Early Relative Growth Rate of Abdominal Aortic Aneurysms and Future Risk of Rupture or Repair

OBJECTIVE

This study aimed to test whether the relative growth rate of subthreshold abdominal aortic aneurysms (AAAs) in the first 24 months of surveillance predicts the risk of future rupture or repair.

METHODS

This was a single centre retrospective observational analysis of all small (< 45 mm diameter) and medium (45 - 54 mm in men, 45 - 50 mm in women) AAAs entered into ultrasound surveillance between January 2002 and December 2019, which received ≥ 24 months of surveillance. Relative growth rates were calculated from measurements taken in the first 24 months of surveillance. The Kaplan-Meier method was used to estimate intervention and rupture free proportions five years following diagnosis for AAAs growing by < 5% and by ≥ 5% in the first 24 months of surveillance. Multivariable Cox regression analysis was used to further analyse this relationship by adjusting for factors found to be significantly associated with outcome in univariable analysis.

RESULTS

A total of 556 patients with AAAs (409 men, 147 women) were followed for ≥ 24 months. This included 431 small AAAs. Of these, 109 (25.3%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.98 ± 0.05 at five years compared with 0.78 ± 0.05 for the ≥ 5% growth group (p < .001). Of 125 medium AAAs, 26 (20.8%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.73 ± 0.11 at five years compared with 0.29 ± 0.13 for the ≥ 5% growth group (p = .024). Baseline diameter and early relative growth rate were strongly and independently predictive of future intervention or rupture with hazard ratios of 9.16 (95% CI 5.98 - 14.03, p < .001) and 4.46 (95% CI 2.45 - 8.14, p < .001), respectively.

CONCLUSION

The results suggest that slow expansion of small (< 45 mm) AAAs observed over an isolated 24 month period is indicative of a very low risk of rupture or repair in the medium term. Isolated growth rates may be a useful tool with which to triage low risk AAAs and prevent unnecessary surveillance.

Quality of life preferences in colorectal cancer patients aged 80 and over

BACKGROUND

Management of patients with colorectal cancer (CRC) is about not only survival, but also quality of life (QoL). What patients want is important but is not well researched or understood for elderly patients where it is very relevant. This study aimed to measure and compare what patients with CRC aged 80 and over and surgeons consider important in terms of survivorship after surgery for CRC.

METHODS

Patients aged 80 and over who were having surgery for CRC were recruited and interviewed using closed and open questions about their expectations of surgery and various QoL dimensions. These were assessed preoperatively and 3 months post-operatively. Surgeons ranked the same QoL dimensions of patients by questionnaire.

RESULTS

Nineteen patients (median age 87.5, range 80-95, eight males and 11 females) were recruited. Patients rated items relating to health, mobility and independence (n = 23) as top three items most often followed by people outside self (n = 13). Surgeons underestimated importance in 17 domains with the biggest discrepancy being in 'avoiding a stoma' (4.11 versus 2.3, P < 0.01).

CONCLUSION

With patients over 80 years having surgery for CRC, there is a lack of concordance between what surgeons think is important and what patients think is important. Despite this, CRC patients aged 80 and older are almost always satisfied with the outcome of surgery. Surgeons should ensure that they understand patients' expectations and that they are aligned with likely outcomes of surgery.

What Are the Most Challenging Aspects of Inflammatory Bowel Disease? An International Survey of Gastroenterologists Comparing Developed and Developing Countries

Background and Aims

As inflammatory bowel disease (IBD) becomes more prevalent, the challenges that gastroenterologists face in managing these patients evolve. We aimed to describe the most important challenges facing gastroenterologists from around the world and compare these between those working in developed and developing countries.

Methods

An online questionnaire was developed, and a link distributed to gastroenterologists. Data were analyzed descriptively using Friedman and Wilcoxon matched-pair signed rank tests to compare rankings for responses. Mann-Whitney U tests were used to compare rankings between responses from gastroenterologists from developed and developing countries. Lower scores reflected greater challenges.

Results

Of 872 who started, 397 gastroenterologists (45.5%) completed the survey. Respondents represented 65 countries (226 [56.9%] from developed countries). Overall, the challenge ranked most important (smallest number) was increasing IBD prevalence (13.6%). There were significant differences in mean ranking scores for many simple aspects of care for those from developing countries compared to providers from developed countries, such as access to simple IBD treatments (5.52 vs. 6.02, p = 0.01), access to anti-TNF drugs including dose escalation (3.33 vs. 3.93, p < 0.01), access to good stoma care (2.57 vs. 3.03, p < 0.001), access to therapeutic drug monitoring (1.47 vs. 1.84, p < 0.001), and access to care for people from low socioeconomic status (2.77 vs. 3.37, p < 0.001).

Conclusions

Increasing IBD prevalence is seen by gastroenterologists as the greatest challenge facing them. There are significant differences between the IBD challenges facing gastroenterologists from developed and developing countries that reflect inequities in access to health care.

Overcoming Workplace Disability in IBD Patients: An Observational Study

Background

Inflammatory Bowel Disease (IBD) can have considerable effects on employment outcomes because of its disabling character.

Goals

We aimed to investigate the impact of IBD in the workplace and to better understand the need for accommodations and adaptations.

Study

Between November 2017 and March 2018, IBD patients were recruited from outpatient clinics in Christchurch Hospital, New Zealand. The survey assessed employment, the need for workplace accommodations and the difficulty arranging it, insurance, and disability using the item-reduced Inflammatory Bowel Disease Disability Index for self-report (IBD-DI-SR). Data were analyzed using descriptive statistics and multivariate logistic regression modeling.

Results

One hundred twenty-three patients were included (response rate 64%), 112 of whom reported that they experienced symptoms while working (60% female, 71% Crohn's disease, mean age 41.9 years). Ninety-one percent needed at least 1 workplace accommodation when symptoms were most severe. Almost half of the patients who needed an accommodation had difficulty arranging it. The most needed accommodations were time to go to medical appointments (71%) and easy access to a suitable toilet (71%). Being female, having less effective medication, and being distressed were associated with the need for 2 or more accommodations, difficulty in arranging accommodations, and not asking for needed accommodation.

Conclusions

Many IBD patients need accommodations at work while symptomatic in order to overcome workplace disability, which can be difficult to arrange. Improved resources are needed to inform employees and employers about the disease, the possibilities for workplace accommodations, and practical strategies to request them.

Measuring Diet Intake and Gastrointestinal Symptoms in Irritable Bowel Syndrome: Validation of the Food and Symptom Times Diary

INTRODUCTION

Patients with irritable bowel syndrome (IBS) identify food as a trigger for the onset or worsening of gastrointestinal symptoms. Despite this, there is no published validated contemporaneous food and symptom diary to investigate the association between diet and IBS symptoms. The objective of this prospective observational study was to assess the construct validity of a novel food diary and symptom questionnaire, the Food and Symptom Times (FAST) diary, and the predictive validity of the food diary component with relation to fiber and fermentable oligosaccharides, disaccharides, monosaccharides, and polyols consumption and subsequent gastrointestinal symptoms.

METHODS

Fifty-one participants with IBS completed the FAST diary and several legacy instruments. The relationship between the FAST gastroenterological symptoms and legacy instruments was examined using Spearman correlation coefficients. Further statistical analysis investigated the relationship between diet and postprandial gastrointestinal symptoms.

RESULTS

Consistent with a priori predictions, the FAST symptoms showed moderate correlations with the most similar Patient-Reported Outcome Measurement Information System gastrointestinal scales (0.328-0.483, P < 0.05) and the most similar Gastrointestinal Symptom Rating Scale questions (0.303-0.453, P < 0.05), with the exception of the weakly correlated subscale constipation for both instruments (-0.050 to -0.119, P > 0.05). The IBS-Quality of Life instrument showed moderate correlations with the FAST symptom abdominal swelling/distension (0.313-0.416, P < 0.05). The consumption of a high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols meal was associated with participants with IBS-D experiencing abdominal bloating and participants with IBS-C not experiencing abdominal swelling (P < 0.05). The consumption of fiber was correlated with abdominal fullness and bloating in participants with IBS-C (P < 0.05).

DISCUSSION

The FAST diary validly measures gastrointestinal symptoms as they occur in people with IBS and correlates these symptoms with specific aspects of diet.

Newly Diagnosed Crohn's Disease Treated with Standard Care or Enteral Nutrition: Psychological Outcomes over 6 Months

Background and Aim

Impaired health-related quality of life and higher rates of anxiety and depression are observed in patients with Crohn's disease. This single center study aimed to describe and compare longitudinal psychological outcomes of newly diagnosed Crohn's disease patients treated with standard care or enteral nutrition to induce remission.

Methods

Two separate cohorts of patients were recruited from one center and treated with standard care (n = 22) or enteral nutrition (n = 18) to induce disease remission. Disease activity, quality of life, anxiety, and depression were -assessed at diagnosis and month 6.

Results

At baseline, quality of life (n = 40) was not correlated with disease activity; symptoms of anxiety and depression were present in 15 (38%) and 5 (13%) of the 40 patients, respectively. Significant improvements in quality of life (p < 0.0001) and anxiety scores (p = 0.002) were observed after 2 weeks of exclusive enteral nutrition, and at month 6 significant improvements in all psychological outcomes were observed. At month 6, patients who received standard care had a significant improvement in quality of life (p = 0.004), but not in anxiety or depression scores, and there were no differences in psychological outcomes between the treatment groups. Overall, 34/40 (85%) patients were in clinical remission at month 6, and a clinically significant quality of life score was achieved by 31/40 (78%).

Conclusions

Patient health-related quality of life and symptoms of anxiety and depression improved as disease activity improved, and 6 months after diagnosis psychological outcomes were similar in patients treated with standard care or enteral nutrition to initially induce remission.

Accommodations and Adaptations to Overcome Workplace Disability in Inflammatory Bowel Disease Patients: A Systematic Review

Background

Inflammatory bowel diseases (IBD) are chronic, incurable diseases which are often characterized by unpredictable flares and troubling symptoms which can interfere with a patient's ability to work. Accommodations in the workplace can help persons with IBD to cope with their illness and work effectively. We systematically reviewed all studies regarding workplace disability in IBD patients.

Summary

Systematic searches were undertaken on February 5 and March 5, 2018, for the following databases: PubMed, MEDLINE (Ovid), Cochrane Central Register of Controlled Trials, and CINAHL, for studies that addressed workplace needs, accommodations and adaptations using survey tools. Of 430 studies screened, 54 met initial eligibility criteria and then 6 studies were ultimately included, with a total of 7,700 participants. Five studies were quantitative, and 1 study was qualitative. Common themes were the importance of reasonable adjustments and accommodations in the workplace, mixed with the finding that a significant proportion reported that they had some difficulty arranging accommodations. Adaptations most required were access to a toilet or toilet breaks and time to go to medical appointments.

Key Messages

People with IBD often need accommodations, but many do not ask or have difficulty arranging it. Better resources are needed to inform people with IBD about the possibilities for workplace accommodations and practical strategies to request them.

Validation of the inflammatory bowel disease disability index for self-report and development of an item-reduced version

BACKGROUND AND AIM

The Inflammatory Bowel Disease Disability Index (IBD-DI) is a measure of disability in inflammatory bowel disease (IBD). The IBD-DI is validated for use as a clinical interview but not for use as a self-report questionnaire. We aimed to validate the IBD-DI for self-report (IBD-DI-SR) and to reduce the number of items, using IBD patients from two centers.

METHODS

Between April and August 2017, ambulatory IBD patients were recruited from Christchurch Hospital, New Zealand and Concord Hospital, Australia. The IBD-DI clinical interview version was compared with a self-report version. Participants were randomized to do the clinical interview or self-report first. Validation of the IBD-DI-SR involved calculating the correlation coefficient between the clinician completed and self-reported version of the IBD-DI and Cronbach's α of internal consistency of the IBD-DI-SR. To create an item-reduced version, multiple linear regression was used. The R² of the model described the overall association between the item-reduced IBD-DI-SR and the IBD-DI.

RESULTS

One hundred fourteen patients (57 from Christchurch and 57 from Sydney) completed the IBD-DI-SR validation phase, of whom 63 had Crohn's disease and 51 had ulcerative colitis. The Pearson correlation coefficient between the IBD-DI-SR and IBD-DI is 0.90 (P < 0.001), and Cronbach's α of the IBD-DI-SR was 0.86. The item-reduced version of the IBD-DI-SR consisted of eight questions instead of 28, explaining 77% of the variance.

CONCLUSIONS

The IBD-DI-SR has demonstrated reliability and validity. The item-reduced IBD-DI-SR is a concise self-report instrument for measuring IBD disability, which makes the IBD-DI more widely usable.

Psychotherapy for inflammatory bowel disease: a review and update

BACKGROUND

Psychotherapy may be a useful intervention for inflammatory bowel disease (IBD) patients. We systematically reviewed all randomized controlled trials that have been performed in psychotherapy for inflammatory bowel disease patients.

METHODS

Systematic searches were undertaken on 1 and 8 March, 2012 of studies of psychotherapy for IBD.

RESULTS

Eighteen studies (19 papers) were included in this review. Psychotherapy was found to have minimal effect on measures of anxiety, depression, QOL and disease progression although shows promise in reducing pain, fatigue, relapse rate and hospitalisation, and improving medication adherence. It may also be cost effective.

CONCLUSIONS

The effects of psychotherapy on IBD is mixed: future studies should determine whether patient screening or measuring different dependent variables improves outcomes and whether particular psychotherapies are superior over others.