Dietary intake and nutritional status in patients with newly diagnosed inflammatory bowel disease: insights from the IBSEN III study

BACKGROUND

Dietary recommendations in inflammatory bowel disease (IBD) are inconclusive, and patients may follow restrictive diets with increased risk of malnutrition. The aim of this study was to compare dietary intakes and nutritional status in men and women with newly diagnosed IBD with a general population sample, and to investigate whether intakes were in line with the Nordic Nutrition Recommendations.

METHODS

This was a cross-sectional study including adults≥ 40 years with IBD from the Inflammatory Bowel Disease in South-Eastern Norway (IBSEN) III cohort study. A validated food frequency questionnaire (FFQ) was used in dietary data collection, and a sample from the seventh survey of the Tromsø Study was included as a comparison group.

RESULTS

A total of 227 men and women with IBD were included. IBD patients had higher intake of grain products, sweetened beverages, energy, fat and polyunsaturated fat (PUFA), but lower intake of dairy products, alcohol and iodine compared to adults from the comparison sample (p < 0.01). Intakes of saturated fat and carbohydrates in both genders, and vitamin D in women were not within recommended levels. Anemia and hypoalbuminemia were more prevalent in IBD patients than in the comparison sample.

CONCLUSIONS

Dietary intakes in newly diagnosed IBD patients were mostly in line with Nordic Nutrition Recommendations. Higher proportion of IBD patients exceeded recommended allowances of fat and added sugar than the comparison sample. Insufficient micronutrient intake, anemia and hypoalbuminemia are present challenges in IBD patients that require monitoring.

Fatigue in Patients with Newly Diagnosed Inflammatory Bowel Disease: Results from a Prospective Inception Cohort, the IBSEN III Study

BACKGROUND AND AIMS

Although fatigue is common in inflammatory bowel disease [IBD], its pathogenesis remains unclear. This study aimed to determine the prevalence of fatigue and its associated factors in a cohort of patients newly diagnosed with IBD.

METHODS

Patients ≥18 years old were recruited from the Inflammatory Bowel Disease South-Eastern Norway [IBSEN III] study, a population-based, observational inception cohort. Fatigue was assessed using the Fatigue Questionnaire and compared with data from a Norwegian general population. Univariate and multivariate linear and logistic regression analyses were performed to evaluate the associations of total fatigue [TF; continuous score] and substantial fatigue [SF; dichotomized score ≥4] with sociodemographic, clinical, endoscopic, laboratory, and other relevant patient data.

RESULTS

In total, 983/1509 [65.1%] patients with complete fatigue data were included (ulcerative colitis [UC], 68.2%; Crohn's disease [CD], 31.8%). The prevalence of SF was higher in CD [69.6%] compared with UC [60.2%] [p < 0.01], and in both diagnoses when compared to the general population [p < 0.001]. In multivariate analyses, depressive symptoms, pain intensity, and sleep disturbances were associated with increased TF for both diagnoses. In addition, increased clinical disease activity and Mayo endoscopic score were significantly associated with TF in UC, whereas all disease-related variables were insignificant in CD. Similar findings were observed for SF, except regarding the Mayo endoscopic score.

CONCLUSIONS

SF affects approximately two-thirds of patients newly diagnosed with IBD. Fatigue was associated with depressive symptoms, sleep disturbances, and increased pain intensity in both diagnoses, while clinical and endoscopic activity were associated factors only in UC.

Health-related quality of life in patients with newly diagnosed inflammatory bowel disease: an observational prospective cohort study (IBSEN III)

PURPOSE

This unselected, population-based cohort study aimed to determine the level of health-related quality of life (HRQoL) in patients with Crohn's disease (CD) and ulcerative colitis (UC) at the time of diagnosis compared with a reference population and identify the demographic factors, psychosocial measures, and disease activity markers associated with HRQoL.

METHODS

Adult patients newly diagnosed with CD or UC were prospectively enrolled. HRQoL was measured using the Short Form 36 (SF-36) and Norwegian Inflammatory Bowel Disease Questionnaires. Clinical significance was assessed using Cohen's d effect size and further compared with a Norwegian reference population. Associations between HRQoL and symptom scores, demographic factors, psychosocial measures, and disease activity markers were analyzed.

RESULTS

Compared with the Norwegian reference population, patients with CD and UC reported significantly lower scores in all SF-36 dimensions, except for physical functioning. Cohen's d effect sizes for men and women in all SF-36 dimensions were at least moderate, except for bodily pain and emotional role for men with UC and physical functioning for both sexes and diagnoses. In the multivariate regression analysis, depression subscale scores ≥ 8 on the Hospital Anxiety and Depression Scale, substantial fatigue, and high symptom scores were associated with reduced HRQoL.

CONCLUSION

Patients newly diagnosed with CD and UC reported statistically and clinically significantly lower scores in seven of the eight SF-36 dimensions than the reference population. Symptoms of depression, fatigue, and elevated symptom scores were associated with poorer HRQoL.

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.

OP0209-HPR BRIDGE – A QUALITY IMPROVEMENT PROGRAM IN TEAM-BASED REHABILITATION: RESULTS FROM A MIXED METHODS STUDY

Background

There is a well-known variability in the quality of rehabilitation provided to patients with rheumatic and musculoskeletal diseases (RMDs). Elements to be improved are a higher standardization of the core content, optimal patient participation in goal setting and continuation of the process in tailored follow-up. More knowledge is needed on critical features for successful delivery of improvement programs in rehabilitation.

Objectives

To investigate how a team-based quality improvement program was implemented and how it influenced the quality in RMD rehabilitation.

Methods

This convergent mixed methods study is nested within a stepped-wedge, randomized controlled trial where providers at 8 rehabilitation-centers delivered traditional programs in the control phase (T1), and added the BRIDGE quality improvement program in the intervention phase (T2). The BRIDGE program addressed a dialog-based, multidisciplinary approach to support the patients’ self-management, comprising motivational interviewing, goal setting, plans for rehabilitation, feedback and monitoring of progress, and tailored follow up. Providers answered 19 structure indicators from a quality indicator (QI) set for RMD rehabilitation [1] at T1 and T2, and a program-fidelity checklist with 18 items at T2 (both scored 0-100%, 100=best). Qualitative data was collected in three focus groups (FG) with the BRIDGE providers, and analyzed using reflexive thematic analysis. Integration and discussion of findings from the different data sources are ongoing, in our research group.

Results

Median summary pass rate for the structure QIs for all centers increased from 53 to 90% between T1 and T2. Program-fidelity was high, with a median summary score of 94% (range 6–100%), but lowest for program-components related to follow-up and communication with external services. Themes developed from the FG interviews reflected that variations in how the program was implemented related to features of the providers and institutions. More specific; the delivery of high-quality rehabilitation depended on the degree to which the providers trained their communication skills, used available tools to support their practice, and grounded their interventions in professional reasons. Critical organisational features at the institutions were dedicated time for team-work based on the patients’ plans for self-management, and sufficient attention to needs for involvement of next of kin or external services. Additionally, better program-implementation occurred if providers experienced an institutional culture for quality improvement, such as educational initiatives from the leaders.

Preliminary integration of data is summarized in Figure 1. Congruent evidence in both quantitative and qualitative findings addressed the sustained needs for better quality in the area of follow-up across levels of care. However, the qualitative findings provided expanded insights on variability also in initial parts of the rehabilitation process. Presumably, these variations in delivery reported in interviews are important for the effectiveness of a quality improvement program, but difficult to capture in questionnaires.

Figure 1.

Complementary viewpoints on how the BRIDGE program was provided and how it influenced the quality of rehabilitation.

Conclusion

To target specific strategies for quality improvement, we suggest a combined attention not only to recommended care reflected in quality indicators and measurable aspects of fidelity, but also to contextual factors, including the providers’ confidence and skills needed to provide a high-quality delivery of all components in a rehabilitation improvement program.

References

[1]Johansen et al. A quality indicator set for use in rehabilitation team care of people with rheumatic and musculoskeletal diseases; development and pilot testing. BMC Health Serv Res. 2019;19(1).

Disclosure of Interests

None declared

Inflammatory bowel disease in South-Eastern Norway III (IBSEN III): a new population-based inception cohort study from South-Eastern Norway

BACKGROUND AND AIM

Modern treatment strategies for inflammatory bowel disease (IBD) are postulated to change the natural disease course. Inception cohort studies are the gold standard for investigating such changes. We have initiated a new population-based inception cohort study; Inflammatory bowel disease in South Eastern Norway III (IBSEN III). In this article, we describe the study protocol and baseline characteristics of the cohort.

METHODS

IBSEN III is an ongoing, population-based observational inception cohort study with prospective follow-up. Adult and pediatric patients with suspected IBD in the South-Eastern Health Region of Norway (catchment area of 2.95 million inhabitants in 2017), during the 3-year period from 2017 to 2019, were eligible for inclusion. Comprehensive clinical, biochemical, endoscopic, demographic, and patient-reported data were collected at the time of diagnosis and throughout standardized follow-up. For a portion of the patients, extensive biological material was biobanked.

RESULTS

The study included 2168 patients, of whom 1779 were diagnosed with IBD (Crohn's disease: 626, ulcerative colitis: 1082, IBD unclassified: 71). In 124 patients, there were subtle findings indicative of, but not diagnostic for, IBD. The remaining 265 patients were classified as symptomatic non-IBD controls.

CONCLUSION

We have included patients in a comprehensive population-based IBD cohort from a catchment population of 2.95 million, and a unique biobank with materials from newly diagnosed and treatment-naïve IBD patients and symptomatic non-IBD controls. We believe this cohort will add important knowledge about IBD in the years to come.

High prevalence of drug-resistant tuberculosis, Republic of Lithuania, 2002

BACKGROUND

Nations of the former Soviet Union have the world's highest reported levels of resistance to anti-tuberculosis drugs. We conducted the first national survey of anti-tuberculosis drug resistance in the Republic of Lithuania.

METHODS

We tested Mycobacterium tuberculosis isolates from all incident culture-positive pulmonary TB patients registered in 2002. New patients were those treated for <1 month with any first-line anti-tuberculosis drug (isoniazid [INH], rifampin [RMP], ethambutol, or streptomycin); previously treated patients were those treated for > or =1 month.

RESULTS

Of 1163 isolates, 475 (41%) were resistant to at least one first-line drug, and 263 (23%) were resistant to at least INH and RMP (MDR); this included 76/818 (9.3%) from new patients and 187/345 (54%) from previously treated patients. Of 52 MDR isolates randomly selected for extended testing at an international reference laboratory, 27 (51%, 95%CI 38-66) had resistance to pyrazinamide, 21 (40%, 95%CI 27-55) to kanamycin, and 9 (17%, 95%CI 8-30) to ofloxacin.

CONCLUSIONS

The prevalence of MDR-TB in Lithuania is among the world's highest. Among MDR-TB isolates, aminoglycoside and fluoroquinolone resistance were common. To combat drug-resistant TB, Lithuania has implemented the WHO global TB control strategy (DOTS), and is developing an MDR-TB treatment program (DOTS-Plus).

Cancer incidence among Danish workers exposed to trichloroethylene

Human evidence regarding the carcinogenicity of the animal carcinogen trichloroethylene (TCE) is limited. We evaluated cancer occurrence among 803 Danish workers exposed to TCE, using historical files of individual air and urinary measurements of TCE-exposure. The standardized incidence ratio (SIR) for cancer overall was close to unity for both men and women who were exposed to TCE. Men had significantly elevated SIRs for non-Hodgkin's lymphoma (SIR = 3.5; n = 8) and cancer of the esophagus (SIR = 4.2; n = 6). Among women, the SIR for cervical cancer was significantly increased (SIR = 3.8; n = 4). No clear dose-response relationship appeared for any of these cancers. We found no increased risk for kidney cancer. In summary, we found no overall increase in cancer risk among TCE-exposed workers in Denmark. For those cancer sites where excesses were noted, the small numbers of observed cases and the lack of dose-related effects hinder etiological conclusions.

[Experiences with teleradiology in general practice in Oppland]

BACKGROUND

Our aim was to evaluate one year of operation of a newly established teleradiology service for people in Mid- and North Gudbrandsdalen (30,000 inhabitants). In Otta, one radiographer works with digital pictures (phosphorus plate technology). Pictures are sent to the local hospital in Lillehammer (115 kilometres away) by a broadband network (for health services only) for radiological evaluation.

MATERIAL AND METHODS

We have measured the scope of the service, patient satisfaction, management stability and efficiency, and financial aspects (the latter are not included in this article).

RESULTS

Over one year we have examined 3,081 persons (skeleton, thorax, sinuses). A majority of patients (90%) thought it was better for them to be examined at Otta. Waiting time was short, rarely more than one week. No re-examinations due to insufficient picture quality were required. Some expected and some unexpected problems occurred. Pictures from 37 patients were lost and could not be radiologically evaluated. The lead time from when pictures were taken to when the requisitioning doctor received the report, was too long (one to three weeks). The digital pictures are not easily available to hospital physicians. Copies must be made on film.

INTERPRETATION

Our experience is positive. Most problems will be solved by storing copies at Otta, by better organisation of the radiologic service, and by establishing a digital picture archiving and communication system (PACS) at the hospital.

Third generation electronic pharmacy communications. Recommendations based on ten years' experience

The number of electronic prescriptions in Denmark is increasing and almost 600,000 electronic prescriptions are now sent every month. There is therefore a strong interest in directly reusing the data entered in the medical practitioner systems in the pharmacy systems. It has therefore been decided to introduce a shared data foundation in all medical practitioner and pharmacy systems in Denmark in conjunction with the introduction of the new MEDPRE electronic prescription standard. Parallel to the standardisation work, concrete guidelines have been prepared for the individual EDP (Electronic Data Processing) systems to ensure rapid, problem-free prescription communication. The aim in the longer term is for 95% of all EDIFACT prescriptions to reach the receiving pharmacy no more than 20 minutes after being sent from a medical practice.

Barriers for dissemination of a national health care data network. A list of recommendations for better dissemination

Establishment of a Danish Nation-wide Health Care Data Network for exchange of health care related information using standardised EDIFACT messages is agreed between the Danish Government, the Hospital Owners and the GPs organisations. The aim is, within year 2000 in the MedCom project, to reach a level of 66% of all messages between the secondary and primary health sector must be send electronically using EDIFACT. There are many barriers for reaching this goal, and to reveal this barriers an investigation was done, and a list of recommendations are set up. The investigation was based upon literature, interviews and most important a questionnaire among 200 GPs and specialists all over the country. After 6 months where the recommendations have been handled there is seen an increase in communicated messages on 40%, and from January 1999 more than 1.1 mill messages are exchanged each month.

Ultrasonic tomography of biological tissue

In this paper, quantitative tomographic reconstructions of biological tissue are presented. First, the experimental setup and a hybrid filtered backpropagation (FBP) technique are briefly described. Using this technique, which includes exact backpropagation of data prior to reconstruction by means of the classical FBP algorithm, quantitative velocity maps of relatively large biological objects can be obtained. Since the FBP algorithm is based on a first-order scattering approximation, the deteriorating effects of higher-order scattering in diffraction tomography are also discussed. The higher-order scattering limits the size of the biological object to a few centimeters.

Quantitative results in ultrasonic tomography of large objects using line sources and curved detector arrays

A tomographic reconstruction technique valid for line sources, curved detector arrays, and large object is presented. For acquisitions involving a curved detector array, inverse diffraction is first used to propagate the field back to a straight line and then the standard filtered backpropagation (FBP) algorithm is employed to reconstruct the image. Using inverse diffraction the measured field can be accurately propagated all the way back to the reconstruction area. Thus an essential improvement is obtained compared to using the approximate backpropagation of Rytov data contained in the FBP algorithm, which becomes inaccurate when the distance from the measurement surface to the reconstruction area is large. This technique is applied to measured data and it is shown that it gives reconstructions of high quality, both with respect to geometry and velocity. It is also shown that, when the illuminating wave is cylindrical rather than plane, segmentation of the image can be used in combination with inverse diffraction and FBP reconstruction to obtain high-quality images of large objects.

DNA strand breaks measured within 100 milliseconds of irradiation of Escherichia coli by 4 MeV electrons

A method was developed in which E. coli cells were irradiated with four MeV electrons and transferred to alkaline detergent within a fraction of a second. This technique minimizes the amount of repair of radiation damage before analysis without the necessity of using physical or chemical treatments to inhibit repair and alter the physiological condition of the cells. The yield of DNA strans breaks formed in covalent circular superhelical lambda DNA molecules superinfecting E. coli lysogens was about 4-fold greater when the cells were irradiated in oxygen than when they were irradiated under nitrogen anoxia. The same yields were obtained in phosphate buffer at 3 degrees and 22 degrees as well as in growth medium at 37 degrees, and the yields were not altered by the polA1 mutation. When E. coli lysogenic cells superinfected with lambda were irradiated with doses sufficient to introduce at least seven breaks in the phage DNA, the chromosomal DNA and the superinfecting phage DNA sedimented similarly in alkaline sucrose gradients, indicating that both DNAs were broken to a similar extent during irradiation. However, the yield of breaks calculated for chromosomal DNA in similar experiments was greater than the yield calculated from the first break introduced into covalent circular lambda DNA molecules. These apparently contradictory results are explicable either if the initial break in a superhelical molecule occurs with an efficiency different from that for subsequent breaks, or if the pulsed electron radiation produces a high proportion of double-strand breaks.

The radiobiology of DNA strand breakage

The yield of single-strand breaks in lambda DNA within lysogenic host bacteria was measured after exposure to 4-MeV electrons (50 msec) and rapid transfer (45 msec) to alkaline detergent. In nitrogen anoxia the yield was 1.2 X 10(-12) DNA single-strand breaks per rad per dalton, and under full oxygenation the yield increased to 5 X 10(-12) breaks per rad per dalton. A search for the presence of fast repair of strand breaks operating within a fraction of a second. Strand breaks produced in the persence of oxygen were repaired in 30-40 sec, while breaks produced under anoxia were rejoined even slower. A functional product from the po[A] gene was needed for the rejoining of the broken molecules. Intermediate levels of DNA strand breakage seen at low concentrations of oxygen are dependent on the concentration of cellular sulfhydryl compounds, suggesting that in strand breakage oxygen donors compete for reactions with radiation-induced transients in the DNA. Intercomparisons of data on radiation-induced lethality of cells and single-strand breaks in episomal DNA allow the distinction between two classes of radiation-induced radicals, R-1 and R-2, with different chemical properties; R-1 reacts readily with oxygen and N-oxyls under formation of potentially lethal products. The reactivity of oxygen in this reaction is 30-40 times higher than that of TMPN. R-2 reacts 16 times more readily that R-1 with oxygen under formation of single-strand breaks in the DNA. R-2 does not react with N-oxyls.

Time scale for rejoining of bacteriophage lambda deoxyribonucleic acid molecules in superinfected pol+ and polA1 strains of Escherichia coli after exposure to 4 MeV electrons

The time scale for rejoining of radiation-induced deoxyribonucleic acid (DNA) single-strand breaks was measured in the presence and absence of oxygen. The involvement of DNA polymerase I in this repair process was studied. Formation and rejoining of DNA strand breaks were measured in lambda DNA infecting lysogenic pol(+) and polA1 strains of Escherichia coli irradiated by 4 MeV electrons under identical conditions. Irradiation and transfer to alkaline detergent could be completed in less than 180 ms. The initial yields of DNA strand breaks were identical in pol(+) and polA1 host cells and four- to fivefold higher in the presence of oxygen than in nitrogen anoxia. Evidence for the existence of a very fast repair process, independent of DNA polymerase I, was not found, since no rejoining of radiation-induced DNA strand breaks was observed during incubation from 45 ms to 3 s. In pol(+) host cells most of the strand breaks produced in the presence of oxygen were rejoined within the first 30 to 40 s of incubation, whereas no rejoining could be detected within the same period of time in anoxic cells. Since no rejoining of broken lambda DNA molecules was observed in polA1 host cells, it is concluded that the synthetase activity of DNA polymerase I is involved in the rejoining of DNA breaks induced by radiation in the presence of oxygen.

Enhancement of the viability of irradiated bacteria by chromosome transfer

The effect of x-irradiating recipient cells of Escherichia coli K-12 before mating on the formation of recombinants and on the distribution of parental genetic material among recombinants was investigated in both the wild-type (Rec+) and a recombination-deficient (Rec-) mutant. In crosses involving Rec- recipients, recombinants selected for a late donor marker were formed in almost normal numbers. Rec- cells exposed to otherwise lethal doses of x-rays were still able to form viable recombinants for a distal male marker. These recombinants had inherited almost all the transferred donor chromosome, as evidenced by the preponderance of male markers in the recombinants. In contrast, the recombinant-forming ability was about as x-ray-sensitive as the colony-forming ability in Rec+ cells. No preference for donor chromosomal material was observed in recombinants from crosses involving x-irradiated Rec+ cells.