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Bakgrund: I Europa drabbas 1 av 198 individer av Ulcerös kolit och 1 av 310 individer av Crohns sjukdom. Ulcerös kolit och Crohns är kroniska, inflammatoriska tarmsjukdomar (IBD) som drabbar olika delar av mag-tarmkanalen, vilket resulterar i påfrestande symtom och behandlingar som påverkar livet. Genom att begripa individens upplevelse av sjukdomen kan sjuksköterskan bidra till ökat välbefinnande och minskat lidande. Syfte: Syftet var att undersöka patienters upplevelse av att leva med inflammatorisk tarmsjukdom. Metod: Som metod genomfördes en litteraturstudie. Från databaserna Cinahl och PubMed valdes fjorton kvalitetsgranskade artiklar som utgjorde grunden för den kvalitativa analysen. Väsentliga delar från artiklarna samlades in, sammanställdes och kategoriserades utifrån patientens upplevelse. KASAM (känsla av sammanhang) valdes som teoretisk referensram. Resultat: Resultatet delades in i tre huvudkategorier: Påverkan på vardagen, psykisk påverkan samt kunskap, stöd och acceptans. Resultatet påvisar upplevelsen av att leva med IBD vilket genererar i flera känslor som sorg, utsatthet, skam, skuld, rädsla med mera. IBD har en tydlig påverkan på det dagliga livet där familj, relationer och vänner är inkluderade. Sjukdomen beskrivs också generera i en förändrad självkänsla på grund av en stor livsförändring. Drabbade lyfter även upplevelsen av information, kunskap och stöd och hur det har påverkat acceptansen. Slutsats: Slutsatsen belyser tydliga likheter av upplevelsen av att drabbas av IBD. Information och kunskapsbrist framkommer som ett tydligt hinder, vilket påverkar vardagen och det sociala. Genom bättre information, personcentrerad vård och individanpassat stöd skulle den drabbade uppnå en högre nivå av KASAM, vilket skulle utveckla strategin för egenvård, hantering samt den bidragande sociala isoleringen.

Introduction: Colorectal cancer (CRC) survivors may experience functional deficits due to cancer-associated impairments. However, we do not understand their type and extent of functional deficits and how we could measure the associated cause of functional deficits, such as fatigue. As the survival of CRC survivors improves, the burden of living with functional deficits can be high. Purpose: My research program aims to understand (1) the functional changes and deficits that CRC survivors experience and (2) how to best measure fatigue in this population. Methods: To address the first aim, we used the data from the International Study of the Risk Factors for Gastrointestinal Bleeding and Cardiovascular Events after Gastrointestinal Bleeding to examine individuals’ functional abilities within 1 year of gastrointestinal cancer diagnosis (CRC being the most prevalent type). For the second aim, we conducted a systematic review on fatigue measures in adults with inflammatory bowel disease (IBD) because the causes, severity, and impact of IBD and CRC- related fatigue might be similar. We identified fatigue measures in the IBD population, appraised their psychometric properties, and recommended the most psychometrically robust and feasible measures for clinical and research use, indicating the optimal measures for CRC survivors. Results: After gastrointestinal cancer diagnosis, the majority (~70%) performed fewer functional tasks, mostly in the instrumental activities of daily living; and about 44% had more difficulty walking. Our review identified 16 measures, reviewed the content and psychometric properties, and recommended the Functional Assessment of Cancer Therapy Instrument-Fatigue and the IBD- Fatigue scale for research and clinical use in IBD and CRC populations. Conclusion: We provided a novel understanding of the functional deficits that CRC survivors experience and recommended the optimal measures for assessing CRC-related fatigue. As CRC survivors commonly experience fatigue, fatigue should be measured to understand its role in the functional abilities of CRC survivors. / Thesis / Master of Science Rehabilitation Science (MSc) / More people are living with colorectal cancer (CRC), but may have problems performing their daily activities (i.e. functional problems) due to cancer-associated impairments. However, we do not understand the extent of these impairments and functional problems. We used a sample of people with newly-diagnosed gastrointestinal cancer (CRC being the most common type) to understand their type and extent of functional problems. People were found to participate less in functional activities and particularly have more difficulty walking after a cancer diagnosis. Fatigue is common among those with CRC and may primarily cause functional problems. However, it is not commonly measured, and it is unclear how to best measure fatigue among them. Therefore, we reviewed key qualities of 16 fatigue measures in a similar population (inflammatory bowel disease, IBD) and recommended the Functional Assessment of Cancer Therapy Instrument-Fatigue and the IBD-Fatigue scale (English) as the most promising measures for those with CRC.

As of 2012, 233,000 Canadians were reported to be living with inflammatory bowel disease (IBD), 2.5% of which were <18 years of age. In Ontario, the incidence of pediatric IBD is ~11.8 per 100,000 population, which is one of the highest rates in the world. Youth with IBD experience numerous health problems secondary to their diagnosis, including poor fitness and lower lean mass. The extent to which youth with IBD can respond to an exercise training program designed to improve fitness remains unknown. The aim of this thesis was to assess the safety, feasibility and physiological efficacy of an exercise training program for youth in remission from IBD. Additionally, we attempted to understand the barriers and facilitators to physical activity in this population. A total of 104 patients were approached to participate in this study, 18 demonstrated interest and 11 consented to participate. Ten youth (nine males, age: 15.4±1.2 years) with IBD completed the study. Participants trained three times per week (2d in lab, 1d at home) for 16 weeks. Training sessions lasted 30 to 60 minutes, and consisted of a customized combination of aerobic and resistance exercises. Fat mass and lean mass were measured via Dual Energy X-ray Absorptiometry. Isometric and isokinetic torque of elbow flexion and knee extension were evaluated using an isokinetic dynamometer system. Peak oxygen consumption (VO2peak) and peak mechanical power (Wpeak) were determined using the McMaster All-Out Continuous cycling test. Barriers and facilitators to physical activity were measured via qualitative interviews pre-training. Body composition, muscle strength and aerobic fitness variables were measured at baseline, after 8 weeks, and after 16 weeks of training. Participants completed 89.1±5.2% of lab training sessions and 55.0±26.5% of home training sessions. There were significant increases in whole body lean mass (p<0.001), isokinetic knee extension strength (p<0.05) and Wpeak (p<0.001) over the course of the training program with small, moderate and large effect sizes respectively. All participants were in remission post-training, demonstrated small deviations in features of disease activity and reported no adverse events with training. Participants described similar barriers and facilitators to physical activity, to those of the general public, such as lack of access to facilities and peer support, respectively. Additionally barriers and facilitators unique to individuals with this condition were identified including the physical burden of disease (e.g., episodic abdominal pain) and creating modifications to activities to facilitate accessibility. Our results demonstrate that exercise training in youth in remission from IBD is safe, feasible and has the capacity to counteract a broad range of secondary symptoms such as deficits in lean mass, muscle weakness and aerobic deconditioning. Youth with IBD should be encouraged to exercise on a regular basis. Results from this study will inform the design of a larger, randomized controlled trial. / Thesis / Master of Science in Kinesiology

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24476号 / 医博第4918号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 羽賀 博典, 教授 小濱 和貴, 教授 川口 義弥 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Despite advancements in the treatment of individuals with Inflammatory Bowel Disease (IBD), many patients will require the need to utilize biological therapies during their disease course. Moreover, some patients with IBD develop disease manifestations outside of the GI (gastrointestinal) tract termed extraintestinal manifestations (EIM). We sought to establish an association between prior EIM exposure and the sequential use of biological therapies in patients with IBD. A retrospective analysis of 555 patients with confirmed IBD and relevant EIM data was performed. EIM exposure was treated as both a dichotomized (ever, never) variable and a categorical (0, 1, 2 or more) variable in our analysis. Crude ratios were established using logistic regression and multinomial regression models. Bivariate analysis was used to test for significant confounding variables and significant confounders were included in the final multivariate regression model. We found female sex (p < 0.001), a disease duration of 13 years or longer (p = 0.001), and an ileocolonic disease location (p = 0.036) to be significantly associated with EIM exposure. We found that a disease duration of 13 years or longer (p = 0.037), diagnosis of Crohn’s Disease (CD) (p < 0.001), corticosteroid use (p < 0.001), and an ileocolonic disease location (p = 0.021) to be significantly associated with use of biologics. Our final adjusted model did not show statistical significance, but did notably indicate that individuals exposed to 2 or more EIM had 1.51 times the odds of progressing to biological therapy (95%CI: 0.67, 3.41; p = 0.32) compared to those patients with no EIM history. As a result, EIM exposure may be an indicator for high-risk IBD patients likely to require biological therapy, especially among particular groups. Our data emphasizes the need for further studies to characterize the association between EIM exposure and specific EIM with the utilization of biologics.

Bakgrund: Inflammatorisk tarmsjukdom är en grupp av autoimmuna sjukdomar som idag är ett globalt folkhälsoproblem och ökar i hela världen. Ulcerös kolit och Crohns sjukdom är de två huvudsakliga typerna. Symtomsbördan är stor och kan begränsa det sociala livet samtidigt som stigmatisering och känslor av skam är förekommande. Syfte: Syftet var att belysa unga vuxnas erfarenheter av att leva med inflammatorisk tarmsjukdom. Metod: Studien var en allmän litteraturstudie som omfattade nio vetenskapliga artiklar som bearbetades i en induktiv ansats. Resultat: De unga vuxnas erfarenheter av att leva med IBD sammanställdes i tre huvudkategorier; ”Erfarenheter av psykosocial påverkan”, ”Erfarenheter av behandlingen för inflammatorisk tarmsjukdom” och ”Erfarenheter av stöttning från vård- och omsorgspersonal”. Konklusion: Unga vuxna med inflammatorisk tarmsjukdom upplevde symtombesvär som gav upphov till känslor av kontrollöshet, skam och begränsningar i vardagen. Erfarenheter av läkemedelsbehandlingarna innehöll upplevelser av otillräcklig effekt, information och efterföljdsamhet. Behandlingen med stomi upplevdes vara symtomlindrande men hade en psykisk påverkan initialt. Informationsgivning och stöttning från hälso- och sjukvården var bristande. Litteraturstudien bidrar till en ökad förståelse för dessa erfarenheter och behov hos de unga vuxna med inflammatorisk tarmsjukdom. / Background: Inflammatory bowel disease is a group of autoimmune diseases and is today a public health problem that is increasing worldwide. The primary types: Ulcerative colitis and Crohn's disease both affect the gastrointestinal tract. The symptoms can limit social life, stigmatization and feelings of shame are also common. Aim: The aim of this study is to describe young adults experiences of living with inflammatory bowel disease. Method: This study was a general literature study which includes nine scientific articles that were processed with an inductive approach. Results: The young adults experiences of living with inflammatory bowel disease were compiled into three categories; “Experiences of psychosocial influence”, “Experiences of the treatment for inflammatory bowel disease” and “Experiences of support from health care professionals”. Conclusion: Young adults with inflammatory bowel disease experienced symptom distress that gave rise to feelings of lack of control, shame and limitations in everyday life. Experiences of the drug treatments included feelings of insufficient effect, information and compliance. Stoma as a non-pharmacological treatment relieved symptoms but had a psychological impact. Experiences from the healthcare system included lack of information and support. This literature study contributes to the increased understanding of needs to young adults with inflammatory bowel disease.

No description available.

BACKGROUND: Vitamin D deficiency and insufficiency are rising healthcare concerns in the United States (US) and worldwide. The latest data collected by the National Health and Nutrition Examination Surveys (NHANES) between 2002-2006 showed that approximately one third of Americans over one-year-old were vitamin D deficient (serum 25-hydroxy vitamin D (25-OHD) < 12 ng/mL) or insufficient (serum 25-OHD < 20 ng/mL) (Looker et al., 2011). Environmental exposures, acute or chronic disease, and genetics can exacerbate vitamin D deficiency. People with malabsorptive disorders such as Inflammatory Bowel Disease (IBD) are at an even greater risk of becoming vitamin D deficient. Pediatric patients with IBD are particularly vulnerable to the short and long-term effects of vitamin D deficiency, given the prominent role played by this agent on skeletal development. More recent data have demonstrated that vitamin D also plays an important role in maintaining and regulating the immune system. For this reason, investigators have been interested in a better understanding of the relationship between vitamin D and inflammation. Vitamin D may prove to be an important adjunct therapy for people suffering from IBD and other autoinflammatory diseases. OBJECTIVES: Many patients and medical providers understand the importance that vitamin D has in a growing child’s skeletal development. However, compliance with daily supplementation remains low. The design of this study allows patients to receive high-dose vitamin D supplementation during scheduled biologic infusions. The goal is to assess the safety and efficacy of high-dose interval vitamin D therapy. The secondary goal of this study will be to determine if optimal vitamin D levels impact the inflammation observed in the gastrointestinal (GI) tract of patients with IBD. METHODS: 60 patients with IBD, between 5-25 years of age, who received regularly scheduled infliximab or vedolizumab infusions, and had serum 25-OHD levels below 30 ng/mL were recruited for the study. These patients were screened for the exclusion criteria, including underlying liver or kidney disease. Enrolled participants were given eight high-dose oral vitamin D3 supplements during scheduled infliximab or vedolizumab infusions for 8-16 months. Serum 25-OHD levels, urine calcium and creatinine levels, and research blood samples were collected at baseline, midpoint, and final visits. Questionnaires were also dispensed to patients to measure quality of life (QoL). This data was collected and analyzed to assess the safety and efficacy of high-dose interval vitamin D supplementation in pediatric patients with IBD. RESULTS: The data from this study showed statistical significance in the change of serum-25OHD level from baseline to midpoint and final visits. The mean increase from baseline to midpoint was 15.71±10.1 ng/mL for the 30 participants who had completed 3 study doses (2,500 mCg or 5,000 mCg) (mean±95% CI). The mean increase from baseline to final visit was 18.1±11.67 ng/mL for the 19 participants who completed all 7 study doses (2,500 mCg or 5,000 mCg) (mean±95% CI). A single factor ANOVA test confirmed statistical significance with p < 0.0001. Urine calcium and creatinine levels did not have a statistically significant change from baseline to final visit for the 12 participants who had completed both samples. Lastly, IMPACT-III QoL scores were not significantly different from baseline. However, there was an overall increase in the mean scores in all 6 subcategories of the survey. As more participants complete the study, the statistical significance and the validity of results will likely be strengthened. CONCLUSION: High-dose interval vitamin D supplementation was a safe and effective way to achieve serum 25-OHD levels to an optimal range (i.e., 40-60 ng/mL) in pediatric patients and young adult patients with IBD. The data suggests that three doses of high-dose vitamin D may be sufficient to bring levels to an optimal and stable plateau. Patient compliance with supplementation was 100% in this study, because of provider-observed ingestion of vitamin D. Patients also noted that this was their preferred method of supplementation. The safety and efficacy results of this study serve as a framework for developing a more standard approach to vitamin D supplementation for our patients with IBD. Future studies may benefit from expanding this method of delivery to patients who have other inflammatory diseases that require both regular oral vitamin D therapy and in person visits for treatments (i.e., intravenous (IV) medication).

The use of computed tomography in patients with gastrointestinal disease is increasing. However, the triple-phase computed tomographic angiographic appearance of the canine small intestine and the effects that phase of contrast enhancement and plane of reconstruction have on the appearance of the small intestine have not been fully evaluated. The purposes of this study were to investigate these effects on the appearance of the small intestinal wall. The minimal and maximal small intestinal diameter, wall thickness, number of wall layers identified, and degree of mucosal enhancement were recorded. The plane of reconstruction did not have any significant effects on wall thickness, diameter, degree of mucosal enhancement, or number of wall layers identified. There was a positive association between body weight and intestinal diameter. The arterial phase demonstrated the greatest mucosal enhancement and number of wall layers identified. The transverse plane was subjectively the most useful for evaluation of the small intestines.