Correlation between physician- and patient-directed disease assessments in ulcerative colitis patients from Saudi Arabia and Kuwait: Data from ICONIC

Background

The aim of the observational, prospective study was to validate a novel, nonverbal assessment tool for perceived disease burden-Pictorial Representation of Illness and Self-Measure (PRISM)-in ulcerative colitis (UC) against established patient health questionnaires. The cumulative burden of patients recently diagnosed (<3 years) with UC was also evaluated.

Methods

"ICONIC" - Understanding the impact of ulcerative colitis and its associated disease burden on patients - was a noninterventional, multicountry, multicenter study performed in a 2-year follow-up format in adult patients with recently diagnosed UC in 33 countries, regardless of disease severity or treatment. Data collection consisted of five visits, scheduled at approximately 6-month intervals. For the current analysis, patient data from Saudi Arabia and Kuwait were evaluated. The collected data comprised demographics, disease-related data, UC treatment, and healthcare resources, as well as physician- and patient-assessed quality-of-life and disease burden questionnaires. Correlations between selected questionnaire scores were performed using Spearman's rho.

Results

Disease severity at baseline and throughout the study was slightly less favorable in this country analysis compared with the global study cohort. Disease burden was assessed by PRISM and improved within 24 months.

Conclusions

The detected moderate correlation between PRISM and other assessment methods supports the validity of PRISM. Differences in perceptions of UC-related burden between physician and patient may reflect to some degree insufficient patient-physician communication.

A cross-sectional survey on the psychological impact of the COVID-19 pandemic on inflammatory bowel disease patients in Saudi Arabia

Background/Aims

The coronavirus (COVID-19) pandemic has caused significant disruption to patients with chronic illnesses. We explored the emotional state, perception, and concerns of Saudi patients with inflammatory bowel disease (IBD) during the crisis.

Materials and Methods

We conducted a cross-sectional survey from 30 March to 5 April, 2020 using a pre-designed questionnaire distributed through social media platforms to IBD patients. The five-part questionnaire included an assessment of psychological wellbeing using a previously validated Arabic version of the Hospital Anxiety and Depression Scale (HADS), which includes domains for anxiety (HADS-A) and depression (HADS-D). A logistic regression analysis was used to uncover possible associations between patient characteristics and anxiety and depression.

Results

The data from 1156 IBD patients were analyzed. Normal, borderline, and HADS-A scores consistent with a diagnosis of anxiety were reported by 423 (36.6%), 174 (15.1%), and 559 (48.4%) patients, respectively. However, 635 (69%) patients had normal scores and 273 (30.1%) had borderline HADS-D scores; no patients reported scores consistent with depression. Based on a multiple logistic regression analysis, patients educated till a high school diploma (OR = 2.57, 95% CI: 0.09-6.05, P = 0.03) and that had indeterminate colitis (OR = 2.23, 95% CI: 1.27-3.89, P = 0.005) were more likely to express anxiety.

Conclusions

Many patients expressed symptoms of anxiety, although not depression. Female patients, patients educated till a high school diploma, and those with indeterminate colitis were more likely to have anxiety. IBD patients require greater attention during a pandemic to avoid adverse disease-related outcomes.

Patterns of Complementary and Alternative Medicine Use in Saudi Arabian Patients With Inflammatory Bowel Disease: A Cross-Sectional Study

Background Inflammatory bowel disease (IBD) concerns a group of chronic autoimmune diseases that results in uncontrolled inflammation of the gastrointestinal (GI) tract, which can lead to long-term complications. Conventional treatments for IBD usually target inflammation and include biologics and immunosuppressants, which have been associated with significant adverse effects. Also, non-response to biologics has been reported in up to 50% of patients. Hence, patients sometimes turn to unconventional methods of treatment, such as complementary and alternative medicine (CAM). In this study, we examine patterns of CAM use in Saudi patients diagnosed with IBD. Materials and methods We conducted a cross-sectional study of patients with IBD who were seen at the outpatient gastroenterology clinic between January 2018 and December 2019. Adult patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) were identified and surveyed. Clinical, laboratory, endoscopic, radiologic, and histologic data were collected. The patients completed a detailed questionnaire focusing on CAM use. Descriptive statics, quantitative variables, means, standard deviations (SDs), and minimum and maximum values or medians with interquartile ranges were used where appropriate; for qualitative variables, we reported frequencies. The prevalence of CAM use was calculated using standard prevalence formulae. Logistic regression analysis was performed to identify predictors for CAM use. A p-value of <0.05 was set as statistically significant. Results A total of 71 IBD patients were surveyed, of which 75% had CD. Severe symptoms were reported by 54% of patients, and 41% were receiving biological treatment; 90% of this cohort reported using some form of CAM, of which 78% used them within the past year, and 52% reported CAM treatment having a positive effect. Of note, 63% of patients reported using CAM therapy without the knowledge of their treating physician. The most common source of advice regarding the use of CAM medicine was relatives (66%), and the most common forms of CAM used were honey (62%), Zamzam water (54%), and physical activity (32%). Binary logistic regression analysis identified watery diarrhea (OR=5.7, 95% CI=1.0-31, P=0.04) and azathioprine (OR=18.1, 95% CI=1.3-255, P=0.03) as predictors of CAM use. Conclusions CAM use is very common in Saudi patients with IBD. The majority of patients seem to turn to CAM if their symptoms are severe. They generally appear to be influenced by culture, the Internet, local society, and family tradition in their decision to use CAM, rather than expert advice from their treating physician.

The diagnostic yield of urgent colonoscopy in acute lower gastrointestinal bleeding

BACKGROUND AND AIMS

Lower Gastrointestinal Bleeding (LGIB) is one of the leading causes of ER visits. Colonoscopy is indicated in all patients with LGIB, yet the time frame for performing colonoscopy remains unclear. Whether or not urgent endoscopic evaluation improves outcomes of LGIB has been questioned. We therefore aimed to examine the success of urgent colonoscopy in identifying the source of LGIB.

PATIENTS AND METHODS

A retrospective study was conducted in which timing of colonoscopy was divided into urgent (performed within the first 24 hours of presentation) and delayed (performed following 24 hours of hospitalization). Data on clinical presentation, investigations and endoscopic findings was collected. Risk ratios were calculated and regression analysis was used to examine associations and identify predictors of endoscopic success.

RESULT

A total of 183 patients underwent colonoscopies. 55.4% of colonoscopies were performed within 24 hours of presentation. A source of LGIB was identified in 55.7% of first attempt colonoscopies. Endoscopic intervention was required in 10.9% of cases and rebleeding occurred in 24.6%, of which 6.5% required hospital re-admission. 2.7% required emergency colectomy and the calculated mortality rate was 1%. Risk ratios comparing urgent to delayed colonoscopy for source of LGIB identification, colectomy and mortality were 1.01, 4.8 and 1.2, respectively. Age and timing of colonoscopy appeared to be predictive of colectomy on regression analysis.

CONCLUSIONS

Urgent colonoscopy for LGIB did not improve the rate of identification of the source of bleeding, colectomy rate or mortality rate and was predictive of the need for emergency colectomy.

Arabic translation and psychometric testing of the self-screening malnutrition universal screening tool in inflammatory bowel disease patients

OBJECTIVES

To translate and validate the malnutrition universal screening tool (MUST) for use in Arabic-speaking outpatients with inflammatory bowel disease (IBD).

METHODS

We translated the MUST into Arabic by using the Brislin back-translation method. This methodological study was performed between August 2016 and November 2017 on 143 outpatients with IBD at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The patients must completed the self-administered (PSA) Arabic version of the MUST. Then, the health-care practitioners (HCPs) administered the Arabic MUST and performed standard patient clinical assessment. The nutrition risk was defined as low (MUST score=0), medium (MUST score=1), or high (MUST score greater than 1). The chance-corrected proportional agreement between the scores from the PSA and HCP-administered Arabic MUST was evaluated using Cohen's kappa coefficient. Internal consistency was evaluated using Cronbach's alpha statistic.

RESULTS

The overall agreement between the PSA and HCP-administered Arabic MUST was almost perfect (agreement=95.9%, expected agreement=72.4%, kappa=0.85, p less than 0.0001). The calculated Cronbach's alpha statistic for MUST scores in 15/143 (10%) patients was 0.79. The calculated Pearson's correlation coefficient between PSA and HCP-administered MUST scores was 0.93 (p less than 0.0001).

CONCLUSIONS

The PSA and HCP-administered Arabic MUST showed perfect agreement in outpatients with IBD.

Risk Stratification of Patients with Crohn's Disease: A Retrospective Analysis of Clinical Decision Making and Its Impact on Long-Term Outcome

BACKGROUND AND AIMS

Complications such as need for bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain "high-risk" features require an early introduction of anti-tumor necrosis factor-α therapy to prevent such complications. We aim to evaluate the prevalence of "high-risk" features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease outcome.

PATIENTS AND METHODS

All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory, and radiological data were collected. Patients were divided into "low" and "high" risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or cross-sectional imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach ("step-up" vs. "accelerated step-up" vs. "top-down") within 6 months of diagnosis were recorded. Rates of CD-related bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between "discordance" of early treatment selections and risk stratification categories with outcomes.

RESULTS

Eighty-five CD patients were included. The median age and duration of disease were 25 (interquartile range [IQR] 19-32) and 5 (IQR 4-6) years, respectively. Sixty five percent were females and 66% were native Saudis. Smoking was reported in 12% of patients and perianal disease in 18%. "High-risk" features were identified in 43 (51%) patients, of which only 6 (14%) were treated with "top-down" therapy and 7 (16%) with "accelerated step-up" care. The risk of requiring a bowel resection, and hospitalization was higher for "high-risk" patients compared to "low-risk" patients (risk ratio [RR] 13.67, 95% CI 1.88-99.41; p = 0.003, and RR 1.86, 95% CI 0.03-0.43; p = 0.0312, respectively). "Discordance" occurred in 34% of cases. Bowel resection was required in 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization within 5 years of diagnosis. Logistic regression analysis identified a statistically significant association between "discordance" and need for bowel resections (OR 6.50, 95% CI 1.59-26.27, p = 0.009), and hospitalizations (OR 3.01, 95% CI 1.08-8.39, p = 0.035) within 5 years of diagnosis.

CONCLUSIONS

"Discordance" between patient risk-profile and treatment selection early in the course of CD has a significant impact on disease outcome, specifically need for bowel resection and hospitalization, which are more likely to occur in the presence of "high-risk" features. Early identification of "high-risk" features could help prevent long-term complications.

A cross-sectional survey of multi-generation inflammatory bowel disease consanguinity and its relationship with disease onset

Background\Aim: Consanguinity influences the phenotypic variations of some hereditary and immune-mediated disorders, including inflammatory bowel disease. This study estimated the prevalence of consanguinity among the ancestors of patients with inflammatory bowel disease and examined the effect of various consanguinity levels on inflammatory bowel disease onset.

PATIENTS AND METHODS

Patients with inflammatory bowel disease who were seen at two gastroenterology outpatient clinics were consecutively recruited and surveyed for demographics, disease onset, and presence of ancestral consanguinity within three generations. The prevalence of different consanguinity levels was calculated. The association between age at inflammatory bowel disease onset and consanguinity was examined.

RESULTS

Two hundred seventeen patients were recruited. The mean age, mean age at diagnosis, and mean illness duration were 32.9 ± 13.4, 18.6 ± 11.5, and 8.6 ± 7.7 years, respectively. Of the cohort, 53.5% were women, and 74.2% were native Saudis. Cigarette smoking was reported in 17.1%; 51% had Crohn's disease, while the remaining patients had ulcerative colitis. A family history of inflammatory bowel disease was reported in 29.5% of patients; consanguinity within three generations was reported in 57.6%. Consanguinity in more than one generation was reported in 38.7%; 17.5% had consanguinity in three consecutive generations. There was no association between inflammatory bowel disease onset and multi-generation consanguinity, but there was an association with disease subtype in favor of ulcerative colitis (b coefficient = 7.1 [95% confidence interval = 4.1, 10]).

CONCLUSIONS

Consanguinity is extremely common among Saudi patients with inflammatory bowel disease but does not seem to influence age at disease onset. Genetic studies are needed to further clarify the effect of consanguinity on disease behavior.

Knowledge, attitude, and practices of primary health care physicians toward colorectal cancer screening

BACKGROUND/AIM

Early diagnosis of chronic illnesses and cancers mainly occurs at primary health care centers (PHCs) by primary health care physicians (PHPs). The incidence of colorectal cancer (CRC) in the Kingdom of Saudi Arabia (KSA) is rising and this has been attributed to many factors. The increasing incidence of CRC is compounded by nonadherence to screening recommendations. Therefore, evaluating PHPs knowledge, attitudes, and practices of screening for CRC is clinically important. We aimed to evaluate the knowledge, attitudes, and practices of PHPs regarding CRC screening and to identify the factors associated with nonadherence of PHPs to screening recommendations.

MATERIALS AND METHODS

PHPs working at three tertiary care centers and PHCs across the city of Jeddah were randomly recruited. Participants were surveyed using a comprehensive questionnaire that recorded data on demographics, qualifications, and knowledge of various modalities and guidelines related to CRC screening. Perspectives about effectiveness of, or adherence to, factors that influence physicians' perspectives or recommendations for CRC screening were also assessed. Logistic regression analysis was used to identify physician characteristics associated with PHPs perspectives and nonadherence to CRC screening.

RESULTS

A total of 127 PHPs were recruited. The average age of participants was 34 (±8.4) years, 86.6% were native Saudi's and 56.7% were females. The majority of surveys (66.9%) were completed at 24 PHCs and the remaining at hospital-based family medicine clinics. Most of the PHPs (55%) had a bachelor's degree and 31.5% were board-certified or carried a PhD in family medicine; 95% of participants believed that CRC screening in general was effective, but as much as 55% reported that they did not practice screening. The male physicians [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.19-0.99, P = 0.048)] and PHPs with only a bachelor degree or less (OR = 0.72, 95% CI = 0.55-0.93, P = 0.011) were less likely to recommend screening for CRC.

CONCLUSIONS

A considerable proportion of PHPs do not adhere to CRC screening recommendations despite a wide belief that screening is effective. Male PHPs with lower qualifications appear to be less likely to recommend screening.

Screening irritable bowel syndrome patients for symptoms predictive of crohn's disease using the red flag score

BACKGROUND/AIMS

The diagnosis of inflammatory bowel disease (IBD) is often delayed due to misdiagnosing patients with irritable bowel syndrome (IBS), mostly because of the under-recognition of high-risk features. The red flag score (RFS) has been recently developed to identify patients with higher risk of IBD rather than IBS. The aim of this study is to estimate the prevalence of high-risk features, according to the RFS, among patients diagnosed with IBS who would consequently be candidates for ileocolonoscopic evaluation.

PATIENTS AND METHODS

Adult patients with IBS seen at the general medicine clinic were recruited and surveyed using the RFS. Clinical and demographic data were collected. The prevalence of high-risk features, defined as a RFS >5, was calculated. Logistic regression analysis was used to identify predictors of RFS >5.

RESULTS

A total of 255 patients with IBS were recruited. The mean age was 30.6 years (±9.9 years); 71.4% of patients were women (182/255), and 90.2% were from Saudi Arabia (230/255). More than half of the patients we surveyed (51.4%) had not visited a gastroenterologist previously. The mean RFS was 6.6 (±3.6) and 54.9% of patients (140/255) scored more than 5 and accordingly were selected for further investigations. Statistical analysis identified no previous visits to a gastroenterologist as the only significant predictor of RFS >5 (OR = 2.2, 95% CI = 1.3-3.7, P = 0.003).

CONCLUSIONS

More than half of the patients known to have IBS are candidates for further investigations to eliminate the possibility of IBD as a diagnosis according to the validated RFS. Patients who did not seek a specialized consultation with a gastroenterologist might be at a higher risk of being misdiagnosed as having IBS.

p16 protein is upregulated in a stepwise fashion in colorectal adenoma and colorectal carcinoma

BACKGROUND/AIMS

p16 is tumor suppressor gene acting as a cell cycle regulator. The present study was conducted to compare p16 expression in normal, dysplastic, and malignant colonic mucosae, and to explore its relation to clinicopathological variables and follow-up data in colorectal carcinoma (CRC).

PATIENTS AND METHODS

Tissue microarrays were performed from 25 normal colonic mucosae, 41 colonic adenomas, and 191 CRC, with corresponding 50 nodal metastases. Immunohistochemistry was performed using anti-p16 antibody, sections were scored, and statistical analysis was performed. K-ras mutation detection was also performed.

RESULTS

Immunoexpression of p16 was significantly higher in CRC than in adenomas (P = 0.033) and normal colonic mucosa (P = 0.005). There was no statistically significant difference between p16 expression in CRC and nodal metastasis. There was no significant association between p16 immunoexpression in CRC and all clinicopathological data and survival probability. K-ras mutations were detected in 34% of CRC. However, there was no correlation between K-ras status and p16 expression (P = 0.325).

CONCLUSION

Absence of p16 expression is correlated to a benign course of CRC adenomas. p16 has a key role in CRC progression and can be used as a marker for colorectal adenoma. On the other hand, it has no role as a predictive and/or prognostic factor in CRC. Further extended studies are required to explore the role of p16 as indicator of premalignant lesions in the colon and to test its relation with CRC histological grade, as well as to test its value as a new therapeutic target.

High expression of matrix metalloproteinases: MMP-2 and MMP-9 predicts poor survival outcome in colorectal carcinoma

AIM

To evaluate the expression pattern of matrix metalloproteinases (MMPs); MMP-2, MMP-7 and MMP-9 in colorectal cancer (CRC) and determine its prognostic potential.

PATIENTS & METHODS

CRC samples of 127 patients were studied. Protein expressions of MMP-2, -7 and -9 were analyzed by immunohistochemistry and association with clinicopathological variables was statistically analyzed.

RESULTS

Overexpressions of MMP-2 and MMP-9 correlated with poor outcome as evaluated by univariate Kaplan-Meier for disease-free survival (p = 0.04, p = 0.0001) and disease-specific survival (p = 0.01, p = 0.01), respectively. Cox analysis of MMP-2 and -9 were significant independent predictors of disease-free survival (p = 0.006, p = 0.018) and disease-specific survival (p = 0.004, p = 0.049), respectively.

CONCLUSION

MMPs expression patterns provide useful prognostic information in CRC, while predicting the patients at high risk for recurrent disease.