Bjørn Moum

Background: Pain and vitamin D deficiency are common in inflammatory bowel disease (IBD). Disease activity, fatigue, frequent relapses, prior surgery and psychological factors all seem to influence the experience of pain in IBD. Vitamin D deficiency has been associated with muscle and skeletal pain. This study aimed to determine whether there is an association between vitamin D deficiency and severity of pain in patients with IBD, and to investigate the influence of other socio-demographic and psychological variables on the experience of pain. Methods: Patients with IBD were recruited from nine hospitals in Norway in a multicenter cross-sectional study. The Brief Pain Inventory (BPI) questionnaire was used to measure pain. Disease activity was assessed using clinical disease activity indices, C-reactive protein (CRP) and fecal calprotectin. Regression models were fitted to explore a possible association between 25-hydroxyvitamin D and pain severity. Results: Of 407 patients included in the analyses, 229 (56%) had Crohn’s disease (CD) and 178 (44%) had ulcerative colitis (UC). Vitamin D deficiency was present in half (203/407) of patients. Presence of pain was reported by 76% (309/407). More severe pain was associated with female gender and increased disease activity scores, but not with increased CRP or fecal calprotectin. In CD, patients without prior intra-abdominal surgery reported more severe pain. In multivariate analyses, there was no association between 25-hydroxyvitamin D and pain severity. Conclusions: In this study, no significant association between pain severity and vitamin D deficiency was revealed in patients with IBD.

A person’s sense of coherence (SOC) reflects their perception that the world is meaningful and predictable, and impacts their ability to deal with stressors in a health-promoting manner. A valid, reliable, and sensitive measure of SOC is needed to advance health promotion research based on this concept. The 13-item Sense of Coherence Scale (SOC-13) is widely used, but we reported in a previous evaluation its psychometric limitations when used with adults with morbid obesity. To determine whether the identified limitations were specific to that population or also generalize to other populations, we have replicated our prior study design and analysis in a new sample of adults with inflammatory bowel disease (IBD). A sample of 428 adults with IBD completed the SOC-13 at a routine clinic visit in Norway between October 1, 2009 and May 31, 2011. Using a Rasch analysis approach, the SOC-13 and its three subscales were evaluated in terms of rating scale functioning, internal scale validity, person-response validity, person-separation reliability and differential item functioning. Collapsing categories at the low end of the 7-category rating scale improved its overall functioning. Two items demonstrated poor fit to the Rasch model, and once they were deleted from the scale, the remaining 11-item scale (SOC-11) demonstrated acceptable item fit. However, neither the SOC-13 nor the SOC-11 met the criteria for unidimensionality or person-response validity. While both the SOC-13 and SOC-11 were able to distinguish three groups of SOC, none of the subscales could distinguish any such groups. Minimal differential item functioning related to demographic characteristics was also observed. An 11-item version of the sense of coherence scale has better psychometric properties than the original 13-item scale among adults with IBD. These findings are similar to those of our previous evaluation among adults with morbid obesity and suggest that the identified limitations may exist across populations. Further refinement of the SOC scale is therefore warranted.

Fatigue is a frequently reported symptom in chronic medical disorders. In IBD, chronic fatigue has been found to be 2 to 3 times more common than in healthy controls as well as to affect up to 40% of patients in remission. In addition to fatigue, pain is also frequently reported in IBD patients. The latter refers to abdominal pain per se, but also to extra-intestinal pain—particularly affecting the joints. The relationship between fatigue and pain in IBD remains unexplored and the aim of this study was consequently to investigate potential associations between these 2 symptoms. Patients were recruited from 9 hospitals in the southeastern and western part of Norway as a part of an observational, multicenter study. Clinical and epidemiological data was gathered by interview, medical records and laboratory tests. Pain was measured with the brief pain inventory (BPI) containing a pain intensity section 4 items scored from 0 (no pain) to 10 (worst possible pain), and a functional interference section 7 items that are scored from 0 (no interference) to 10 (complete interference). A pain severity score is calculated from the mean of the 4 pain intensity items and a pain interference score is calculated from the mean of the 7 pain interference items. Fatigue was measured with the fatigue questionnaire (FQ) consisting of 11 items divided into: Physical Fatigue (PF; 7 items) and Mental Fatigue (MF; 4 items). Responses were based on 4 options (0-1-2-3). Higher scores imply higher levels of fatigue. The scale scores of the FQ are also scored on a dichotomized scale (0 = better than usual and no more than usual, 1 = worse than usual, and much worse than usual). Substantial fatigue was defined as a dichotomized score >4, while chronic fatigue (CF) was defined as a dichotomized score >4 and, in addition, a duration ≥6 months. A total of 452 patients were eligible and asked to participate. Four hundred and fourteen patients (91.6%) gave written informed consent. Six out of 414 patients were excluded due to missing data, leaving the number included for analyses at 408. Of these, 228 were diagnosed with CD and 180 with UC. Among UC patients, substantial (SF) and chronic fatigue (CF) was present in 50.6 and 25.6%, respectively. The corresponding figure in Crohn's disease was 45.2 and 21.9%. Substantial fatigue was associated with significantly increased pain intensity and interference (all P's < 0.001) regardless of diagnosis. In CD, chronic fatigue was associated with increased pain intensity at the P < 0.05 level. Pain interference in CD as well as intensity and interference in UC were all associated with chronic fatigue at P < 0.001. Substantial and chronic fatigue was significantly associated with increased pain intensity and interference regardless of IBD diagnosis. These findings may be important to consider in daily clinical follow-up in IBD in order to alleviate the patients' symptom burden. Moreover they may be useful in planning future intervention studies.

Background: Faecal (f-) calprotectin is a widely used marker for intestinal inflammation. However, extraction procedure is time consuming and cumbersome. The main aim of this study was to evaluate patient-performed extraction of f-calprotectin compared to extraction performed in the laboratory.Methods: A total of 81 adult patients with an established diagnosis of inflammatory bowel disease provided two samples from the same bowel movement, one conventional faeces sample and one sample with a patient administered extraction device. A laboratory technician extracted the conventional faeces sample with the same extraction device.Results: F-calprotectin results from the laboratory-performed extraction and the patient-performed extraction correlated significantly, with a Spearman rank correlation coefficient of 0.92. Method comparison showed a slope of 1.20 (95% confidence interval 1.08–1.36) with intercept of –0.30 (95% confidence interval –9.00 to 4.62). This demonstrates a small proportional difference between the results from the home extracted samples and the results from the laboratory extracted samples, where the home extracted samples are slightly higher. However, six of the 81 patients had made obvious mistakes in the extraction process and their samples were excluded from the study.Conclusions: Patient administered extraction of f-calprotectin can be a realistic alternative for selected patients. However, instructions must be very precise to avoid mistakes.

The incidence and prevalence of IBD, both Crohn's disease (CD) and ulcerative colitis (UC), have increased in recent years, especially in industrialized countries. Still, the etiology of IBD remains largely unknown. Most research on IBD before the 1990s was conducted on selected patient populations. Selected patient populations are likely to introduce important bias and limit the interpretation and generalizability. The inclusion of both incident and prevalent cases or the inclusion of incident cases over long periods of time (decades) might also introduce bias due to changes in treatment regimens and socioeconomic factors over timer (time-trend bias). Consequently, the choice of a well-characterized population-based inception cohort provides the best opportunity to describe the natural course of a disease. The IBSEN (Inflammatory Bowel Disease in South-Eastern Norway) study followed a large population-based cohort of newly diagnosed IBD patients for 20 years and has contributed significantly to the knowledge of the natural course of IBD.

Background. In chronic inflammatory bowel disease (IBD) (Crohn’s disease [CD] and ulcerative colitis [UC]), symptoms from outside the gastrointestinal tract are frequently seen, and the joints, skin, eyes, and hepatobiliary area are the most usually affected sites (called extraintestinal manifestations [EIM]). The reported prevalence varies, explained by difference in study design and populations under investigation. The aim of our study was to determine the prevalence of EIM in a population-based inception cohort in Europe and Israel. Methods. IBD patients were incepted into a cohort that was prospectively followed from 1991 to 2004. A total of 1145 patients were followed for 10 years. Results. The cumulative prevalence of first EIM was 16.9% (193/1145 patients) over a median follow-up time of 10.1 years. Patients with CD were more likely than UC patients to have immune-mediated (arthritis, eye, skin, and liver) manifestations: 20.1% versus 10.4% (p < 0.001). Most frequently seen was arthritis which was significantly more common in CD (12.9%) than in UC (8.1%), p = 0.01. Pan-colitis compared to proctitis in UC increased the risk of EIM. Conclusion. In a European inception cohort, EIMs in IBD were consistent with that seen in comparable studies. Patients with CD are twice as likely as UC patients to experience EIM, and more extensive distribution of inflammation in UC increases the risk of EIM.

Background. Patients with inflammatory bowel disease (IBD) have proven an increased risk of venous thromboembolism (VTE), particularly when hospitalized. The estimate of the true risk varies considerably between studies, primarily due to differences in methodology. We set out to determine the incidence of VTE in a population-based European inception cohort. Methods. IBD patients were incepted into a cohort that was prospectively followed from the early 1990s to the early 2000s. A total of 1145 patients were followed for a total of 10,634 patient-years (p.y.). Results. A total of 19 thromboembolic events were identified - 13 deep vein thrombosis and 6 with pulmonary embolism. The incidence rate of VTE was 1.8 per 1000 p.y. Conclusion. The risk of VTE was elevated in this IBD cohort but lower than previously reported. The highest risk was seen in hospitalized patients, but corticosteroids-requiring disease in outpatients also conferred some risk.