Sleep and Fatigue in IBD: an Unrecognized but Important Extra-intestinal Manifestation

Fatigue in Patients with Inflammatory Bowel Disease in Remission One Year After Diagnosis (the IBSEN III Study)

BACKGROUND AND AIMS

Fatigue is commonly observed in Crohn's disease (CD) and ulcerative colitis (UC) but its association to achieving remission is not clearly established. In this study, we describe the odds for fatigue in patients with CD/UC 1 year after diagnosis based on different definitions of remission and identified factors associated with chronic fatigue (CF) among patients in endoscopic/radiological remission.

METHODS

Patients ≥ 18 years old with CD/UC were recruited from the IBSEN III cohort. Using the Fatigue Questionnaire, and dichotomizing the score, CF was defined as the presence of substantial fatigue (SF) for ≥6 months. Remission was divided into symptomatic (CD: Harvey-Bradshaw Index score < 5/UC: SCCAI score < 3), biochemical (fecal calprotectin ≤ 250 µg/g), endoscopic/radiological (CD: normal intestinal MRI/CT combined with normal endoscopy/UC: Mayo endoscopic score 0), and histological (normal mucosal biopsies). Both the likelihood of SF/CF, depending on the definition of remission, and associations between CF and selected factors for CD/UC in endoscopic/radiological remission were evaluated using binary logistic regression analysis.

RESULTS

In total, 711/1416 patients were included. For both CD and UC, symptomatic remission significantly reduced the odds for SF and CF. In addition, the odds for SF were significantly reduced for UC in biochemical remission. Among those in endoscopic/radiological remission (n = 181), CF was independently associated with sleep disturbances (OR = 10.40, 95%CI [3.28;32.99], p < 0.001) and current treatment with infliximab (OR = 4.31, 95%CI [1.15;16.17], p = 0.03).

CONCLUSIONS

Stricter definitions of disease remission were not associated with a decreased likelihood of fatigue. For patients in endoscopic/radiological remission, CF was independently associated with sleep disturbances and current treatment with infliximab.

The Substantial Role of Sleep, Stress, and Physical Activity in Persistent High Levels of Fatigue in Patients With Inflammatory Bowel Disease: A Longitudinal Trajectory Study

BACKGROUND AND AIMS

Fatigue is a common and burdensome problem for patients with inflammatory bowel disease (IBD). Previous studies lack insight into the individual variability in fatigue severity and course over time, and the characteristics of patients at risk of severe and persistent fatigue. This study aimed to identify distinct groups of IBD patients based on their level and course of fatigue over 5 years. Subsequently, we examined the relationship between these trajectories, patient characteristics, and trajectories of perceived stress, sleep, and physical activity.

METHODS

This longitudinal cohort study used prospectively collected data from the myIBDcoach telemedicine monitoring tool, including 320 IBD patients who completed 3 or more online consultations between 2016 and 2021. Latent class growth analyses were performed to identify distinct trajectories.

RESULTS

We found 5 subgroups with distinct trajectories of fatigue, differing in level and course over time, with 33% of patients experiencing chronic stable and high levels of fatigue. Few differences in patient characteristics were found between trajectories, yet the chronic high fatigue subgroup was more likely to report persistent stable sleep problems, perceived stress, and little physical activity over time compared to the other groups.

CONCLUSIONS

Distinct subgroups of IBD patients can be identified based on longitudinal fatigue trajectories. The relatively stable levels of fatigue, stress, sleep, and physical activity suggest that a one-time screening of patients on these topics may be sufficient to identify those at risk. Interventions aiming to reduce fatigue should target persistent stress, sleep problems, and low levels of physical activity.

US and European Patient and Health Care Professional Perspectives on Fatigue in Ulcerative Colitis and Crohn's Disease: Results From the Communicating Needs and Features of Inflammatory Bowel Disease Experiences Survey

Background

Fatigue is a burdensome symptom of Crohn's disease (CD) and ulcerative colitis (UC). The Communicating Needs and Features of Inflammatory Bowel Disease Experiences (CONFIDE) study investigated how patients and health care professionals (HCPs) in the United States (US) and Europe (France, Germany, Italy, Spain, and the United Kingdom) perceived the experiences and impact of CD/UC-related symptoms.

Methods

Online, quantitative, cross-sectional surveys were conducted separately among patients with moderate-to-severe CD/UC (defined based on previous treatment, steroid use, and/or hospitalization) and HCPs who treated patients with CD/UC. US and Europe data are presented as descriptive statistics.

Results

Surveys were completed by 215 US and 547 European patients with CD, 200 US and 556 European patients with UC, and 200 US and 503 European HCPs. Overall, 35.8% US and 34.2% European patients with CD and 27.5% US and 20.9% European patients with UC reported currently experiencing fatigue (in past month). Most of these patients reported severe fatigue and indicated that CD/UC negatively affected their sleep, energy levels, and quality of life (QoL). The majority of patients currently experiencing but not discussing fatigue with their HCPs at every appointment wished they discussed it more frequently. However, most HCPs reported proactively discussing fatigue at routine appointments. Approximately 20% patients with CD/UC reported declining participation in work/school, social activities, and sports/physical exercise, and avoiding sexual activities due to fatigue.

Conclusions

US and European patients with CD/UC experienced severe burden of fatigue, which negatively affected their QoL. Assessing and discussing fatigue in routine appointments is critical for effectively managing this debilitating symptom.

Management of Fatigue in Inflammatory Bowel Disease: A Narrative Review

Inflammatory bowel disease (IBD) encompasses chronic inflammatory conditions of the digestive tract, including Crohn's disease and ulcerative colitis. Fatigue is one of the common and important extraintestinal symptoms in IBD patients, which significantly affects the patient's ability to work, daily life, social activities, emotional state, and cognitive function. Although the impact of fatigue on patients' quality of life cannot be ignored, medical professionals still have limited knowledge of its concepts, assessment tools, influencing factors, and non-pharmacological interventions, which may lead to neglect and inadequate management of the symptoms. The purpose of this article is to review the definition and epidemiological characteristics of IBD-related fatigue and to discuss the application of four commonly used fatigue assessment tools in patients with IBD. In addition, we will analyze the multiple factors that affect fatigue in IBD patients from three levels: physiological, psychological, and sociodemographic. Finally, we will assess the effectiveness of different non-pharmacological interventions in alleviating fatigue in people with IBD and make corresponding clinical recommendations.

Trends in Mortality Due to Inflammatory Bowel Disease in the United States: A CDC WONDER Database Analysis (1999-2020)

INTRODUCTION

Inflammatory bowel disease (IBD) is a global health issue profoundly impacting quality of life. The United States accounts for nearly a quarter of the world's IBD patients, with the highest prevalence rates. This study aims to identify the demographic and regional trends of IBD-related mortality in the U.S. from 1999 to 2020.

METHODOLOGY

Our study utilized the CDC Wonder database to gather mortality data for IBD (Crohn's disease and ulcerative colitis) from 1999 to 2020. Results were presented as age-adjusted mortality rates (AAMR) per 100,000 population, with Joinpoint regression used to analyze trend changes and calculate annual percentage change (APC).

RESULTS

A total of 62,310 IBD-related deaths were recorded. From 1999 to 2020, AAMR for Crohn's disease increased from 0.79 to 0.97, declining from 1999 to 2018 (APC: - 0.22) but surging from 2018 onwards (APC: 11.26). Women had a higher AAMR (0.81) compared to men (0.77). The highest rates were among non-Hispanic whites (0.86), followed by non-Hispanic blacks (0.48) and Hispanics (0.21). AAMR varied by state, ranging from 0.29 in Hawaii to 1.42 in Vermont. For ulcerative colitis, AAMR rose from 0.56 in 1999 to 0.63 in 2020, following a similar trend: a decline from 1999 to 2018 (APC: - 0.37) followed by an increase (APC: 12.21). State-specific AAMR ranged from 0.14 in Hawaii to 0.67 in Oregon.

CONCLUSION

This study highlights a decrease in AAMR for both diseases from 1999 to 2018, followed by significant increases from 2018 to 2020, indicating a need for targeted interventions.

The relationship between fatigue, sleep quality, and sleep deprivation

BACKGROUND

Fatigue, sleep disorders, and daytime sleepiness are interconnected, posing significant risks to occupational health and workplace safety. However, the literature on their relationships remains fragmented, with notable gaps, particularly concerning working populations. This descriptive cross-sectional study aimed to evaluate sleep quality (SQ), daily sleep time in hours (DST), daytime sleepiness, fatigue levels among employees in an automotive workplace, and their interrelationships.

METHODS

This study assessed fatigue, DST, SQ, and daytime sleepiness (DTS) among employees aged 21-51 years working under the same conditions. Data were collected using questionnaires and two validated scales: the Check Individual Strength Scale (CIS) for fatigue and the Epworth Sleepiness Scale (ESS) for excessive daytime sleepiness.

RESULTS

None of the Check Individual Strength Scale (CIS), or SQ points, mean values or DST hours values significantly differ due to any sociodemographic independent variables. Epworth Sleepiness Scale (ESS) points mean values differ significantly due to BMI values. However, statistically significant relationships were identified among CIS, ESS, SQ points, and DST hours. Additionally, a positive correlation was observed between ESS and CIS scores. These findings suggest reciprocal effects among fatigue, SQ, DST, and daytime sleepiness.

CONCLUSION

While sleep problems cause fatigue also chronic fatigue syndrome may be the reason of worse SQ. Further research is necessary to emphasize the importance of addressing the interplay between fatigue, excessive daytime sleepiness, SQ, and DST in hours to improve workplace safety and employee well-being.

Poor sleep quality is common and independently associated with disease activity and poor quality of life in inflammatory bowel disease: a long-term follow-up study

Background

The association between inflammatory bowel disease (IBD) activity and poor sleep quality is reported. However, most research subjectively investigated this issue and lacked long-term follow-up.

Objectives

Our study aimed to investigate the prevalence of sleep disturbance in IBD patients across disease activity and evaluate the long-term correlation between disease activity, sleep quality, and quality of life.

Design

This prospective observational study assessed sleep quality in patients with IBD.

Methods

Patients with IBD were categorized into groups based on clinical activity scores. The sleep questionnaire (Pittsburgh Sleep Quality Index (PSQI)) and IBD questionnaire (IBDQ) were evaluated monthly for 12 months. Seven-day sleep data from wrist actigraphy (Actiwatch®) were collected at initiation and completion. Longitudinal correlation was analyzed.

Results

A total of 98 participants were enrolled, consisting of 68 remission, 21 mild, and 9 moderate-to-severe disease activities. At baseline, 60% of participants demonstrated poor sleep quality, defined by a PSQI of >5. The group with greater disease severity reported numerically poorer sleep quality; however, this difference was not statistically significant. On actigraphy, there was no statistically significant difference in sleep latency, wake after sleep onset, or sleep efficiency between the groups. During follow-up, 90 patients responded to questionnaires. The mean PSQI decreased from 7.1 to 5.4 among 22 patients whose active disease transitioned to remission (p < 0.001). However, the score did not change in 11 patients with remission and developed disease flare (5.9-5.8). The mean PSQI was 7.7 and 6.3 in 4 and 53 patients whose disease remained active and inactive during follow-up, respectively. Multivariable longitudinal analysis revealed that PSQI was independently associated with active disease (odds ratio = 1.22) and inversely associated with IBDQ (β = -2.23). Sleep latency was evaluated by PSQI, and actigraphy was significantly correlated.

Conclusions

Patients with IBD frequently experience poor sleep quality, which significantly correlates with active disease and worse quality of life longitudinally.

Fatigue Is Strongly Associated with Depressive Symptoms in Patients with Inflammatory Bowel Disease

Introduction

Fatigue is an extraintestinal manifestation in patients with inflammatory bowel disease (IBD), such as Crohn's disease (CD) and ulcerative colitis (UC), with limited information on the underlying factors. This study aimed to determine the prevalence of fatigue and associated factors in IBD patients.

Methods

This prospective observational study assessed 216 IBD patients treated with intravenous infliximab or vedolizumab. Clinically meaningful fatigue was defined using a visual analog scale with a score ≥4 (VAS-F, range 0-10). Further assessments included the patient health questionnaire (PHQ-8) for depressive symptoms, the IBD-control-8 questionnaire to evaluate subjective disease control and the fatigue impact scale (FIS) for patients' quality of life (QoL). Demographic, clinical and laboratory data of the study population were collected and compared to identify fatigue-associated factors.

Results

Overall, 53.2% (n = 115) of the IBD patients reported clinically meaningful fatigue with a higher prevalence in UC (63.0%) versus CD (47.4%). Among patients with CD, disease activity was significantly associated with fatigue symptoms (p < 0.001), whereas no such correlation was observed in UC patients (p = 0.85). Clinically meaningful fatigue symptoms were reported in 90.9% of patients with depressive symptoms (PHQ-8 ≥10). Furthermore, patients with fatigue were younger (40 vs. 42 years, p = 0.04), reported more frequent use of concomitant psychoactive and/or sedative medication (p = 0.03) and had lower IBD-control-8 scores (median 12 vs. 16 points, p < 0.001). Only minor differences were observed when comparing serum and fecal laboratory values of patients with fatigue symptoms to those without.

Conclusion

Fatigue is highly prevalent among IBD patients treated with vedolizumab or infliximab and has a substantial impact on patients' QoL. Fatigue and depressive symptoms were strongly associated, suggesting closer monitoring for depression and the use of psychoactive medication in patients with IBD.

Greater Fatigue and Reduced Neurocognitive Speed With Symptomatic Crohn's Disease

Background

While patients with Crohn's disease commonly report fatigue, an association of Crohn's disease with mild neurocognitive impairment has also been suggested. This study investigated the relationship between Crohn's disease activity, fatigue, and neurocognitive functioning.

Methods

In this cross-sectional study, adults with Crohn's disease (n = 25) and healthy controls (n = 26) completed the PROMIS Fatigue 7a form and Multidimensional Fatigue Inventory and neurocognitive testing across 6 domains. Symptomatic and endoscopic remission were assessed with a short Crohn's Disease Activity Index and Simple Endoscopic Score for Crohn's Disease. Linear regression adjusting for age and sex was used to compare fatigue and neurocognition among patients with Crohn's disease versus controls and those with active Crohn's disease versus those in remission.

Results

Compared to controls, adults with Crohn's disease reported greater overall and domain-specific fatigue (general, physical, and mental) (P < .05 for all comparisons). Patients in symptomatic remission had significantly less fatigue (P < .05). No differences were found in neurocognitive accuracy or speed between Crohn's disease and controls. Disease activity was not associated with accuracy on neurocognitive testing; however, patients with symptomatic Crohn's disease had longer correct response times for social cognition and episodic memory compared to asymptomatic patients (P < .05). Endoscopic disease activity was associated with longer correct response times for tasks linked to social cognition, episodic memory, and complex cognition (P < .05). These differences persisted after adjusting for fatigue.

Conclusions

Patients with symptomatic Crohn's disease experience greater fatigue and have slower response times on neurocognitive testing. However, fatigue does not appear to mediate the slower response times.

Prevalence and risk factors of sleep disorders in inflammatory bowel disease: a cross-sectional study

BACKGROUND

Sleep disorders are one of the major public health problems, which can potentially induce inflammation and exacerbate disease activity, resulting in compromised sleep quality. This study aimed to investigate the prevalence and risk factors associated with sleep disorders among patients with inflammatory bowel disease (IBD).

METHODS

Between March 2023 and February 2024, the Pittsburgh Sleep Quality Index was employed to assess sleep quality in both IBD patients and healthy control subjects. Univariate and multivariate analysis were performed to identify the risk factors associated with SD in IBD patients.

RESULTS

Overall, 208 IBD patients [150 Crohn's disease (CD) and 58 ulcerative colitis (UC)] and 199 healthy individuals were included. Sleep disorders were observed in 59.6% of patients with IBD, with a higher prevalence among females (63.5%) compared to males (56.9%) (P = 0.476). The prevalence of sleep disorders in IBD patients was significantly higher than that found in healthy controls (37.7%) (all P < 0.01). The prevalence of sleep disorders  among CD and UC patients was 58% and 63.8%, respectively (P = 0.291). The multivariate analysis revealed that older age (OR, 1.070; 95% CI: 1.035-1.105, P = 0.000), smoking (OR, 2.698; 95% CI: 1.089-6.685, P = 0.032), and depression (OR, 4.779; 95% CI: 1.915-11.928, P = 0.001) were risk factors for sleep disorders in IBD patients. However, higher body mass index (OR, 0.879; 95% CI: 0.790-0.977, P = 0.017) was identified as a protective factor.

CONCLUSION

Sleep disorders are common among IBD patients regardless of activity levels. Smoking and depression are the major risk factors.

Shared Pathophysiology of Inflammatory Bowel Disease and Psoriasis: Unraveling the Connection

Psoriasis (PS) and inflammatory bowel disease (IBD) are immune-mediated chronic conditions that share pathophysiological processes, including immune system dysfunction, microbiome dysbiosis, and inflammatory pathways. These pathways result in increased turnover of epithelial cells and compromised barrier function. The assessment of the literature suggests that immunopathogenic mechanisms, such as tumor necrosis factor (TNF)-α signaling and IL-23/IL-17 axis dysregulation, are shared by PS and IBD. Clinical characteristics and diagnostic approaches overlap significantly, and advances in biomarker identification benefit both conditions. Current treatments, namely biologics that target TNF-α, IL-17, and IL-23, show promising results in decreasing inflammation and controlling symptoms. Precision medicine approaches are prioritized in prospective therapeutic procedures to tailor pharmaceuticals based on specific biomarkers, perhaps improving outcomes and minimizing side effects. This study thoroughly examines and evaluates the body of research on PS and IBD. Several papers were examined to compile data on clinical features, diagnosis, therapies, pathophysiology, epidemiology, and potential future therapeutic developments. The selection of articles was based on three methodological qualities: relevance and addition to the knowledge of IBD and PS. The retrieved data were combined to provide a coherent summary of the state of the knowledge and to spot new trends. The overview of the latest studies demonstrates that both PS and IBD share pathophysiological foundations and therapeutic approaches. With a spotlight on particular biomarkers, advances in precision medicine provide a promising path toward enhancing therapeutic effectiveness and minimizing side effects.

Qualitative and Psychometric Evaluation of 29-Item Patient-Reported Outcomes Measurement Information System® to Assess General Health-Related Quality of Life in Patients With Moderately to Severely Active Inflammatory Bowel Disease

OBJECTIVES

To evaluate content validity and psychometric properties of the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29) to determine its suitability in inflammatory bowel disease (IBD) clinical trials.

METHODS

Content validity of PROMIS-29 was evaluated using qualitative interviews, including concept elicitation and cognitive debriefing, among patients living with Crohn's disease (Crohn's disease n = 20) or ulcerative colitis (UC, n = 19). PROMIS-29 validity, reliability, and responsiveness were assessed using data from phase II clinical trials of Crohn's disease (N = 360) and UC (N = 518).

RESULTS

Common (≥74%) symptoms reported in qualitative interviews were increased stool frequency, fatigue, abdominal pain/cramping, blood/mucus in stool, bowel urgency, and diarrhea. Disease impact aligned with PROMIS-29 content (depression, anxiety, physical function, pain interference, fatigue, sleep disturbance, and ability to participate in social roles/activities). Cognitive debriefing indicated that PROMIS-29 instructions were easily understood, items were relevant, and the recall period was appropriate. Psychometric evaluations demonstrated that PROMIS-29 scores indicating worse symptoms/functioning were associated with lower health-related quality of life and greater disease activity and severity. PROMIS-29 domain scores correlated (rs ≥ 0.40) with IBD Questionnaire domains and EuroQol-5-Dimension-5-Level dimensions measuring similar concepts. Test-retest reliability among patients with stable disease was moderate-to-excellent (0.64-0.94) for nearly all domains in all studies. PROMIS-29 was responsive to change in disease status from baseline to week 12. Thresholds for clinically meaningful improvement ranged from ≥3 to ≥8, depending on domain.

CONCLUSIONS

PROMIS-29 is valid, reliable, and responsive for assessing general health-related quality of life and treatment response in IBD clinical trials.

Saffron as a Promising Therapy for Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory illness of the gastrointestinal tract (GI), characterized by recurrent episodes of inflammation and tissue destruction. It affects an increasing number of individuals worldwide who suffer from Crohn's disease (CD) or ulcerative colitis (UC). Despite substantial advances in understanding the underlying causes of IBD, the available treatments remain restricted and are sometimes accompanied by severe consequences. Consequently, there is an urgent need to study alternate therapeutic options. This review assesses the present drugs, identifies their limitations, and proposes the use of saffron, a natural plant with great therapeutic potential based on preclinical and clinical investigations. Saffron has gained attention for its potential therapeutic benefits in treating various ailments due to its established bioactive compounds possessing antioxidant and anti-inflammatory properties. This review covers how saffron impacts the levels of calprotectin, an inflammatory marker, for various inflammatory responses in multiple diseases including IBD. Data from clinical trials were assessed to determine the efficacy and safety of using saffron to counter inflammation in multiple diseases. Studies have shown that saffron may protect against inflammatory bowel disease (IBD) through several mechanisms by inhibiting pro-inflammatory cytokines (TNF-α, IL-1β, and IL-6), reducing oxidative stress through antioxidant effects, enhancing mucosal barrier function by upregulating tight junction proteins, and modulating the gut microbiota composition to promote beneficial bacteria while suppressing pathogenic ones; these combined actions contribute to its therapeutic potential in managing and alleviating the symptoms of IBD. This will enable future research endeavors and expedite the translation of saffron-based interventions into clinical practice as a valuable adjunctive therapy or a potential alternative to conventional treatments, thereby enhancing the quality of life for individuals suffering from inflammatory diseases including IBD.

Post-traumatic stress disorder symptoms are frequent among inflammatory bowel disease patients of South Asian descent-A case-control study

BACKGROUND

Post-traumatic stress (PTS) is the psycho-physiological response to a traumatic or life-threatening event and is implicated in inflammatory bowel disease (IBD). IBD-PTS is present in up to 30% of white, non-Hispanic patients. The rates of IBD in Asian populations are expanding, making the exploration of IBD-PTS in this population imperative.

METHODS

Adult patients of South/Southeast (S/SE) Asian decent with IBD for more than 6 months were recruited online via social media and patient-support groups. Participants completed the post-traumatic stress disorder (PTSD) Checklist-5 (PCL-5), the United States National Institutes of Health's Patient-Reported Outcomes Measurement Information System (NIH-PROMIS) -43 profile and demographics. S/SE Asian participants were age and sex matched (1:2) with randomly selected white, non-Hispanic controls. Statistical analyses evaluated differences in IBD-PTS symptoms between groups, the relationship between disease severity and health-related quality of life (HRQoL) and predictors of IBD-PTS severity.

RESULTS

Forty-seven per cent of the 51 S/SE Asian participants met the diagnostic cut-off for PTSD on the PCL-5 compared to 13.6% of 110 IBD controls. The mean global score on the PCL-5 was three times higher in S/SE Asians. Patients of S/SE Asian decent were over five times more likely to have PTSD due to their IBD experiences than controls, nearly doubling when controlling for disease activity. More severe IBD-PTS was present in S/SE Asian patients with active disease and those with extraintestinal manifestations. Higher global levels of IBD-PTS were associated with poorer HRQoL in S/SE Asians where increased hyperarousal from IBD-PTS predicted more sleep disturbance.

CONCLUSIONS

S/SE Asian patients are five times more likely to experience IBD-PTS than their white, non-Hispanic counterparts. Several cultural factors lead to IBD-PTS in S/SE Asian patients that must be considered by IBD providers. Preventing, screening for and treating IBD-PTS in this population appears warranted.

The impact of the COVID-19 pandemic on the mental health of patients diagnosed with inflammatory bowel diseases

Understanding the profound impact of a viral pandemic on the mental health of patients with autoimmune diseases undergoing biological treatment is crucial for future insights. This cross-sectional case-control study aimed to assess the mental health implications of the COVID-19 pandemic on individuals with inflammatory bowel disease (IBD) in Romania, spanning from November 2022 to March 2023. A specialized self-report questionnaire in the Romanian language was developed to measure the multifaceted effects of COVID-19 on the mental well-being of these patients. The findings revealed a significant decline in the mental health of patients with IBD during the pandemic compared to the control group. Patients with IBD exhibited elevated levels of anxiety and concern regarding the virus. Intriguingly, despite the challenges, the vaccination rate was notably higher among patients with IBD, indicating a proactive approach to safeguarding their health. The study also shed light on various coping mechanisms employed by patients with IBD to navigate the pandemic-related restrictions. Engaging in activities such as social media and computer games emerged as effective strategies for managing heightened stress and limitations. In conclusion, the emergence of a novel viral pathogen represents a significant distress factor for patients with autoimmune diseases. Recognizing and comprehending these consequences enhances our understanding of the intricate interplay between physical and mental health and equips authorities with valuable insights to better manage future epidemics or viral outbreaks. This study underscores the importance of tailored support systems and strategies for patients with autoimmune diseases during global health crises.

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.

Prevalence and Determinants of Fatigue in Patients with IBD: A Cross-Sectional Survey from the GETAID

BACKGROUND

Fatigue is commonly reported by patients with inflammatory bowel disease [IBD], but the determinants of IBD-related fatigue have yet to be determined.

AIMS

To identify the factors associated with fatigue in a large population of patients with IBD.

PATIENTS AND METHODS

Fatigue and nine other IBD-related disability dimensions were assessed in a cohort of 1704 consecutive patients with IBD using the IBD-disk questionnaire in a cross-sectional survey of 42 French and Belgian centres. Fatigue and severe fatigue were defined as energy subscores >5 and >7, respectively. Determinants of fatigue were assessed using univariate and multivariate analyses (odds ratios [ORs] are provided with 95% confidence intervals).

RESULTS

The prevalence rates of fatigue and severe fatigue were 54.1% and 37.1%, respectively. Both fatigue and severe fatigue were significantly higher in patients with active disease than in patients with inactive disease [64.9% vs 44.7% and 47.4% vs 28.6%, respectively; p < 0.001 for both comparisons]. In the multivariate analysis stratified by age, sex, type of IBD and IBD activity, fatigue was associated with age >40 years (OR = 0.71 [0.54-0.93]), female sex (OR = 1.48 [1.13-1.93]) and IBD-related sick leave (OR = 1.61 [1.19-2.16]), and joint pain (OR = 1.60 [1.17-2.18]), abdominal pain (OR = 1.78 [1.29-2.45]), regulating defecation (OR = 1.67 [1.20-2.32]), education and work (OR = 1.96 [1.40-2.75]), body image (OR = 1.38 [1.02-1.86]), sleep (OR = 3.60 [2.66-4.88]) and emotions (OR = 3.60 [2.66-4.88]) subscores >5.

CONCLUSION

Determinants of fatigue are not restricted to IBD-related factors but also include social factors, sleep and emotional disturbances, thus supporting a holistic approach to IBD patient care.

Economic Burden of Fatigue in Inflammatory Bowel Disease

Background

This retrospective study gathered medical/pharmacy claims data on patients with inflammatory bowel disease (IBD) between January 01, 2000 and March 31, 2019 from the IBM MarketScan commercial claims database to assess the real-world impact of fatigue on healthcare costs in patients newly diagnosed with IBD.

Methods

Eligible participants were ≥18 years, newly diagnosed with IBD (≥2 separate claims), and had ≥12 months of continuous database enrollment before and after fatigue diagnosis. The date of fatigue diagnosis was the index date; participants were followed for 12 months post-index. Patients with (cases) or without (controls) fatigue were matched 1:1 by propensity score matching. Patients with evidence of prior IBD diagnosis/treatment, or those with a chronic disease other than IBD wherein fatigue is the primary symptom, were excluded. Healthcare resource utilization (HCRU), including hospitalizations, inpatient and outpatient visits, and associated costs were compared between cases and controls.

Results

Matched IBD cohorts (21 321 cases/21 321 controls) were identified (42% Crohn's disease [CD] and 58% ulcerative colitis [UC]) with similar baseline characteristics (average age: 46 years; 60% female). Cases versus controls had significantly more all-cause outpatient visits (incidence rate ratio [IRR], 95% confidence intervals [95% CI]: 1.64 [1.61, 1.67], P < .001) and all-cause hospitalizations (IRR [95% CI]: 1.92 [1.81, 2.04], P < .001); as well as significantly higher all-cause total direct healthcare costs (mean: $24 620 vs. $15 324; P < .001). Similar findings were observed for IBD-related outcomes, as well as in CD- and UC-specific subgroups.

Conclusions

Presence of fatigue is associated with an increase in HCRU and total medical costs among patients newly diagnosed with IBD.

Relationship between the Biological Clock and Inflammatory Bowel Disease

The biological clock is a molecular oscillator that generates a 24-hour rhythm in accordance with the earth's rotation. Physiological functions and pathophysiological processes such as inflammatory bowel diseases (IBD) are closely linked to the molecular clock. This review summarizes 14 studies in humans and mice on the interactions between the biological clock and IBD. It provides evidence that IBD negatively affect core clock gene expression, metabolism and immune functions. On the other hand, disruption of the clock promotes inflammation. Overexpression of clock genes can lead to inhibition of inflammatory processes, while silencing of clock genes can lead to irreversible disease activity. In both human and mouse studies, IBD and circadian rhythms have been shown to influence each other. Further research is needed to understand the exact mechanisms and to develop potential rhythm-related therapies to improve IBD.

Use of Benzodiazepines and Z-Drugs in Inflammatory Bowel Disease

INTRODUCTION

We estimated the incidence and prevalence of benzodiazepine and Z-drug (separately and jointly as BZD) use in the inflammatory bowel disease (IBD) population compared with matched controls without IBD and examined the association of mood/anxiety disorders (M/ADs) with the use of BZD from 1997 to 2017.

METHODS

Using administrative data from Manitoba, Canada, we identified 5,741 persons with incident IBD who were matched in a 1:5 ratio to controls on sex, birth year, and region. Validated case definitions were used to identify M/AD. Dispensations of BZD were identified. Multivariable generalized linear models were used to assess the association between IBD, M/AD, and BZD use.

RESULTS

In 2016, the incident age/sex-standardized benzodiazepine use rates per 1,000 were 28.06 (95% confidence interval [CI] 26.41-29.81) in the IBD cohort and 16.83 (95% CI 16.28-17.39) in controls (adjusted rate ratio = 1.69 [95% CI 1.56-1.79]). Benzodiazepine incidence rates were higher for women with IBD than men, but the RR between cases and controls were similar for men and women. The incident age/sex-standardized Z-drug use rate per 1,000 was 21.07 (95% CI 19.69-22.41) in the IBD cohort. This was 1.87-fold higher than in controls (95% CI 1.73-2.01). In 2017, approximately 20% of persons with IBD used benzodiazepines and 20% used Z-drugs. There was a subadditive effect of both benzodiazepine and Z-drug uses between IBD and M/AD after adjusting for covariates.

DISCUSSION

The use of BZD is more common in people with IBD than in population controls. Strategies to reduce the use of BZDs in persons with IBD and to offer alternative management strategies for M/ADs, sleep disorders, and other symptomatic concerns are needed.

Associations of chronic diarrheal symptoms and inflammatory bowel disease with sleep quality: A secondary analysis of NHANES 2005-2010

Objective

Poor sleep quality is highly prevalent in patients with chronic diarrheal symptoms or inflammatory bowel disease (IBD). This study aimed to evaluate the associations of chronic diarrheal symptoms and IBD with sleep quality in the general US population.

Methods

14,696 adults (≥20 years) from the National Health and Nutrition Examination Survey (2005-2010) were included in the study. Chronic diarrheal symptoms and IBD were defined by self-reports. Sleep quality was assessed by sleep disorder, sleep trouble, and sleep duration. Multivariable logistic regression models were used to examine the associations.

Results

After adjustment of a series of covariates, we found that participants with chronic diarrheal symptoms or IBD had higher odds of sleep disorder [chronic diarrheal symptoms: odds ratio (OR) = 1.20, 95% confidence interval (CI) = 1.04-1.38; IBD: OR = 3.86, 95% CI = 1.92-7.77] and sleep trouble (chronic diarrheal symptoms: OR = 1.19, 95% CI = 1.09-1.30; IBD: OR = 2.32, 95% CI = 1.30-4.14), respectively. Sleep duration for participants with IBD was significantly shorter than that for those without IBD (β = -0.39, 95% CI = -0.78 to 0.01, P = 0.045). Subgroup analyses revealed that the associations of chronic diarrheal symptoms and IBD with sleep disorder and sleep trouble were more pronounced among women.

Conclusions

In this large sample of US adults, we found that chronic diarrheal symptoms and IBD were significantly associated with sleep quality, particularly in women. The findings highlight the importance of managing bowel health to promote high quality of sleep; and thus, improve quality of life in this subpopulation.

Effect of the Coronavirus Disease 2019 Lockdown on Lifestyle Factors in Japanese Patients with Inflammatory Bowel Disease

Objective To examine the effect of the coronavirus disease 2019 (COVID-19) lockdown on lifestyle factors and psychological stress in patients with inflammatory bowel disease (IBD). Methods A retrospective study was conducted on patients with IBD in Japan 2 months after the initiation of the first state of emergency (June 16 to August 21, 2020). A self-reported questionnaire was used to collect data, and lifestyle factors and psychological stress levels before and after the state of emergency were compared. Patients Patients with IBD who were followed up regularly at Osaka City University Hospital from June 16 to August 21, 2020, were included and were classified into elderly (≥65 years old) and non-elderly groups (<65 years old). Results The study sample comprised 451 responders (241, ulcerative colitis; 210, Crohn's disease; 0, COVID-19). The sleep duration increased, whereas the exercise, working, and walking durations decreased during the COVID-19 lockdown. The proportion of patients with psychological stress due to COVID-19, those with an inability to exercise, and those staying indoors increased significantly during COVID-19 lockdown. Lifestyle factors changed more markedly in non-elderly patients, those who were more stressed due to COVID-19, those with the inability to exercise, and those staying indoors during COVID-19 lockdown. Among elderly patients, no significant changes were identified in stress-causing factors. Conclusion The COVID-19 lockdown affected lifestyle factors and psychological stress in patients with IBD, particularly non-elderly patients. These findings may be helpful in suggesting favorable lifestyle changes for patients with IBD.

The Role of Race, Sex, and Age in Circadian Disruption and Metabolic Disorders

Circadian rhythms are 24-hour internal biological cycles that play an important role in metabolism, and their disruption has been implicated in the development of diseases such as diabetes mellitus type 2, obesity, coronary artery disease, hypertension, and metabolic syndrome. This phenomenon is illustrated by increased rates of risk factors for cardiovascular disease in night shift workers. Race, sex, and age are factors that play a role in circadian rhythms and metabolic disorders. The focus of this review article is to assess the link between circadian rhythm physiology and metabolic disorders from a race, sex, and age perspective. Black Americans were noted to have shorter free-running circadian periods, or tau, increased cortisol levels, and poorer sleep habits compared to white Americans, possibly contributing to increased rates of obesity, hypertension, and hyperlipidemia. Women were also noted to have shorter tau, increased levels of proinflammatory gut bacteria, and reduced sleep quality compared to men, possibly leading to higher rates of obesity, metabolic syndrome, hypertension (in postmenopausal women), and nonalcoholic fatty liver disease. Older people were noted to have decreased expression of anti-inflammatory clock genes compared to younger people, possibly leading to increased rates of obesity, diabetes, hyperlipidemia, and hypertension. Groups that are at a higher risk for metabolic disorders such as black Americans, women, and the elderly may have internal time keeping systems that place them at a higher risk for developing abnormal hormonal and/or inflammatory pathways.

Recruitment of α4β7 monocytes and neutrophils to the brain in experimental colitis is associated with elevated cytokines and anxiety-like behavior

Background

Behavioral comorbidities, such as anxiety and depression, are a prominent feature of IBD. The signals from the inflamed gut that cause changes in the brain leading to these behavioral comorbidities remain to be fully elucidated. We tested the hypothesis that enhanced leukocyte–cerebral endothelial cell interactions occur in the brain in experimental colitis, mediated by α4β7 integrin, to initiate neuroimmune activation and anxiety-like behavior.

Methods

Female mice treated with dextran sodium sulfate were studied at the peak of acute colitis. Circulating leukocyte populations were determined using flow cytometry. Leukocyte–cerebral endothelial cell interactions were examined using intravital microscopy in mice treated with anti-integrin antibodies. Brain cytokine and chemokines were assessed using a multiplex assay in animals treated with anti-α4β7 integrin. Anxiety-like behavior was assessed using an elevated plus maze in animals after treatment with an intracerebroventricular injection of interleukin 1 receptor antagonist.

Results

The proportion of classical monocytes expressing α4β7 integrin was increased in peripheral blood of mice with colitis. An increase in the number of rolling and adherent leukocytes on cerebral endothelial cells was observed, the majority of which were neutrophils. Treatment with anti-α4β7 integrin significantly reduced the number of rolling leukocytes. After anti-Ly6C treatment to deplete monocytes, the number of rolling and adhering neutrophils was significantly reduced in mice with colitis. Interleukin-1β and CCL2 levels were elevated in the brain and treatment with anti-α4β7 significantly reduced them. Enhanced anxiety-like behavior in mice with colitis was reversed by treatment with interleukin 1 receptor antagonist.

Conclusions

In experimental colitis, α4β7 integrin-expressing monocytes direct the recruitment of neutrophils to the cerebral vasculature, leading to elevated cytokine levels. Increased interleukin-1β mediates anxiety-like behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02431-z.

Circadian Rhythms, the Gut Microbiome, and Metabolic Disorders

The circadian clock and gut microbiome play integral roles in preserving metabolic homeostasis. Circadian rhythms represent an endogenous time-keeping system that regulates cell and organ functions and synchronizes physiology with external cues to establish metabolic homeostasis. A variety of functions throughout the gastrointestinal tract and liver are under circadian control, including nutrient transport, processing, and detoxification. The gut microbiota also plays an essential role in host metabolism, regulating processes such as digestion, inflammatory modulation, and bile acid metabolism. Both the circadian clock and the gut microbiota influence each other in a reciprocal fashion, as gut dysbiosis can precipitate circadian asynchrony, and vice-versa. Disruption of either system impacts homeostasis in a bidirectional manner and can contribute to metabolic dysfunction. Evidence suggests such disruptions can lead to the development of metabolic diseases, including obesity, diabetes, nonalcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. This review will provide a basic overview of the circadian and gut microbial systems, how they are intertwined, and their impact on the liver and gastrointestinal tract and in the development of metabolic disease. Particular areas of discussion include epigenetic regulation of circadian pathways as well as a mechanistic overview of microbial dysbiosis. In addition, therapeutic targets of these systems, including dietary modifications, behavioral modifications, and microbial-directed therapies, will be explored.

The Gut Microbiome and Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD) arise from a convergence of genetic risk, environmental factors, and gut microbiota, where each is necessary but not sufficient to cause disease. Emerging evidence supports a bidirectional relationship between disease progression and changes in microbiota membership and function. Thus, the study of the gut microbiome and host-microbe interactions should provide critical insights into disease pathogenesis as well as leads for developing microbiome-based diagnostics and interventions for IBD. In this article, we review the most recent advances in understanding the relationship between the gut microbiota and IBD and highlight the importance of going beyond establishing description and association to gain mechanistic insights into causes and consequences of IBD. The review aims to contextualize recent findings to form conceptional frameworks for understanding the etiopathogenesis of IBD and for the future development of microbiome-based diagnostics and interventions.

A meta-analysis on sleep quality in inflammatory bowel disease

Evidence of poor sleep quality in inflammatory bowel disease (IBD, i.e., Crohn's disease and ulcerative colitis) has been reported but never systematically reviewed or meta-analysed. We conducted a systematic review and meta-analysis of pairwise comparisons that included 1) IBD patients/controls, 2) Crohn's disease/ulcerative colitis, 3) active/inactive IBD on standardised measures of sleep quality. PubMed, Medline, PsycINFO, Scopus, and CINAHL were searched up to March 2021. Forty-two studies met the inclusion criteria. Results showed poorer subjective sleep quality in IBD patients than in controls, with moderate effect sizes (g = .49, [95% CI = .32 - .66], p < .001). No differences within IBD subtypes were found (g = -.07, [95% CI = -.17-.05], p = .208). Individuals with an active IBD reported poorer sleep quality than those in remission, with a large effect size (g = .66, [95% CI = .35 - .98], p < .001). Results on objectively recorded sleep were mixed, with no clear evidence of objective sleep impairments in individuals with IBD. Results support the view of subjective poor sleep quality as a relevant comorbidity in IBD. As a potential factor affecting immune and inflammatory responses as well as patients' quality of life, sleep quality should be taken into account in the treatment of IBD.

Extraintestinal Manifestations of Inflammatory Bowel Disease: Current Concepts, Treatment, and Implications for Disease Management

Inflammatory bowel diseases (IBDs) are systemic diseases that manifest not only in the gut and gastrointestinal tract, but also in the extraintestinal organs in many patients. The quality of life for patients with IBD can be substantially affected by these extraintestinal manifestations (EIMs). It is important to have knowledge of the prevalence, pathophysiology, and clinical presentation of EIMs in order to adapt therapeutic options to cover all aspects of IBD. EIMs can occur in up to 24% of patients with IBD before the onset of intestinal symptoms, and need to be recognized to initiate appropriate diagnostic procedures. EIMs most frequently affect joints, skin, or eyes, but can also affect other organs, such as the liver, lung, and pancreas. It is a frequent misconception that a successful therapy of the intestinal inflammation will be sufficient to treat EIMs satisfactorily in most patients with IBD. In general, peripheral arthritis, oral aphthous ulcers, episcleritis, or erythema nodosum can be associated with active intestinal inflammation and can improve on standard treatment of the intestinal inflammation. However, anterior uveitis, ankylosing spondylitis, and primary sclerosing cholangitis usually occur independent of disease flares. This review provides a comprehensive overview of epidemiology, pathophysiology, clinical presentation, and treatment of EIMs in IBD.

[Inflammatory Bowel Disease - Challenges in the Workplace and Support for Coping with Disease]

PURPOSE

Patients with inflammatory bowel diseases (IBD) are often impaired in their ability to be employed due to IBD symptoms. The aim of this study was to explore work-related problems and support requested by IBD patients and develop rehabilitation programs meeting their needs.

METHODS

A total of 235 IBD patients (97 rehabilitants, 138 outpatients) completed a questionnaire assessing disease-specific impairments, work-related concerns and the need for support services. Subjective work disability was determined with the SPE scale.

RESULTS

Participants were on average 46 years old, 60% were women, 45% suffered from Crohn's disease and 67% worked full-time; 72% (n=170) had a negative subjective prognosis of gainful employment. Participants reported an average of 12 disease-specific and 22 work-related problems. About 50% of the participants reported disease-specific problems, namely fatigue (66%), weakness (55%) and urge to pass stool (55%). The three most common work-related problems affecting more than 50% of the respondents almost every day were reduced work ability (56%), worrying about not being fully efficient (55%) and stress at work (53%). Support services requested were counselling for information on the disease (91%), treatment options (88%), social law benefits (85%) and exercises to increase physical fitness (84%).

CONCLUSION

The wide range of work-related physical and psychosocial impairments affecting IBD patients reveals a need to extend current rehabilitation services, with a stronger occupational focus and to implement a standardized screening for work-related problems. Disease-specific support services can be developed and addressed in a multimodal and interdisciplinary setting such as the rehabilitation sector.

Sleep disturbances in the irritable bowel syndrome and functional dyspepsia are independent of psychological distress: a population-based study of 1322 Australians

BACKGROUND

Psychological distress, strongly associated with functional gastrointestinal disorders (FGIDS), likely plays a central role in the pathophysiology. The role of sleep disturbances in FGIDs is unclear, and an association with psychological factors is uncertain.

AIM

To determine whether sleep disturbances are associated with irritable bowel syndrome (IBS) and functional dyspepsia (FD) and if a potential association is explained by psychological distress.

METHODS

Adult sample randomly selected from a region in New South Wales, Australia in 2015 who returned a follow-up mail survey in 2018 (response rate, 60.5%) that contained questions on IBS, FD, sleep (MOS-Sleep Scale) and psychological distress (Kessler 6 scale).

RESULTS

Among this population, 10.4% (95% CI 8.8-12.2) and 17.9% (95% CI 15.9-20.1) met Rome III criteria for IBS and FD, respectively. The prevalence of any sleep disturbance at least most of the time was common, with a significantly higher prevalence in FGID (IBS and/or FD) compared with the remaining population (41.8% vs 32.2%, P = 0.003). The total sleep problem index was significantly higher for IBS (OR = 1.71 [95% CI 1.29-2.27], P < 0.0001) (IBS-diarrhoea predominant and IBS-mixed but not IBS-constipation) and FD (OR = 1.80 [1.43-2.26], P < 0.0001) (both epigastric pain syndrome and postprandial distress syndrome) even after adjusting for age, sex and psychological distress.

CONCLUSION

Both IBS and FD, and most of their major subtypes except IBS-C, are associated with a range of sleep disturbances. These sleep problems do not appear to be explained by psychological factors and may play an independent role in the pathophysiology.

Sarcopenia, severe anxiety and increased C-reactive protein are associated with severe fatigue in patients with inflammatory bowel diseases

Patients with inflammatory bowel disease (IBD) report fatigue more frequently than healthy population, but the precise mechanisms underlying its presence are unknown. This study aimed to evaluate the prevalence of fatigue in IBD and its relation with potential causative factors. A survey on fatigue, depression, anxiety, sleep disorders, and the presence of sarcopenia and malnutrition, was sent by email to 244 IBD outpatients of the Gastroenterology Unit of Academic Hospital of Padua. Demographics and clinical data, including the levels of fecal calprotectin (FC) and C-reactive protein (CRP), and current pharmacological treatments were obtained from patients' medical records. Ninety-nine (40.5%) subjects answered the survey. Ninety-two (92.9%) patients reported fatigue, with sixty-six having mild to moderate fatigue and twenty-six severe fatigue. Multivariate analysis showed that abnormal values of CRP (OR 5.1), severe anxiety (OR 3.7) and sarcopenia (OR 4.4) were the factors independently associated with severe fatigue. Fatigue has a high prevalence in subject affected by IBD. Subjects with altered CRP, sarcopenia and severe anxiety appear more at risk of severe fatigue.

Neurologic Manifestations of Systemic Disease: Sleep Disorders

Purpose of review

Sleep is intimately involved in overall health and wellbeing. We provide a comprehensive report on the interplay between systemic diseases and sleep to optimize the outcomes of systemic disorders.

Recent findings

Spanning the categories of endocrinologic disorders, metabolic/toxic disturbances, renal, cardiovascular, pulmonary, gastrointestinal, infectious diseases, autoimmune disorders, malignancy, and critical illness, the review highlights the prevalent coexisting pathology of sleep across the spectrum of systemic disorders. Although it is rare that treating a sleep symptom can cure disease, attention to sleep may improve quality of life and may mitigate or improve the underlying disorder. Recent controversies in assessing the cardiovascular relationship with sleep have called into question some of the benefits of treating comorbid sleep disorders, thereby highlighting the need for an ongoing rigorous investigation into how sleep interplays with systemic diseases.

Summary

Systemic diseases often have sleep manifestations and this report will help the clinician identify key risk factors linking sleep disorders to systemic diseases so as to optimize the overall care of the patient.