Hormonal Contraceptives Reduce Active Symptomatic Disease but May Increase Intestinal Inflammation in IBD.

BACKGROUND: Among women of reproductive age with inflammatory bowel disease (IBD), we aimed to assess the relationship of hormonal contraceptives (HCs) with IBD-related symptoms, and intestinal inflammation. METHODS: A nested cohort of women in the longitudinal Manitoba Living with IBD Study, ages 18 to 49, were followed for 1 year, with bi-weekly online surveys. This included a validated measure of disease activity; IBD Symptom Inventory (IBDSI), and stool samples obtained at 3 time-points for assessment of fecal calprotectin (FCAL). Use of HC included oral and vaginal intrauterine devices. Logistic regression analysis was used to assess the association between HC and IBD-related symptoms (IBDSI>14 for Crohn disease, >13 for ulcerative colitis), or inflammation (FCAL>250 ug/g) at any measurement point in the study. RESULTS: Of 71 women, 17 (24%) reported taking HC in the 1 year period. Adjusting for age, disease type, disease duration, and smoking status, the odds of having increased IBD-related symptoms (IBDSI) during the year were lower for women using HC compared with women not using HC [adjusted odds ratio 0.16, 95% CI, 0.02-0.90]. Conversely, women using HC were more likely to have inflammation during the year [adjusted odds ratio 5.7, 95% CI, 1.23-43.6]. CONCLUSIONS: HC use among women with IBD was associated with a lower likelihood of IBD-related symptoms but a higher likelihood of experiencing intestinal inflammation (FCAL>250 ug/g) over 1 year. Further work is needed to examine this dichotomous result, potentially examining aspects such as duration of HC use, and the types of HC.

Clinician based decision tool to guide recommended interval between colonoscopies: development and evaluation pilot study.

BACKGROUND: Optimal intervals between repeat colonoscopies could improve patient outcomes and reduce costs. We evaluated: (a) concordance between clinician and guideline recommended colonoscopy screening intervals in Winnipeg, Manitoba, (b) clinician opinions about the utility of an electronic decision-making tool to aid in recommending screening intervals, and (c) the initial use of a decision-making smartphone/web-based application. METHODS: Clinician endoscopists and primary care providers participated in four focus groups (N = 22). We asked participating clinicians to evaluate up to 12 hypothetical scenarios and compared their recommended screening interval to those of North American guidelines. Fisher's exact tests were used to assess differences in agreement with guidelines. We developed a decision-making tool and evaluated it via a pilot study with 6 endoscopists. RESULT: 53% of clinicians made recommendations that agreed with guidelines in ≤ 50% of the hypothetical scenarios. Themes from focus groups included barriers to using a decision-making tool: extra time to use it, less confidence in the results of the tool over their own judgement, and having access to the information required by the tool (e.g., family history). Most were willing to try a tool if it was quick and easy to use. Endoscopists participating in the tool pilot study recommended screening intervals discordant with guidelines 35% of the time. When their recommendation differed from that of the tool, they usually endorsed their own over the guideline. CONCLUSIONS: Endoscopists are overconfident and inconsistent with applying guidelines in their polyp surveillance interval recommendations. Use of a decision tool may improve knowledge and application of guidelines. A change in practice may require that the tool be coupled with continuing education about evidence for improved outcomes if guidelines are followed.

An International Multicenter Comparison of IBD-Related Disability and Validation of the IBDDI.

BACKGROUND: The IBD disability index (IBDDI) has been shown to be valid and reliable. We compared the distributional and predictive properties of the IBDDI, when collected from five populations of people living with IBD- from Winnipeg, Chicago, Toronto, Hong Kong, and Jerusalem. METHODS: People with IBD from five jurisdictions were invited to complete a survey including the IBDDI, the World Health Organization Disability Assessment Scale, the Work and Social Adjustment Scale, the IBDQ, the Kessler-6 distress scale, and the Stanford presenteeism scale. Between sites, we compared the correlation between IBDDI and the other 4 measures of disability/quality of life/distress, and the association between IBDDI and presenteeism and having been hospitalized in the past year. RESULTS: There were 1121 participants from Winnipeg, 511 from Chicago, 147 from Toronto, 97 from Hong Kong, and 96 from Jerusalem. The majority had Crohn's disease. Although the mean IBDDI score varied by site, the correlation between IBDDI and each of the other 4 measures of disability/QOL/distress was nearly identical. Similarly, the regression coefficient showing the association between IBDDI and presenteeism was nearly identical in all sites, and the risk ratios showing the association between hospitalization and high IBDDI was similar in all sites. CONCLUSION: The correlation between IBDDI and different measures of disability/QOL/distress was similar across all sites. There is strong evidence of the association between IBD-related disability and presenteeism, and between hospitalization and high IBD-related disability, and that the associations are the same across different populations. The severity of disability that an individual with a given IBDDI score has is directly comparable across populations.

Determining the influence of the Workers Compensation Board of Manitoba's opioid policy on prescription opioid use amongst WCB recipients.

BACKGROUND: Opioid medications are commonly used by Workers Compensation Board (WCB) claimants following workplace injuries. The purpose of this study is to describe the impact of an opioid management policy on opioid prescriptions amongst a WCB-covered population compared to changes in the use of these medications in the general population of a Canadian province. METHODS: We linked WCB claims data from 2006 to 2016 (13,155 claims, 11,905 individuals) to Manitoba provincial health records and compared opioid use amongst this group to 478,606 individuals aged 18-65. Linear regression was performed to examine the change over time in number of individuals being prescribed opioids for various durations and dosages of 50 or more, and 120 or more morphine equivalents (ME)/day for both the WCB and Manitoba population. RESULTS: WCB claimants totaled 2.5% of Manitoba residents aged 18-65 who were prescribed opioids for non-cancer pain. After the introduction of the opioid use policy for the WCB population in November 2011, the number of people prescribed opioids declined 49.4% in the WCB group, while increasing 10.8% in the province as a whole. The number of individuals using 50 ME/day or more declined 43.1% in the WCB group and increased 5.8% in the province. CONCLUSIONS: Opioid management programs organized by a compensation board can lead to a substantial reduction in the prescription of opioid medications to a WCB client population, including individuals who were prescribed higher doses of these medications when compared with general trends in the community.

A comparison of opioid use between WCB recipients and other Manitobans for knee, shoulder, back and carpal tunnel release procedures.

BACKGROUND: This study's objectives were to evaluate whether WCB claimants with conditions requiring certain surgical procedures are more likely to be prescribed outpatient opioids than other Manitobans and whether those prescribed opioids are more likely to still be on opioid medications 6 months post procedure. METHODS: We compared 7,246 WCB claims for a number of surgical procedures to 65,032 similar procedures performed in other Manitobans. Logistic regression was used to explore the association between being a WCB claimant and being prescribed opioids, while controlling for type of surgical procedure and other potential confounders. RESULTS: WCB claimants were more likely than other Manitobans to be prescribed opioids (adjusted OR 1.38; 95%CI 1.30-1.47). Amongst those prescribed opioids, the odds of being still on opioids 6 months post-procedure were not significantly elevated for WCB claimants (adjusted OR 1.09 95%CI 0.97-1.23). CONCLUSIONS: WCB claimants are prescribed opioids more often than non-claimants for similar procedures.

The Urea-to-Creatinine Ratio Is Predictive of Worsening Kidney Function in Ambulatory Heart Failure Patients.

BACKGROUND: Changes in kidney function in heart failure patients convey important prognostic information. We investigated the association of the urea-to-creatinine (BUN/Cr) ratio, the fractional excretion of urea (FeUr), and the fractional excretion of sodium (FeNa) and subsequent declines in kidney function in ambulatory heart failure patients. METHODS AND RESULTS: We prospectively enrolled adult patients with ejection fraction <40% at a multidisciplinary heart failure clinic and measured serial measurements of laboratory values from September 2008 to July 2011. The study outcome was changes in the estimated glomerular filtration rate (eGFR). In 138 patients contributing 10,350 patient-hours of follow-up, we found that participants with a decline of >25% in eGFR had higher mean BUN/Cr ratio (0.110 ± 0.043 vs 0.086 ± 0.026; P = .02) and no difference in the FeNa (1.81 vs 1.43; P = .2) or FeUr (32.3 vs 37.2; P = .9) compared with those with no change. There was an association of BUN/Cr ratio with the rate of change of eGFR (coefficient -25.67, 95% confidence interval [CI] -10.99 to -40.35; P < .0001). The BUN/Cr ratio was an independent predictor of eGFR drop >25% (odds ratio 1.19, 95% CI 1.07-1.32) and improved model discrimination (c-statistic increased from 0.624 to 0.693) and reclassification (net reclassification index 11.38% [P < .0001], integrated discrimination improvement 5.24% [P = .02]). CONCLUSIONS: The BUN/Cr ratio is associated with worsening kidney function and adds incremental risk prediction information relative to traditional predictive measures in outpatients with heart failure at risk for worsening kidney disease.

The impact of opioid prescription dose and duration during a workers compensation claim, on post-claim continued opioid use: A retrospective population-based study.

BACKGROUND: Workers Compensation Board (WCB) recipients are a group commonly prescribed opioids. METHODS: We explored factors influencing post-claim opioid dose and duration by linking data from 22,451 claims with the Manitoba Center for Population Health registry. RESULTS: On average, the WCB paid for 94.55% of opioids prescribed during a claim. The amount paid for by the WCB varied significantly by total opioids prescribed. The main predictors of high opioid dosage (120 + morphine equivalents (ME)/day) during the first year post-claim (logistic regression), and of longer post-claim opioid usage (survival analysis), included opioid dosage during the final month of the claim both paid for and not paid for by the WCB. CONCLUSIONS: Amongst low dose opioid claims, the WCB covers most opioids prescribed. Higher opioid dose WCB recipients are often prescribed opioids not covered by the WCB. Both opioids paid for and not paid for by the WCB are associated with post-claim opioid use.

Proportion of opioid use due to compensated workers' compensation claims in Manitoba, Canada.

BACKGROUND: This study identifies the percentage of opioids prescribed for compensated workplace conditions in Manitoba, Canada and whether Workers Compensation Board (WCB) status is associated with higher prescription opioid doses. METHODS: Opioid prescriptions for WCB recipients were linked with databases housed at the Manitoba Center for Health Policy. Duration of continuous opioid prescription and morphine equivalents (ME) per day (ME/D) were calculated for individuals age 18-65. RESULTS: Over the period from 1998 to 2010, 3.8% of the total opioid dosage of medication prescribed in the study population were prescribed to WCB recipients. WCB recipients accounted for 2.1% of the individuals prescribed opioids. In adjusted analyses WCB recipients were more likely to be prescribed over 120 ME/D (OR 2.06 95% CI, 1.58-2.69). CONCLUSIONS: WCB recipients account for a small, but significant amount of the total opioid prescribed in Manitoba. Manitoba's WCB population is a group at increased risk of being prescribed over 120 ME/day.

Younger age at diagnosis is associated with panenteric, but not more aggressive, Crohn's disease.

BACKGROUND & AIMS: Crohn's disease (CD) diagnosed in pediatric patients has been reported to have a more aggressive phenotype and course, with a greater prevalence of upper gastrointestinal involvement, than in adults. However, studies have not accounted for differences in diagnostic tests. We aimed to discern whether, in fact, CD diagnosed in childhood has a different outcome than CD diagnosed in adults. METHODS: We performed comprehensive medical chart reviews of 571 patients with CD (451 with complete data) who were followed in a single referral inflammatory bowel disease clinic in Winnipeg, Canada, from 1993-2012. For specific time intervals, we determined types and numbers of imaging studies performed and parameters of disease phenotype, including age at diagnosis according to the Montreal classification (A1 diagnosed <17 years of age, A2 diagnosed 17-40 years, and A3 diagnosed >40 years). RESULTS: Within 1 year of diagnosis, a higher proportion of A1 patients had upper gastrointestinal involvement and ileocolonic (L3) disease than A2 or A3 patients. These differences could be partly accounted for by the diagnostic tests performed during this time period. Although A1 patients underwent more extensive imaging studies, they had a lower prevalence of complicated disease, particularly compared with A3 patients. After a median follow-up period of 11.1 years, complicated disease behavior (B2 [structuring] or B3 [penetrating]) was similar among the 3 groups. Nonetheless, at the end of the study period, rates of inflammatory bowel disease-related abdominal surgery were significantly lower for A1 than A2 patients (odds ratio, 0.63; 95% confidence interval, 0.41-0.98) but not for A3 patients (odds ratio, 0.71; 95% confidence interval, 0.40-1.27). CONCLUSIONS: On the basis of a database analysis of different age groups of patients with CD, studies of disease phenotypes among different cohorts should account for different patterns of diagnostic imaging evaluation. Our data show that although children are at increased risk of panenteric disease, they are not more likely to have more complicated disease or undergo surgery than adults.

The dual impact of antiretroviral therapy and sexual behaviour changes on HIV epidemiologic trends in Uganda: a modelling study.

OBJECTIVES: Antiretroviral therapy (ART) availability in a population may influence risky sexual behaviour. We examine the potential impact of ART on the HIV epidemic, incorporating evidence for the impact that ART may have on risky sexual behaviour. METHODS: A mathematical model, parameterised using site-specific data from Uganda and worldwide literature review, was used to examine the likely impact of ART on HIV epidemiologic trends. We varied assumptions about rates of initiating ART, and changes in sexual partner turnover rates. RESULTS: Modelling suggests that ART will reduce HIV incidence over 20 years, and increase prevalence. Even in the optimistic scenario of ART enrollment beginning after just five months of infection (in HIV stage 2), prevalence is estimated to rise from a baseline of 10.5% and 8.3% among women and men, respectively, to at least 12.1% and 10.2%, respectively. It will rise further if sexual disinhibition occurs or infectiousness while on ART is slightly higher (2% female to male, rather than 0.5%). The conditions required for ART to reduce prevalence over this period are likely too extreme to be achievable. For example, if ART enrolment begins in HIV stage 1 (within the first 5 months of infection), and if risky sexual behaviour does not increase, then 3 of our 11 top fitting results estimate a potential drop in HIV prevalence by 2025. If sexual risk taking rises, it will have a large additional impact on expected HIV prevalence. Prevalence will rise despite incidence falling, because ART extends life expectancy. CONCLUSIONS: HIV prevalence will rise. Even small increases in partner turnover rates will lead to an additional substantial increase in HIV prevalence. Policy makers are urged to continue HIV prevention activities, including promoting sex education, and to be prepared for a higher than previously suggested number of HIV infected people in need of treatment.

Patterns and trends in Pakistan's heterogeneous HIV epidemic.

BACKGROUND: Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan. METHODS: The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana. RESULTS: The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17-22% among MSWs/HSWs in Karachi, 44-49% among IDUs in Lahore and 46-66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65-75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana. CONCLUSIONS: There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

The risk of peritonitis after an exit site infection: a time-matched, case-control study.

BACKGROUND: Exit site infections (ESIs) have been previously associated with the development of peritonitis; however, the evidence to support this association is limited. We conducted a time-matched, case-control study to determine the association between ESIs and subsequent peritonitis. METHODS: The cohort comprised 962 incident adult peritoneal dialysis (PD) patients from January 2000 to December 2009. Patients with an ESI were matched to those with no ESI based on the duration of PD. The subsequent risk of peritonitis was determined using Cox models and conditional logistic regression. RESULTS: During the study period, there were a total of 1002 ESI and 1228 peritonitis episodes among 962 individuals. The time to subsequent peritonitis was shorter in individuals who had at least one ESI [hazard ratio (HR) 1.59; 95% confidence interval (CI) 1.22-2.07, P<0.001]. The risk of peritonitis post-ESI was increased for all Gram-positive infections [adjusted hazard ratio (aHR) 1.75; 95% CI 1.25-2.43], and for the subtypes of coagulase-negative Staphylococcus (CNS) and S. aureus, but not for Gram-negative or culture-negative infections. These findings were similar when examining the odds of subsequent peritonitis within prespecified time intervals of the ESI through conditional logistic regression. CONCLUSIONS: The risk of peritonitis after ESI is increased, particularly with S. aureus and CNS, despite appropriate antibiotic treatment of the ESI.

Changes in PTSD symptomatology and mental health during pregnancy and postpartum.

Changes in mental health symptoms throughout pregnancy and postpartum may impact a woman's experience and adjustment during an important time. However, few studies have investigated these changes throughout the perinatal period, particularly changes in posttraumatic stress disorder (PTSD) symptoms. The purpose of this study was to examine longitudinal changes in PTSD, depression, and anxiety symptomatology during pregnancy and postpartum. Pregnant women of ethnically diverse backgrounds receiving services for prenatal care at an outpatient obstetric-gynecology clinic or private physicians' office were assessed by interview on symptoms of PTSD, depression, anxiety, and general stress up to four times, including their first, second, and third trimester, and postpartum visits. Overall, during pregnancy there was a declining trend of PTSD symptoms. For anxiety, there was no overall significant change over time; however, anxiety symptoms were individually variable in the rate of change. For both depression and general stress symptoms, there was a declining trend, which was also variable in the individual rate of change among women during their pregnancy. Visual and post hoc analyses also suggest a possible peak in PTSD symptoms in the weeks prior to delivery. While most mental health symptoms may generally decrease during pregnancy, given the individual variability among women in the rate of change in symptoms, screening and monitoring of symptom fluctuations throughout the course of pregnancy may be needed. Further studies are needed to examine potential spiking of symptoms in the perinatal period.

Exploring the potential impact of a reduction in partnership concurrency on HIV incidence in rural Uganda: a modeling study.

BACKGROUND: A number of African countries have planned campaigns against concurrency. It will not be possible to separate the effects of a reduction in concurrency from other behavior changes when evaluating these campaigns. This modeling study explores the potential impact of an intervention to reduce partnership concurrency on HIV incidence in contemporary rural Uganda, keeping incidence of sex acts and partnerships in the population constant. METHODS: Data on demography, sexual behavior, and HIV prevalence from Uganda were used to parameterize an individual-based HIV transmission model. Three baseline model scenarios were simulated, representing the best estimate of concurrency prevalence in this population, and low and high plausible bounds. Interventions that reduced concurrency by 20% and 50% between 2010 and 2020 were simulated, and the impact on HIV incidence in 2020 was calculated. RESULTS: Data showed 9.6% (7.9%-11.4%) of men and 0.2% (0.0%-0.4%) of women reported concurrency in 2008. Reducing concurrency had a nonlinear impact on HIV incidence. A 20% reduction in concurrency reduced HIV incidence by 4.1% (0.3%-5.7%) in men and 9.2% (2.1%-16.8%) in women; a 50% reduction in concurrency reduced HIV incidence by 6.0% (1.4%-10.8%) in men and 16.2% (6.3%-23.4%) in women. CONCLUSIONS: Interventions against concurrency have the potential to reduce HIV incidence and may have a higher impact in women than in men. In rural Uganda, overall impact was modest, and this study does not provide strong support for the prioritization of concurrency as a target for behavior change interventions. However, it may be more useful in higher concurrency settings and for reducing HIV incidence in women.

Effect of pregnancy on immunological and virological outcomes of women on ART: a prospective cohort study in rural Uganda, 2004-2009.

OBJECTIVES: Before antiretroviral therapy (ART) introduction, pregnancy was associated with a sustained drop in CD4 cell count in HIV-infected women. We examined the effects of pregnancy on immunological and virological ART outcomes. METHODS: Between January 2004 and March 2009, we studied HIV-infected women receiving ART in a prospective open cohort study in rural Uganda. We used random effects regression models to compare the CD4 counts of women who became pregnant and those who did not, and among the pregnant women before and after pregnancy. CD4 count and proportions with detectable viral load (≥400 copies/ml) were compared between the two groups using the Mann-Whitney rank sum test and logistic regression respectively. RESULTS: Of 88 women aged 20-40 years receiving ART, 23 became pregnant. At ART initiation, there were no significant differences between those who became pregnant and those who did not in clinical, immunological and virological parameters. Among women who became pregnant, CD4 cell count increased before pregnancy (average 75.9 cells/mm(3) per year), declined during pregnancy (average 106.0) but rose again in the first year after delivery (average 88.6). Among women who did not become pregnant, the average CD4 cell count rise per year for the first 3 years was 88.5. There was no significant difference in the proportions of women with detectable viral load at last clinic visit among those who became pregnant (8.7%) and those who did not (16.1%), P = 0.499. CONCLUSION: Pregnancy had no lasting effect on the immunological and virological outcomes of HIV-infected women on ART.

Does severity of spinal cord injury predict likelihood of suffering chronically from severe depression and anxiety?

STUDY DESIGN: Qualitative Survey study. OBJECTIVE: One might assume that those with higher and more complete spinal cord injuries are at higher risk of depression and anxiety. The objective of this study was to assess the association between level and severity of injury with the degree of anxiety and depression in chronic spinal cord injury. SETTING: Spinal Cord Injury Rehabilitation outpatient clinic. METHODS: 49 subjects were recruited from our research database. Time from injury ranged from 6 months to 20+ years. Sample included 23 motor complete and 26 motor incomplete participants; of these 24 were people with paraplegia, 25 were people with tetraplegia. They answered HADS, BDI-FS and PHQ-9 questionnaires. Participants were grouped based on time post injury and then were further divided by motor complete (AIS A/B) and incomplete (AIS C/D) and level (tetraplegia cf. paraplegia). Two-sample t-tests were conducted to evaluate the differences in depression and anxiety scores, between individuals with different completeness and injury type. RESULTS: There were no significant differences amongst the groups tested regarding severity of depression and anxiety, however, those with paraplegia or incomplete injuries had higher but not significantly higher average scores for depression and anxiety. CONCLUSION: We found there were no statistically significant differences in depression and anxiety scores among the groups. These results suggest that all people with SCI may be at similar risk of depression and anxiety, regardless of SCI severity and level.

Self-reported flares among people living with inflammatory bowel disease are associated with stress and worry but not associated with recent diet changes: The Manitoba Living with IBD Study.

BACKGROUND: In this matched case-control longitudinal study among people living with inflammatory bowel disease (IBD), we investigated beliefs about what triggers a flare. METHODS: Adults with confirmed IBD and active disease within 2 years were enrolled in the Manitoba Living with IBD Study and followed biweekly with online surveys for 1 year. The 7-point IBD Symptom Change Indicator was used for participant identification of a flare. Flare cases were matched to non-flare controls by sex and disease type. Members of each matched pair completed supplementary information on diet changes and psychological functioning in the previous 2 weeks and provided stool samples to assess fecal calprotectin (FCAL). RESULTS: Of 128 enrolled participants, 95 matched flare/non-flare pairs were created. Those reporting a flare were more likely to have elevated FCAL (51% vs 34% among non-flares, P = 0.043). Although 61% of study participants believed at baseline that a food may trigger flares, and 25% of those in a flare believed that a food may have triggered their current flare, there was no difference in consumption of assessed foods between flares and non-flares in the previous 2 weeks. Patients with flares were more likely to be having difficulties in emotional state than controls (40% vs 18%, P = 0.001) and more likely to be stressed or worried (64% vs 33%, P = 0.001). CONCLUSION: Although a majority of individuals with IBD believe that specific foods trigger their disease flares, this was not supported by the current findings. Recent psychological functioning was associated with self-reported IBD flare.

IBD Disability Index Is Associated With Both Direct and Indirect Costs of Inflammatory Bowel Disease.

INTRODUCTION: We aimed to determine both direct (medical) and indirect (lost wages) costs of IBD and the association between the degree of IBD-related disability and extent of IBD-related costs. METHODS: Persons age 18-65 from the population-based University of Manitoba IBD Research Registry completed a survey including the IBD Disability Index (IBDDI) and questions related to employment, missed work (absenteeism), and reduced productivity at work (presenteeism). Administrative health data including surgeries, hospitalizations, physician claims, and prescriptions were linked to the survey and assessed. To calculate annual wage loss, number of days of missed work was multiplied by the average wage in Manitoba for the given occupation per Statistics Canada. Costs were adjusted to 2016-17 Canadian dollars. Using descriptive and regression analysis, we explored the association between IBDDI and annual direct and indirect costs associated with IBD. RESULTS: Average annual medical costs rose from $1918 among those with IBDDI 0-4 to $9,993 among those with IBDDI 80-86. Average annual cost of lost work rose from $0 among those with IBDDI 0-4 to $30,101 among those with IBDDI 80-86. Using linear regression, each additional unit of IBDDI was associated with an increase of $77 in annual medical cost (95% CI, $52-102; P < .001) and an increase of $341 in annual cost of lost wages (95% CI, $288-395; P < .001). CONCLUSIONS: Costs related to IBD are significantly associated with the degree of IBD-related disability. Among the approximate 30% of the IBD population with IBDDI scores ≥40, the indirect costs of absenteeism and presenteeism accounts for ~75% of the total IBD-related costs.

Costs related to IBD (both direct and indirect) are significantly associated with the degree of IBD-related disability. Among the approximately 30% of the IBD population with IBDDI scores ≥40, the indirect costs of absenteeism and presenteeism accounts for ~75% of the total IBD-related costs.

The complex relationship between diet, symptoms, and intestinal inflammation in persons with inflammatory bowel disease: The Manitoba Living With IBD Study.

BACKGROUND: We aimed to examine whether an association exists between diet quality, based on the Prospective Urban Rural Epidemiology (PURE) Healthy Diet Score (HDS), and active inflammatory bowel disease (IBD). METHODS: Participants were drawn from the Manitoba Living With IBD Study cohort. The Harvard Food Frequency Questionnaire (FFQ) was used to calculate the HDS at two time points: baseline and 1-year follow-up. Using generalized estimating equations (GEE) logistic regression, we assessed the association between the HDS and (1) the IBD Symptom Inventory (IBDSI); (2) intestinal inflammation, measured by fecal calprotectin (FCAL); and (3) self-reported IBD flares. RESULTS: There were 294 completed FFQs among 153 people. Of these, 100% had completed data about an IBD flare, 98% had FCAL measurements, and 96% had completed IBDSI scores. On a HDS scoring method of 0-8, the odds of FCAL >250 mcg/g were lower for participants with a HDS of 4 vs 0-3 (adjusted odds ratio [OR], 0.38; 95% CI, 0.19-0.77). When applying a second HDS scoring method (8-40), the odds of having an IBD flare were 3.6 times greater with a HDS between 21 and 24 compared with an HDS ≤20 (adjusted OR, 3.63; 95% CI, 1.03-12.78). CONCLUSIONS: We found that active inflammation was less likely among those with a moderate HDS , whereas symptomatic IBD flares were more likely. People may choose to consume a moderate amount of healthy foods such as fruits and vegetables, even knowing that those foods may cause a symptomatic flare.

Urgency for bowel movements is a highly discriminatory symptom of active disease in persons with IBD (the Manitoba Living with IBD study).

BACKGROUND: The Inflammatory Bowel Disease Symptom Inventory (IBDSI) is a validated patient self-reported measure used to assess IBD disease activity. There have yet to be more granular analyses on which symptoms are most associated with active disease. AIMS: To assess the prevalence of symptoms, and to examine which are most associated with disease activity as measured by a symptom index and objective measure of inflammation METHODS: The Manitoba Living with IBD Study is a prospective study of 156 participants with confirmed IBD who completed bi-weekly IBDSI. Relative risks (RR) and predictive values (NPV and PPV) were reported for each symptom to predict active disease defined as active IBDSI, self-reported flare and elevated faecal calprotectin (FCAL) (>250 µg/g). Analyses were undertaken following stratification based on sex, and disease type (Crohn's disease [CD] and ulcerative colitis [UC]). RESULTS: In total, 69.2% were female; 64.7% had CD. Fatigue was the most prevalent symptom in both inactive and active disease, across all three disease measures (IBDSI: 24.5% and 75.1%, self-reported flare: 42.2% and 72.2%, FCAL: 46.0% and 60.6%). The absence of fatigue had a high NPV for active IBDSI and self-reporting a flare in both CD and UC. Urgency had a consistently strong NPV and RR across all three disease measures in both IBD subtypes and sexes. The number of loose/liquid bowel movements predicted elevated FCAL in UC (RR males = 3.5, 95% CI 1.2-9.9, RR females = 1.8, 95% CI 1.2-2.7), as did blood in stool in UC females (RR = 1.8, 95% CI 1.2-2.7). In males with CD, excessive bowel gas (RR = 2.0, 95% CI 1.2-3.4) and urgency (RR = 3.9, 95% CI 1.6-9.3) best predicted an elevated FCAL. No symptom was strongly predictive of an elevated FCAL in CD females. CONCLUSIONS: Urgency was consistently associated with disease activity, irrespective of the disease measure. Fatigue was the most prevalent symptom irrespective of disease activity measure. Individual symptoms have different impacts on subjective (IBDSI) and objective (FCAL) measures in IBD.