Interventions for the management of abdominal pain in Crohn's disease and inflammatory bowel disease

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

Persons with inflammatory bowel disease (IBD) have an increased risk of suffering from psychological problems. The association is assumed to be bi-directional. Psychological treatment is expected to improve quality of life (QoL), psychological issues and, possibly, disease activity. Many trials have tested various psychotherapy approaches, often in combination with educational modules or relaxation techniques, with inconsistent results.

OBJECTIVES

To assess the effects of psychological interventions on quality of life, emotional state and disease activity in persons of any age with IBD.

SEARCH METHODS

We searched Web of Science Core Collection, KCI-Korean Journal Database, Russian Science Citation Index, MEDLINE, Psyndex, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, and LILACS from inception to May 2023. We also searched trial registries and major gastroenterological and selected other IBD-related conferences from 2019 until 2023.

SELECTION CRITERIA

Randomized controlled trials of psychological interventions in children or adults with IBD compared to no therapy, sham (i.e. simulated intervention), or other active treatment, with a minimum follow-up time of two months, were eligible for inclusion, irrespective of publication status and language of publication. Interventions included psychotherapy and other non-pharmacological interventions addressing cognitive or emotional processing, patient education, or relaxation techniques to improve individual health status.

DATA COLLECTION AND ANALYSIS

Two raters independently extracted data and assessed the study quality using the Risk of Bias 2 Tool. Pooled standardized mean differences (SMD) for continuous outcomes and relative risks (RR) for event data were calculated with 95% confidence intervals (CI), based on separate random-effects models by age group, type of therapy and type of control. An SMD of 0.2 was considered a minimally relevant difference. SMD ≥ 0.4 was considered a moderate effect. Group analyses were planned to examine differential effects by type of IBD, disease activity, psychological comorbidity, therapy subtype, and treatment intensity. Statistical heterogeneity was determined by calculating the I2 statistic. Publication bias was assessed by presenting a funnel plot and calculating the Eggers Test. GRADE Profiling was used to describe the certainty of the evidence for relevant results.

MAIN RESULTS

Sixty-eight studies were eligible. Of these, 48 had results reported in sufficient detail for inclusion in the meta-analyses (6111 adults, 294 children and adolescents). Two trials were excluded from the meta-analysis following sensitivity analysis and tests for asymmetry because of implausible results. Most studies used multimodular approaches. The risk of bias was moderate for most outcomes, and high for some. The most common problems in individual trials were the inability to blind participants and investigators and outcome measures susceptible to measurement bias. The main issues leading to downgrading of the certainty of the evidence were heterogeneity of results, low precision and high or moderate risk of bias in the included trials. Publication bias could not be shown for any of the inspected analyses. In adults, psychotherapy was slightly more effective than care-as-usual (CAU) in improving short-term QoL (SMD 0.23, 95% CI 0.12 to 0.34; I2 = 13%; 20 trials, 1572 participants; moderate-certainty), depression (SMD -0.27, 95% CI -0.39 to -0.16; I2 = 0%; 16 trials, 1232 participants; moderate-certainty), and anxiety (SMD -0.29, 95% CI -0.40 to -0.17; I2 = 1%; 15 studies, 1135 participants; moderate-certainty). The results for disease activity were not pooled due to high heterogeneity (I2 = 72%). Interventions which used patient education may also have small positive short-term effects on QoL (SMD 0.19, 95% CI 0.06 to 0.32; I2 = 11%; 12 trials, 1058 participants; moderate-certainty), depression (SMD -0.22, 95% CI -0.37 to -0.07; I2 = 11%; 7 studies, 765 participants; moderate-certainty) and anxiety (SMD -0.16, 95% CI -0.32 to 0.00; I2 = 10%; 6 studies, 668 participants; moderate-certainty). We did not find an effect of education on disease activity (SMD -0.09, 95% CI -0.28 to 0.10; I2 = 38%; 7 studies, 755 participants; low-certainty). Pooled results on the effects of relaxation techniques showed small effects on QoL (SMD 0.25, 95% CI 0.08 to 0.41; I2 = 30%; 12 studies, 916 participants; moderate-certainty), depression (SMD -0.18, 95% CI -0.35 to -0.02; I2 = 0%; 7 studies, 576 participants; moderate-certainty), and anxiety (SMD -0.26, 95% CI -0.43 to -0.09; I2 = 13%; 8 studies, 627 participants; moderate-certainty). Results for disease activity were not pooled due to high heterogeneity (I2 = 72%). In children and adolescents, multimodular psychotherapy increased quality of life (SMD 0.54, 95% CI 0.06 to 1.02; I2 = 19%; 3 studies, 91 participants; moderate-certainty). The results for anxiety were inconclusive (SMD -0.09; 95% CI 0.-64 to 0.46; 2 trials, 51 patients, very low-certainty). Pooled effects were not calculated for depressive symptoms. Disease activity was not assessed in any of the trials compared to CAU. In education, based on one study, there might be a positive effect of the intervention on quality of life (MD 7.1, 95% CI 2.18 to 12.02; 40 patients; low-certainty evidence) but possibly not on depression (MD -6, 95% CI -12.01 to 0.01; 41 patients; very low-certainty). Anxiety and disease activity were not assessed for this comparison. Regarding the effects of relaxation techniques on children and adolescents, all results were inconclusive (very low-certainty).

AUTHORS' CONCLUSIONS

Psychological interventions in adults are likely to improve the quality of life, depression and anxiety slightly. Psychotherapy is probably also effective for improving the quality of life in children and adolescents. The evidence suggests that psychological interventions may have little to no effect on disease activity. The interpretation of these results presents a challenge due to the clinical heterogeneity of the included trials, particularly concerning the type and various components of the common multimodular interventions. This complexity underscores the need for further research and exploration in this area.

Deep representation learning for clustering longitudinal survival data from electronic health records

Precision medicine requires accurate identification of clinically relevant patient subgroups. Electronic health records provide major opportunities for leveraging machine learning approaches to uncover novel patient subgroups. However, many existing approaches fail to adequately capture complex interactions between diagnosis trajectories and disease-relevant risk events, leading to subgroups that can still display great heterogeneity in event risk and underlying molecular mechanisms. To address this challenge, we implemented VaDeSC-EHR, a transformer-based variational autoencoder for clustering longitudinal survival data as extracted from electronic health records. We show that VaDeSC-EHR outperforms baseline methods on both synthetic and real-world benchmark datasets with known ground-truth cluster labels. In an application to Crohn's disease, VaDeSC-EHR successfully identifies four distinct subgroups with divergent diagnosis trajectories and risk profiles, revealing clinically and genetically relevant factors in Crohn's disease. Our results show that VaDeSC-EHR can be a powerful tool for discovering novel patient subgroups in the development of precision medicine approaches.

Ginseng exosomes modulate M1/M2 polarisation by activating autophagy and target IKK/IкB/NF-кB to alleviate inflammatory bowel disease

BACKGROUND

Exosomes are involved in intercellular communication and regulation of the inflammatory microenvironment. In a previous study, we demonstrated that fresh ginseng exosomes (GEs) alleviated inflammatory bowel disease. However, the precise mechanism by which GEs activate the immune system and subsequently inhibit the formation of intestinal inflammatory microenvironment remains unknown.

METHODS

Herein, we investigated the effects of GEs on autophagy, macrophage polarisation, intestinal inflammation, and the epithelial barrier by means of transcriptome sequencing, network pharmacology, transmission electron microscopy, immunoblotting, flow cytometry and small molecule inhibitors.

RESULTS

GEs significantly activated autophagy and M2-like macrophage polarisation, which could be blocked by the autophagy inhibitor 3-methyladenine. In the co-culture system of macrophages and intestinal epithelial cells, macrophages treated with GEs secreted more interleukin-10 (IL-10) and significantly reduced Nitric oxide (NO) levels in intestinal epithelial cells in vitro. Furthermore, GEs acted directly on intestinal epithelial cells through the IKK/IкB/NF-кB signalling pathway to reduce inflammation and restore the intestinal barrier. Orally administered GEs could restore disrupted colonic barriers, alleviate inflammatory bowel responses, and regulate the polarisation of intestinal macrophages in vivo.

CONCLUSION

In summary, GEs may be a potential treatment for inflammatory bowel disease, and targeting autophagy and macrophage polarisation may help alleviate intestinal inflammation.

Mucosal and Transmural Healing and Long-term Outcomes in Crohn's Disease

BACKGROUND

Healing in Crohn's disease is complex and difficult to measure due to incongruencies between clinical symptoms and disease states. Mucosal healing (MH) and transmural healing (TH) are increasingly used to measure clinical improvement in Crohn's disease, but definitions of MH and TH can vary across studies, and their relationship to long-term outcomes is not clear. To address this knowledge gap, we performed a systematic literature review (SLR) to examine studies measuring MH and TH in Crohn's disease.

METHODS

Database records from 2012 to 2022 were searched for real-world evidence and interventional studies that reported the association of MH or TH with clinical, economic, or quality of life outcomes of adult patients with Crohn's disease.

RESULTS

A total of 46 studies were identified in the systematic literature review, representing a combined patient population of 5530. Outcomes of patients with MH were reported by 39 studies; of these, 14 used validated scales for endoscopic assessment. Thirteen studies reported outcomes of patients with TH. Among studies that examined the outcomes of patients with and without MH or TH, patients with healing generally experienced improved clinical outcomes and reduced healthcare resource utilization, including fewer hospitalizations and surgeries and improved rates of clinical remission. This was especially true for patients with TH.

CONCLUSIONS

Mucosal and transmural healing are associated with positive long-term outcomes for adult patients with Crohn's disease. The adoption of standardized measures and less invasive assessment tools will maximize the benefits of patient monitoring.

Effects of immune cells in mediating the relationship between inflammatory bowel disease and pyoderma gangrenosum: a two-sample, two-step mendelian randomization study

BACKGROUND

Although the precise cause of the co-occurrence of pyoderma gangrenosum (PG) and inflammatory bowel disease (IBD) is still unknown, prior research has shown that the two conditions coexist. Moreover, it is currently unknown how immune cells function in influencing the relationship between IBD and PG.

METHODS

In order to choose independent single nucleotide polymorphism (SNP) as instrumental variables, we were provided with genome-wide association study (GWAS) summary data of European populations from the IEU OpenGWAS project (for IBD) and a the FinnGen database (for PG) publically available. For the MR analysis, a range of analytical techniques were employed to peer into the possible causative relationship between PG and IBD. The two-step MR analysis was used to investigate the mediating role of immune cells between IBD and PG. The chief method utilized was the inverse variance weighted (IVW) approach. Using the Cochran's Q test and the MR-Egger intercept, respectively, heterogeneity or pleiotropy was evaluated to support the findings. MR-PRESSO (Mendelian Randomization Pleiotropy RESidual Sum and Outlier) were used to identify the outlier SNP.

RESULTS

IBD was found to raise the incidence of PG (IVW-FE: OR = 1.604, 95%CI = 1.308-1.966, p = 5.58 × 10- 6), according to MR findings. Moreover, UC or CD were strongly correlated with a greater risk of PG (OR = 1.339, 95%CI = 1.041-1.723, p = 0.023 for UC; OR = 1.339, 95%CI = 1.107-1.621, p = 0.003 for CD). The results of the reverse MR study did not suggest a connection between PG and IBD. CD4+ regulatory T cell is the mediator that particularly stood out in the interaction between UC and PG. There was evidence of neither heterogeneity nor horizontal pleiotropy. And the validity of these conclusions was verified.

CONCLUSION

In the European population, PG risk may be genetically elevated by IBD, including CD and UC, according to the current study. The effect of UC on PG may have been causally mediated by CD4+ regulatory T cells.

Water-assisted colonoscopy in inflammatory bowel diseases: From technical implications to diagnostic and therapeutic potentials

Water-assisted colonoscopy (WAC) application in inflammatory bowel diseases (IBD) endoscopy offers significant technical opportunities. Traditional gas-aided insufflation colonoscopy increases patient discomfort, presenting challenges in the frequent and detailed mucosal assessments required for IBD endoscopy. WAC techniques, including water immersion and exchange, provide superior patient comfort and enhanced endoscopic visualisation. WAC effectively reduces procedural pain, enhances bowel cleanliness, and increases adenoma detection rates, which is crucial for colorectal cancer screening and disease-related evaluations in IBD patients. Additionally, underwater techniques facilitate basic and advanced endoscopic resections, such as polypectomy and endoscopic mucosal and submucosal resections, often required for resecting IBD-associated neoplasia.

Chronic Abdominal Pain in Patients with Inflammatory Bowel Disease in Remission: A Continuing Challenge for Clinicians

Inflammatory bowel disease (IBD) is a chronic condition that includes ulcerative colitis and Crohn's disease. It is characterized by a relapsing and remitting pattern that negatively impacts quality of life (QoL). Current goals of treatment involve symptomatic, biochemical, and endoscopic remission in a treat-to-target approach. Despite effective treatment and remission of IBD, many patients report frequent and isolated abdominal pain. A wide range of etiologies exist, including surgery-related, infections, pelvic conditions, immune-related, and systemic illnesses. Disorders of the gut-brain interaction (DGBI), frequently characterized by abdominal pain, are increasingly recognized in IBD patients, including those with quiescent disease. Various mechanisms are involved and numerous non-pharmacologic and pharmacologic therapies have been proposed. Hereby, we outline the pertinent findings of the literature on management of chronic abdominal pain, focusing on quiescent IBD.

Abdominal Pain in Inflammatory Bowel Disease-Epidemiology, Pathophysiology, and Management: A Narrative Review

Abdominal pain is a major symptom of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, and has a significant impact on patients' quality of life. Given the evolving understanding of IBD pathology and management strategies, there is an urgent need to review the recent research findings. In this review, we have analyzed the epidemiology, pathophysiology, and management of abdominal pain in IBD over the past decade. We draw on the current literature and highlight emerging trends, challenges, and advances in this field. By synthesizing key findings, this review provides insights into the complex interplay between abdominal pain, disease progression, and therapeutic interventions for IBD.

Patient perception of bowel urgency and remission in moderately to severely active Crohn's disease or ulcerative colitis: a qualitative study

BACKGROUND

Bowel urgency, the sudden and immediate need to have a bowel movement, is common in patients with ulcerative colitis (UC) and Crohn's disease (CD). While its impact in UC is well established, less is known about its importance in CD. Further, what level of bowel urgency control patients with UC or CD would consider to be acceptable or in remission has not been established. This qualitative study aimed to understand perceptions of bowel urgency and remission in these patients.

METHODS

Semi-structured combined concept elicitation and cognitive interviews were conducted to explore how adults with moderate-to-severe UC or CD and current or recent bowel urgency think about the concept of bowel urgency and its remission. The Urgency Numeric Rating Scale (UNRS) was used to examine different levels of bowel urgency severity and to investigate what level of bowel urgency patients would consider as representing remission.

RESULTS

Forty adults (n = 19 UC, n = 21 CD) recruited from six US sites completed the study. Sociodemographic and clinical characteristics were similar in both groups. Both groups reported impacts of bowel urgency on physical, social, professional, and emotional aspects of their lives. Most participants (n = 15 UC, n = 18 CD) reported having experienced one or more incidents of urgency-related fecal incontinence. Most participants considered remission to be a state with a normal or reduced number of bowel movements and no or less frequent bowel urgency, and they noted that remission would increase their ability to engage in daily activities without fear of fecal incontinence. Participants were able to map different levels of severity of bowel urgency to UNRS score ranges (scale: 0-10), and they indicated that a mean UNRS score of 5 (UC) or 4 (CD) would be the highest point on the NRS at which they would still consider their bowel urgency to be in remission.

CONCLUSIONS

Bowel urgency is an important issue for patients with either moderate-to-severe UC or CD, and its remission would improve their lives. Further, these patients may still consider bowel urgency to be in remission even at UNRS scores as high as 4 or 5.

Predictive value of serum markers for mucosal healing in patients with inflammatory bowel disease

OBJECTIVE

To investigate the value of serum markers in assessing mucosal healing (MH) and inflammatory activity in patients with inflammatory bowel disease (IBD).

METHODS

In this retrospective analysis, we examined data from 320 IBD patients, including 176 with ulcerative colitis (UC) and 144 with Crohn's disease (CD), alongside 100 healthy controls during the same period. Serum levels of various markers, including white blood cell (WBC), platelet count (PLT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) were evaluated. These indices were analyzed for their diagnostic value in endoscopic MH in IBD patients. The independent influencing factors affecting MH in IBD patients were identified by univariate and multivariate analyses.

RESULTS

The levels of WBC, PLT, ESR, CRP, PLR, and NLR were significantly higher in IBD patients, UC patients, and CD patients than in healthy controls (all P < 0.05). For those achieving MH, their WBC, PLT, ESR, CRP, PLR, and NLR levels were significantly lower than patients who did not achieve MH (all P < 0.05). The AUCs of WBC, PLT, ESR, CRP, PLR, and NLR for the diagnosis of MH were 0.729, 0.756, 0.673, 0.707, 0791, and 0.724, respectively. A multifactorial analysis found that the presence of abdominal pain (OR: 2.155, 95% CI: 1.081-4.297, P < 0.05), higher WBC (OR: 3.927, 95% CI: 2.008-7.681, P < 0.001), higher PLT (OR: 4.181, 95% CI: 2.078-8.412, P < 0.001), higher ESR (OR: 2.221, 95% CI: 1.082-4.562, P < 0.05), higher CRP (OR: 3.874, 95% CI: 1.861-8.065, P < 0.001), higher PLR (OR: 4.087, 95% CI: 1.586-10.534, P < 0.01), and higher NLR ( OR: 2.688, 95% CI: 1.292-5.592, P < 0.01) were independent risk factors for failure in achieving MH.

CONCLUSION

WBC, PLT, ESR, CRP, PLR, and NLR can be used as noninvasive markers for predicting MH in patients with IBD, and they hold promise for clinical application.

Development and validation of a scale to measure the care needs of Crohn's disease patients: a mixed-methods study

BACKGROUND

Crohn's disease (CD) patients require varying levels of supportive care. In order to facilitate caregivers and nurses in precisely evaluating the caregiving requirements of these patients, we developed the CD-specific Care Needs Scale (CD-CNS).

METHODS

This study employed a mixed-methods approach, integrating qualitative and quantitative methodologies. The initial items of the scale were developed through qualitative interviews, Delphi expert consultation, and literature review, while the final items were refined through clinical testing. Qualitative interviews were conducted based on the supportive care needs framework and Maslow's hierarchy of needs, and scale items were constructed through a literature search and qualitative interviews. The initial version of the scale with 45 items was obtained after the items were verified and modified by expert consultation. A total of 250 CD patients admitted to the gastroenterology department of a hospital in China were selected for verification of the initial version of the scale. A self-designed general questionnaire was used to obtain patients' medical history and sociodemographic data, and the Chinese version of the Inflammatory Bowel Disease Questionnaire (IBDQ) was used as the criterion. Exploratory factor analysis (EFA) was performed on the CD-CNS to evaluate the dimensions, factor structure, reliability, criterion validity, and construct validity.

RESULTS

EFA identified 5 dimensions and retained 27 items with strong internal consistency reliability (α = 0.940). The Cronbach's α coefficients for each dimension ranged from 0.824 to 0.921. Criterion validity was assessed using Spearman's coefficient, which demonstrated a significant correlation with the IBDQ (P < 0.050). The test-retest reliability for each dimension after two weeks ranged from 0.655 to 0.895.

CONCLUSIONS

We developed and validated a new scale that can be used to assess the care needs of CD patients. This new tool can guide the specific supportive care of CD patients.

TRIAL REGISTRATION

This study was reviewed and approved by the Ethics Committee of the Second Hospital of Nanjing (2021-LS-ky-022). The study was duly registered and approved online through the Trial Center of the Second Hospital of Nanjing in 2021. Confidentiality was ensured by anonymizing all the data. The entire study process was conducted under the supervision of the Ethics Committee of Nanjing Second Hospital. Informed consent was obtained from the patients, and each patient volunteered and agreed to participate.

Moxibustion ameliorates chronic inflammatory visceral pain via spinal circRNA-miRNA-mRNA networks: a central mechanism study

This study aimed to unveil the central mechanism of moxibustion treating chronic inflammatory visceral pain (CIVP) from the angle of circRNA-miRNA-mRNA networks in the spinal cord. The rat CIVP model was established using a mixture of 5% (w/v) 2,4,6-trinitrobenzene sulfonic acid and 50% ethanol at a volume ratio of 2:1 via enema. Rats in the moxibustion group received herb-partitioned moxibustion at Tianshu (ST25, bilateral) and Qihai (CV6) points. The abdominal withdrawal reflex (AWR), mechanical withdrawal threshold (MWT), and thermal withdrawal latency (TWL) were adopted for pain behavior observation and pain sensitivity assessment. The circRNA, miRNA, and mRNA expression profiles were detected using the high-throughput sequencing technique. Relevant databases and bioinformatics analysis methods were used to screen for differentially expressed (DE) RNAs and build a circRNA-miRNA-mRNA (competing endogenous RNA) ceRNA regulatory network. The real-time quantitative PCR was employed to verify the sequencing result. CIVP rat models had a significantly higher AWR and lower TWL and MWT than normal rats. Between normal and model rats, there were 103 DE-circRNAs, 16 DE-miRNAs, and 397 DE-mRNAs in the spinal cord. Compared with the model group, the moxibustion group had a lower AWR and higher TWL and MWT; between these two groups, there were 118 DE-circRNAs, 15 DE-miRNAs, and 804 DE-mRNAs in the spinal cord. Two ceRNA networks were chosen to be verified. As a result, moxibustion's analgesic effect on visceral pain in CIVP rats may be associated with regulating the circRNA_02767/rno-miR-483-3p/Gfap network in the spinal cord and improving central sensitization.

Potential therapeutic effects of milk-derived exosomes on intestinal diseases

Exosomes are extracellular vesicles with the diameter of 30 ~ 150 nm, and are widely involved in intercellular communication, disease diagnosis and drug delivery carriers for targeted disease therapy. Therapeutic application of exosomes as drug carriers is limited due to the lack of sources and methods for obtaining adequate exosomes. Milk contains abundant exosomes, several studies have shown that milk-derived exosomes play crucial roles in preventing and treating intestinal diseases. In this review, we summarized the biogenesis, secretion and structure, current novel methods used for the extraction and identification of exosomes, as well as discussed the role of milk-derived exosomes in treating intestinal diseases, such as inflammatory bowel disease, necrotizing enterocolitis, colorectal cancer, and intestinal ischemia and reperfusion injury by regulating intestinal immune homeostasis, restoring gut microbiota composition and improving intestinal structure and integrity, alleviating conditions such as oxidative stress, cell apoptosis and inflammation, and reducing mitochondrial reactive oxygen species (ROS) and lysosome accumulation in both humans and animals. In addition, we discussed future prospects for the standardization of milk exosome production platform to obtain higher concentration and purity, and complete exosomes derived from milk. Several in vivo clinical studies are needed to establish milk-derived exosomes as an effective and efficient drug delivery system, and promote its application in the treatment of various diseases in both humans and animals.

Effects of hospital-family holistic care mode on psychological state and nutritional status of patients with inflammatory bowel disease

OBJECTIVE

This study was designed to determine the effects of hospital-family holistic care mode on psychological state and nutritional status of patients with inflammatory bowel disease (IBD).

METHODS

A retrospective analysis was conducted on the data of 80 patients with IBD treated in The Second Affiliated Hospital of Jiaxing University from May 2021 to November 2022. Among the patients, 37 patients who received conventional care were assigned to a control group and the remaining 43 patients who received hospital-family holistic care were assigned to an intervention group. The changes of psychological state and nutritional status were compared between the two groups before and after intervention. The two groups were also compared in terms of clinical data, serum preprotein (PA) and albumin (ALB) levels, quality of life (QoL), disease cognition level, self-management of patients, and nursing satisfaction.

RESULTS

After 6 months of intervention, the intervention group exhibited significantly lower anxiety and depression scores (P<0.001), and significantly higher Crohn's and Colitis knowledge scale and McMaster inflammatory bowel disease questionnaire scores than the control group (P<0.001). The scores of IBD-self-efficacy scale, mini nutritional assessment, and subjective global assessment in the intervention group were all significantly higher than those in the control group after intervention (P<0.001). Also, the intervention group showed significantly higher PA and ALB levels, as well as higher nursing satisfaction than the control group (P<0.001).

CONCLUSION

The hospital-family holistic care mode can substantially improve the management and nursing of patients with IBD through improving self-management ability, maintaining nutritional status, alleviating negative emotions, and elevating QoL.

Emerging strategy towards mucosal healing in inflammatory bowel disease: what the future holds?

For decades, the therapeutic goal of conventional treatment among inflammatory bowel disease (IBD) patients is alleviating exacerbations in acute phase, maintaining remission, reducing recurrence, preventing complications, and increasing quality of life. However, the persistent mucosal/submucosal inflammation tends to cause irreversible changes in the intestinal structure, which can barely be redressed by conventional treatment. In the late 1990s, monoclonal biologics, mainly anti-TNF (tumor necrosis factor) drugs, were proven significantly helpful in inhibiting mucosal inflammation and improving prognosis in clinical trials. Meanwhile, mucosal healing (MH), as a key endoscopic and histological measurement closely associated with the severity of symptoms, has been proposed as primary outcome measures. With deeper comprehension of the mucosal microenvironment, stem cell niche, and underlying mucosal repair mechanisms, diverse potential strategies apart from monoclonal antibodies have been arising or undergoing clinical trials. Herein, we elucidate key steps or targets during the course of MH and review some promising treatment strategies capable of promoting MH in IBD.

Chronic abdominal pain in inflammatory bowel disease: a practical guide

Pain is common in inflammatory bowel disease (IBD), yet many patients feel their pain is not addressed by healthcare professionals. Listening to a patient's concerns about pain, assessing symptoms and acknowledging the impact these have on daily life remain crucial steps in addressing pain in IBD. While acute pain may be effectively controlled by pain medication, chronic pain is more complex and often pharmacological therapies, particularly opioids, are ineffective. Low-dose tricyclic antidepressants and psychological approaches, including cognitive-behavioural therapy, have shown some promise in offering effective pain management while lifestyle changes such as a trial of low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet in those with overlapping irritable bowel syndrome may also reduce pain. Patients benefit from a long-term, trusting relationship with their healthcare professional to allow a holistic approach combining pharmacological, psychological, lifestyle and dietary approaches to chronic pain. We present a practical review to facilitate management of chronic abdominal pain in IBD.

The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study

BACKGROUND

There are debates in acupuncture related systematic reviews and meta-analyses on whether searching Chinese databases to get more Chinese-language studies may increase the risk of bias and overestimate the effect size, and whether the treatment effects of acupuncture differ between Chinese and non-Chinese populations.

METHODS

In this meta-epidemiological study, we searched the Cochrane library from its inception until December 2021, and identified systematic reviews and meta-analyses with acupuncture as one of the interventions. Paired reviewers independently screened the reviews and extracted the information. We repeated the meta-analysis of the selected outcomes to separately pool the results of Chinese- and non-Chinese-language acupuncture studies and presented the pooled estimates as odds ratios (OR) with 95% confidence interval (CI). We calculated the Ratio of ORs (ROR) by dividing the OR of the Chinese-language trials by the OR of the non-Chinese-language trials, and the ROR by dividing the OR of trials addressing Chinese population by the OR of trials addressing non-Chinese population. We explored whether the impact of a high risk of bias on the effect size differed between studies published in Chinese- and in non-Chinese-language, and whether the treatment effects of acupuncture differed between Chinese and non-Chinese population.

RESULTS

We identified 84 Cochrane acupuncture reviews involving 33 Cochrane groups, of which 31 reviews (37%) searched Chinese databases. Searching versus not searching Chinese databases significantly increased the contribution of Chinese-language literature both to the total number of included trials (54% vs. 15%) and the sample size (40% vs. 15%). When compared with non-Chinese-language trials, Chinese-language trials were associated with a larger effect size (pooled ROR 0.51, 95% CI 0.29 to 0.91). We also observed a higher risk of bias in Chinese-language trials in blinding of participants and personnel (97% vs. 51%) and blinding of outcome assessment (93% vs. 47%). The higher risk of bias was associated with a larger effect estimate in both Chinese-language (allocation concealment: high/unclear risk vs. low risk, ROR 0.43, 95% CI 0.21 to 0.87) and non-Chinese-language studies (blinding of participants and personnel: high/unclear risk vs. low risk, ROR 0.41, 95% CI 0.23 to 0.74). However, we found no evidence that the higher risk of bias would increase the effect size of acupuncture in Chinese-language studies more often than in non-Chinese-language studies (the confidence intervals of all ROR in the high-risk group included 1, Table 3). We further found acupuncture appeared to be more effective in Chinese than in non-Chinese population (Table 4).

CONCLUSIONS

The findings of this study suggest the higher risk of bias may lead to an overestimation of the treatment effects of acupuncture but would not increase the treatment effects in Chinese-language studies more often than in other language studies. The difference in treatment effects of acupuncture was probably associated with differences in population characteristics.

TRIAL REGISTRATION

We registered our protocol on the Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/PZ6XR ).

Disruption of Periaqueductal Gray-default Mode Network Functional Connectivity in Patients with Crohn's Disease with Abdominal Pain

Abdominal pain in Crohn's disease (CD) has been known to be associated with changes in the central nervous system. The periaqueductal gray (PAG) plays a well-established role in pain processing. However, the role of PAG-related network and the effect of pain on the network in CD remain unclear.Resting-state functional magnetic imaging (fMRI) data were collected from 24 CD patients in remission with abdominal pain, 24 CD patients without abdominal pain and 28 healthy controls (HCs). Using the subregions of PAG (dorsomedial (dmPAG), dorsolateral (dlPAG), lateral (lPAG) and ventrolateral (vlPAG)) as seeds, the seed-based FC maps were calculated and one-way analysis of variance (ANOVA) was performed to investigate the differences among the three groups.Results showed that the group differences were mainly involved in the FC of the vlPAG with the precuneus, medial prefrontal cortex (mPFC) as well as orbitofrontal cortex (OFC), and the FC of the right lateral PAG (lPAG) with the precuneus, inferior parietal lobule (IPL), angular gyrus and premotor cortex. The FC values of all these regions decreased successively in the order of HCs, CD without abdominal pain and CD with abdominal pain. The pain score was negatively correlated with the FC of the l/vlPAG with the precuneus, angular gyrus and mPFC in CD patients with abdominal pain.This study implicated the disrupt communication between the PAG and the default mode network (DMN). These findings complemented neuroimaging evidence for the pathophysiology of visceral pain in CD patients.

Comparison and recommendation of dietary patterns based on nutrients for Eastern and Western patients with inflammatory bowel disease

Inflammatory bowel disease (IBD), a non-specific chronic idiopathic inflammatory condition of the digestive system, requires lifelong treatment in which drugs are the mainstay, along with surgery when necessary. In adjuvant therapies, the diet is considered to be an essential, controllable, and economical component. However, the majority of recent nutrition research has focused on the general effects of nutrients on IBD, with little attention given to the advantages and negative aspects of individual foods and dietary combinations. To cover these shortcomings, we surveyed the benefits and drawbacks of typical foods and their chemical compositions on intestinal pathophysiology by comparing nutrients existing in the foods in Eastern and Western countries. Moreover, for Eastern and Western patients with IBD, we innovatively propose a 3-step dietary recommendation based on modified customary eating habits, including lowering the triggering foods, modifying dietary advice to control disease progression, and improving surgery prognosis.