatory Disease Population: A Cross-Sectional Study

Fatigue is a main symptom of chronic diseases, including immune-mediated inflammatory diseases (IMIDs), such as inflammatory bowel disease (IBD) and inflammatory arthritis (IA); however, the pathophysiological mechanisms are not completely understood. The aim of this study was to assess the prevalence of fatigue and the associated factors in an IMIDs population. A control group, IBD, and IA patients, were enrolled. The PROMIS® fatigue questionnaire was used to evaluate the symptoms. Information on demographics, anthropometrics, disease characteristics, and medications was collected for each participant. A total of 471 subjects (137 with IBD, 103 with IA, and 206 controls) were enrolled. IBD and IA patients reported greater fatigue than controls (p < 0.001, each). In univariate regression, patients with anxiety and depression were more likely to report fatigue (p = 1.40 × 10−9 and p = 3.80 × 10−11, respectively). Males, holding a high school diploma, and being employed were inversely correlated to the domain (p = 1.3 × 10−5; p = 0.003 and p = 0.005, respectively). The use of steroids and disease activity determined increased fatigue (p = 0.014 and p = 0.019; respectively). In the multivariate analysis, anxiety and depression remained associated (p = 0.002 and p = 1.3 × 10−5, respectively). IMIDs patients present increased fatigue compared with healthy subjects. Anxiety and depression are the main associated factors, suggesting a psychological component of the symptom; thus, a holistic management should be established.

Impact of the Lockdown Due to the COVID-19 Pandemic on Patients With Inflammatory Bowel Disease

Background: The government of Japan declared a state of emergency on April 16, 2020, owing to the coronavirus disease 2019 (COVID-19) pandemic. The subsequent lockdown altered lifestyles and worsened mental illnesses. Inflammatory bowel disease (IBD) is an intestinal disorder that is affected by environmental factors. Therefore, we aimed to assess the effects of COVID-19 and the state of emergency on the lifestyle and disease activity of patients with IBD. Methods: We conducted a questionnaire survey on patients with IBD from June 16 to August 21, 2020 during their regular follow-up at our hospital, 2 months after the state of emergency was declared. Results: Overall, 241 patients with ulcerative colitis (UC) and 210 with Crohn's disease (CD) completed the survey, of which 82 (34%) and 97 (46%) patients, respectively, reported disease exacerbation within 2 months after the lockdown. Multivariate logistic regression analysis identified age at enrollment (odds ratio, OR 0.98, 95% CI 0.96-0.99; P < 0.05), sleep hours (OR, 0.74; 95% CI, 0.57-0.97; P < 0.05), and increased stress due to the COVID-19 pandemic (OR, 6.06; 95% CI, 1.79-20.50; P < 0.01) as independent factors associated with UC exacerbation. Patients with exacerbated CD were younger at CD onset and had higher patient-reported outcome 2 scores before the state of emergency than patients with non-exacerbated CD. On multivariate analysis, age (OR, 0.97; 95% CI, 0.95-0.99; P < 0.01) and active disease before the state of emergency (OR, 2.20; 95% CI, 1.23-3.95; P < 0.01) were independently associated with CD exacerbation. Conclusions: Improving sleep quality and preventing psychological stress may be crucial in IBD management during a pandemic, especially in young patients.

Psychometric evaluation of an Italian custom 4-item short form of the PROMIS anxiety item bank in immune-mediated inflammatory diseases: an item response theory analysis

Background

There has recently been growing interest in the roles of inflammation in contributing to the development of anxiety in people with immune-mediated inflammatory diseases (IMID). Patient-reported outcome measures can facilitate the assessment of physical and psychological functioning. The National Institutes of Health (NIH)'s Patient-Reported Outcomes Measurement Information System (PROMIS®) is a set of Patient-Reported Outcomes (PROs) that cover physical appearance, mental health, and social health. The PROMIS has been built through an Item Response Theory approach (IRT), a model-based measurement in which trait level estimates depend on both persons' responses and on the properties of the items that were administered. The aim of this study is to test the psychometric properties of an Italian custom four-item Short Form of the PROMIS Anxiety item bank in a cohort of outpatients with IMIDs.

Methods

We selected four items from the Italian standard Short Form Anxiety 8a and administered them to consecutive outpatients affected by Inflammatory Bowel disease (n = 246), rheumatological (n = 100) and dermatological (n = 43) diseases, and healthy volunteers (n = 280). Data was analyzed through an Item Response Theory (IRT) analysis in order to evaluate the psychometric properties of the Italian adaptation of the PROMIS anxiety short form.

Results

Taken together, Confirmatory Factor Analysis and Exploratory Factor analysis suggest that the unidimensionality assumption of the instrument holds. The instrument has excellent reliability from a Classical Theory of Test (CTT) standpoint (Cronbach's α = 0.93, McDonald's ω = 0.92). The 2PL Graded Response Model (GRM) model provided showed a better goodness of fit as compared to the 1PL GRM model, and local independence assumption appears to be met overall. We did not find signs of differential item functioning (DIF) for age and gender, but evidence for uniform (but not non-uniform) DIF was found in three out of four items for the patient vs. control group. Analysis of the test reliability curve suggested that the instrument is most reliable for higher levels of the latent trait of anxiety. The groups of patients exhibited higher levels of anxiety as compared to the control group (ps < 0.001, Bonferroni-corrected). The groups of patients were not different between themselves (p = 1, Bonferroni-corrected). T-scores based on estimated latent trait and raw scores were highly correlated (Pearson's r = 0.98) and led to similar results.

Discussion

The Italian custom four-item short form from the PROMIS anxiety form 8a shows acceptable psychometric properties both from a CTT and an IRT standpoint. The Test Reliability Curve shows that this instrument is mostly informative for people with higher levels of anxiety, making it particularly suitable for clinical populations such as IMID patients.

Health-related quality of life in outpatients with chronic liver disease: a cross-sectional study

Background

The symptoms and complications related to chronic liver disease (CLD) have been shown to affect patient well-being. Currently there is limited research data on how CLD severity may affect both health-related quality of life (HRQOL) and the development of depressive symptoms in CLD patients. Moreover, the ongoing advances in CLD treatment, and its effect on HRQOL, highlight the need for further studies. Therefore, the aim of the present study was to evaluate if the CLD severity may affect the HRQOL and the development of depressive symptoms.

Methods

A cross-sectional study was conducted. Patients with CLDs were identified at their regular visits to the outpatient clinic of the Sant’Orsola-Malpighi Hospital in Bologna, between September 2016 and July 2017. HRQOL was measured with Short Form 12 (SF-12) and Nottingham Health Profile (NHP) questionnaires; depressive symptoms were measured with Beck Depression Inventory-II (BDI). CLD severity was measured using the MELD score and the sample was stratified into five classes according to it. Group comparisons were conducted using the Kruskal–Wallis test.

Results

Two hundred and fifty-four patients were included. Mean age was 62.84 years (SD 11.75) and 57.9% were male. Most participants were affected by compensated cirrhosis (140.2%) and chronic hepatitis (40.2%), with a disease duration ≥ 5 years (69.3%). Regarding the MELD score, 67.7% of patients belonged to Class I, 29.9% to Class II, and 2.4% to Class III. There were not patients belonging to the Classes IV and V.

No statistically significant differences were found in all SF-12 and NHP domains between the MELD classes, except for CLD impact on sexual life and holidays (p = 0.037 and p = 0.032, respectively). A prevalence rate of 26% of depressive symptoms was reported, no statistically significant differences were found in BDI-II total scores between the three MELD classes.

Conclusions

All domains of HRQOL and depression were altered in CLDs patients, nevertheless CLD severity was not confirmed as an affecting factor for HRQOL.

Small Molecule Drugs in Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs), mainly represented by Crohn’s disease (CD) and Ulcerative Colitis (UC), are chronic disorders with an unclear pathogenesis. This incurable and iterative intestinal mucosal inflammation requires the life-long use of anti-inflammatory drugs to prevent flares or relapses, which are the major providers of complications, such as small bowel strictures and intestinal perforations. The introduction of tumor necrosis factor (TNF)-alpha inhibitors and other compounds, such as anti-IL12/23 and anti-alpha4/beta7 integrin monoclonal antibodies, has considerably improved the clinical management of IBDs. They are now the standard of care, being the first-line therapy in patients with aggressive disease and in patients with moderate to severe disease with an inadequate response to conventional therapy. However, for approximately one third of all patients, their efficacy remains insufficient by a lack or loss of response due to the formation of anti-drug antibodies or compliance difficulties with parenteral formulations. To address these issues, orally administered Small Molecules Drugs (SMDs) that use a broad range of novel pharmacological pathways, such as JAK inhibitors, sphingosine-1-phosphate receptor modulators, and phosphodiesterase 4 inhibitors, have been developed for CD and UC. This article provides an updated and complete review of the most recently authorized SMDs and SMDs in phase II/III development.

Faecal Calprotectin in Assessment of Mucosal Healing in Adults with Inflammatory Bowel Disease: A Meta-Analysis

Achieving mucosal healing in patients with inflammatory bowel disease is related to a higher incidence of sustained clinical remission and it translates to lower rates of hospitalisation and surgery. The assessment methods of disease activity and response to therapy are limited and mainly rely on colonoscopy. This meta-analysis reviews the effectiveness of using faecal calprotectin as a marker for mucosal healing in inflammatory bowel disease. Two meta-analyses were conducted in parallel. The analysis on the use of faecal calprotectin in monitoring mucosal healing in colonic Crohn’s disease is based on 16 publications (17 studies). The data set for diagnostic values of faecal calprotectin in ulcerative colitis is composed of 35 original publications (total 49 studies). The DOR for the use of faecal calprotectin in Crohn’s disease is estimated to be 11.20 and the area under the sROCis 0.829. In cases of ulcerative colitis, the DOR is 14.48, while the AUC sROC is 0.858. Heterogeneity of the studies was moderatetosubstantial. Collected data show overall good sensitivity and specificity of the faecal calprotectin test, as well as a good DOR. Thus, monitoring of mucosal healing with a non-invasive faecal calprotectin test may represent an attractive option for physicians and patients with inflammatory bowel disease.

Can Conventional and Diffusion-Weighted MR Enterography Biomarkers Differentiate Inflammatory from Fibrotic Strictures in Crohn's Disease?

Background and Objectives: To retrospectively assess the value of magnetic resonance enterography (MRE) parameters derived from conventional and diffusion weighted imaging (DWI) sequences to differentiate fibrotic strictures from inflammatory ones in adult patients with Crohn’s disease (CD), using surgical specimens as the histopathological reference standard. Material and Methods: Twenty-three patients with CD who had undergone surgical resection of ileal strictures with full-thickness histopathologic analysis within 3 months from preoperative MRE were included. Two radiologists blinded to histopathology in consensus evaluated the following biomarkers on MRE images matched to resected pathological specimens: T1 ratio, T2 ratio, enhancement pattern, mural thickness, pre-stenotic luminal diameter, and apparent diffusion coefficient (ADC). A blinded pathologist graded stricture histological specimens with acute inflammation score (AIS) and fibrosis score (FS). MRE measurements were correlated with the reference standard. Results: Inflammation and fibrosis coexisted in 78.3% of patients. T2 ratio was reduced in patients with severe fibrosis (p = 0.01). Pre-stenotic bowel dilatation positively correlated with FS (p = 0.002). The ADC value negatively correlated with FS (p < 0.001) and was different between FS grades (p < 0.05). The area under the receiver operating characteristic curve for discriminating between none and mild/moderate–severe bowel wall fibrosis was 0.75 for pre-stenotic bowel dilatation (sensitivity 100%, specificity 44.4%) and 0.97 for ADC (sensitivity 80%, specificity 100%). Conclusions: Inflammation and fibrosis often coexist in CD bowel strictures needing surgery. The combination of parameters derived from conventional MR sequences (T2 ratio, pre-stenotic dilatation) and from DWI (ADC) may provide a contribution to detect and grade bowel fibrosis in adult CD patients.

Prevalence of symptoms of anxiety and depression in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a lifelong condition with no cure. Patients with IBD might experience symptoms of common mental disorders such as anxiety and depression because of bidirectional communication via the gut-brain axis and chronicity of symptoms, and because of impaired quality of life and reduced social functioning. However, uncertainties remain about the magnitude of this problem. We aimed to assess prevalence of symptoms of anxiety or depression in adult patients with IBD.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, and PsycINFO for papers published from inception to Sept 30, 2020, reporting observational studies that recruited at least 100 adult patients with IBD and that reported prevalence of symptoms of anxiety or depression according to validated screening instruments. We excluded studies that only used a structured interview to assess for these symptoms and studies that did not provide extractable data. We extracted data from published study reports and calculated pooled prevalences of symptoms of anxiety and depression, odds ratios (OR), and 95% CIs.

FINDINGS

Of 5544 studies identified, 77 fulfilled the eligibility criteria, including 30 118 patients in total. Overall, pooled prevalence of anxiety symptoms was 32·1% (95% CI 28·3-36·0) in 58 studies (I²=96·9%) and pooled prevalence of depression symptoms was 25·2% (22·0-28·5) in 75 studies (I²=97·6%). In studies that reported prevalence of anxiety or depression in patients with Crohn's disease and ulcerative colitis within the same study population, patients with Crohn's disease had higher odds of anxiety symptoms (OR 1·2, 95% CI 1·1-1·4) and depression symptoms (1·2, 1·1-1·4) than patients with ulcerative colitis. Overall, women with IBD were more likely to have symptoms of anxiety than were men with IBD (pooled prevalence 33·8% [95% CI 26·5-41·5] for women vs 22·8% [18·7-27·2] for men; OR 1·7 [95% CI 1·2-2·3]). They were also more likely to have symptoms of depression than men were (pooled prevalence 21·2% [95% CI 15·4-27·6] for women vs 16·2% [12·6-20·3] for men; OR 1·3 [95% CI 1·0-1·8]). The prevalence of symptoms of anxiety (57·6% [95% CI 38·6-75·4]) or depression (38·9% [26·2-52·3]) was higher in patients with active IBD than in patients with inactive disease (38·1% [30·9-45·7] for anxiety symptoms and 24·2% [14·7-35·3] for depression symptoms; ORs 2·5 [95% CI 1·5-4·1] for anxiety and 3·1 [1·9-4·9] for depression).

INTERPRETATION

There is a high prevalence of symptoms of anxiety and depression in patients with IBD, with up to a third of patients affected by anxiety symptoms and a quarter affected by depression symptoms. Prevalence was also increased in patients with active disease: half of these patients met criteria for anxiety symptoms and a third met criteria for depression symptoms. Encouraging gastroenterologists to screen for and treat these disorders might improve outcomes for patients with IBD.

FUNDING

None.

Nursing-sensitive outcomes in adult inflammatory bowel disease: A systematic review

AIMS

To evaluate nursing activity through outcomes that are affected, provided, and/or influenced by nurses and defined as nursing-sensitive outcomes in adult IBD patients.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library databases on August 2019.

REVIEW METHODS

Peer-reviewed articles published between 2000-2020 were reviewed. The outcome measures were contextualized and presented by OMERACT Filter 2.0.

RESULTS

Twenty-four studies were included. Eighteen nursing-sensitive outcomes were identified. These outcomes defined eight domains for health intervention, fitting into three core areas (resource use/economic impact, life impact, pathophysiological manifestations). Fifty-three measurement instruments were identified.

CONCLUSIONS

Through 53 measurement tools, with use of OMERACT framework, 18 nursing-sensitive outcomes in the main 3 core areas were identified, highlighting the multidimensional role of nursing. Further insights are to be carried out to define nursing outcomes included in IBD nursing intervention studies.

IMPACT

These results could serve as a cornerstone for further investigations and validation by a panel of experts to standardizing nursing activity in a multidisciplinary context.

Physical and Metabolic Changes after Ileal Pouch-Anal Anastomosis: A Case Study

This case study examined changes in body composition, resting metabolic rate (RMR), aerobic capacity, and daily physical activity in a patient who had ulcerative colitis and underwent ileal pouch-anal anastomosis (IPAA) surgery. Body composition, RMR, and peak oxygen consumption (VO₂peak) were assessed prior to surgery and four, eight, and 16 weeks after IPAA surgery. Daily physical activity data were extracted from a wrist-worn activity tracker preoperatively and 16 months postoperatively. At baseline, total body mass was 95.3 kg; body fat, 11.6%; lean body mass, 81.1 kg; RMR, 2416 kcal/d; and VO₂peak, 42.7 mL/kg/min. All values decreased from baseline at four weeks postoperatively, body mass was 85.2 kg (-10.5%); body fat, 10.9% (-6.0%); lean body mass, 73.1 kg (-9.9%); RMR 2210 kcal/d (-8.5%) and VO₂peak, 25.5 mL/kg/min (-40.3%). At 16 weeks postoperatively, most parameters were near their baseline levels (within 1-7%), exceptions were VO₂peak, which was 20.4% below baseline, and RMR, which increased to nearly 20% above baseline. After the patient had IPAA surgery, his total and lean body masses, RMR, and aerobic capacity were markedly decreased. Daily physical activity decreased postoperatively and likely contributed to the decreased aerobic capacity, which may take longer to recover compared to body composition and RMR parameters.

COVID-19 and Inflammatory Bowel Disease: Patient Knowledge and Perceptions in a Single Center Survey

Background and objectives: Spreading of SARS-CoV-2 infection from China to countries with a higher prevalence of inflammatory bowel disease (IBD) has generated concern among gastroenterologists and patients. The aim of this survey is to evaluate knowledge about clinical importance of COVID-19, disease management, prevention measures, and anxiety level during pandemic among patients with IBD. Material and methods: From 15th March to 15th April 2020, a questionnaire survey was administered to 200 patients with IBD by email or phone application. The questionnaire consisted of five sections: (1) anthropometric, demographic and clinical characteristics, (2) knowledge about clinical importance of COVID-19, (3) IBD management, (4) prevention measures, (5) anxiety level during pandemic. Results: One hundred forty two questionnaires were completed. Ninety-seven patients (68.3%) were males with a mean age of 46 years (SD 13; range 17-76). Fifty-four individuals (38%) were affected by Crohn disease and 88 (62%) by Ulcerative Colitis. Most patients reported high knowledge about clinical importance of COVID-19 (80%), IBD management (72%), and prevention measures (97%). Sixty-two percent of them showed moderate-high level of anxiety. High education level was independently associated with high knowledge about clinical importance of COVID-19 (odds ratio [OR] 5, 95% confidence interval [CI] 1.49-16.6, p = 0.009) and older age (OR 1, 95%, CI 1.01-1.1, p = 0.01), while the receipt of e-format educational material with low knowledge about clinical importance of COVID-19 (OR 3, 95%, CI 1.08-9.3, p = 0.03). Displaying an active disease appeared to be independently associated with low knowledge of IBD management (OR 5.8, 95% CI 1.4-22.8, p = 0.01) and no variables other than an older age was independently associated with higher level of anxiety (OR 1.04, 95% CI 1.009-1.09, p = 0.01). Conclusions: High educational level and aging promote knowledge about clinical importance of COVID-19, while e-format educational material does not. Taken together with findings that an active disease status compromises knowledge of IBD management and the high level of anxiety related to increasing age, these data suggest the need of further supporting patient-oriented strategies in IBD during Covid-19 pandemic.

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.