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Bernstein CN, Nugent Z, Panaccione R, Marshall DA, Kaplan GG, Vanner S, Dieleman LA, Graff LA, Otley A, Jones J, Buresi M, Murthy S, Bargaonkar M, Bressler B, Bitton A, Croitoru KC, Sidani S, Fernandes A, Moayyedi P. Patient reported symptoms are independent of extent of disease in longstanding ulcerative colitis: MAGIC in IMAGINE. Journal of Clinical Gastroenterology 2026; in press.

 

Background: The Inflammation, Microbiome, and Alimentation: Gastro-Intestinal and Neuropsychiatric Effects Strategy for Patient Oriented Research Network (IMAGINE) has conducted a five-year multicenter prospective observational cohort study, Mind And Gut Interactions Cohort (MAGIC) in 14 centres across Canada from 2018-2022. Herein, we investigated the relationship between ulcerative colitis (UC) phenotypes; demographics and other relevant outcomes and symptom reporting.

Methods:  At baseline, participants answered surveys assessing disease activity, medications and complementary therapies, lifestyle factors, psychological status, and comorbidities. UC phenotypes were classified by the Montreal Classification. Herein, we describe the association between phenotypes and demographics, medications used, comorbidities and symptoms experienced in adults with UC. The Inflammatory Bowel Disease Symptom Inventory (IBDSI) was used to assess symptoms

Results: The maximal extent phenotypic distribution based on chart review was E1 (proctitis) n=261 (14.5%), E2 (left sided colitis) n=671 (37.2%), E3 subtotal or pancolitis n=794 (44.0%). More males had E3. Different phenotypes did not lead to differences in the use of complementary therapies. There was greater likelihood of primary sclerosing cholangitis but a lower likelihood of hypertension in E3. Among the 25 different symptoms queried in the IBDSI there was no difference across phenotypes, except among persons with overall active IBDSI there was more waking for urges for bowel movements in persons with E3.

Conclusions Overall, there was no difference in symptom reporting based on extent of UC except for cohort with overall active IBDSI there were some differences in nocturnal waking based on disease extent.

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Bernstein CN, Nugent Z, Panacione R, Marshall DA, Kaplan GG, Dieleman LA, Vanner S, Graff LA, Otley A, Jones J, Buresi M, Murthy S, Borgaokar M, Bressler B, Bitton A, Croitoru K, Sidani S, Fernandes, Moayyedi P.  Symptoms in persons with either active or inactive Crohn’s disease are agnostic to disease phenotype-the MAGIC in IMAGINE study. Journal of Clinical Gastroenterology 2025; in press.

 

Background We aimed to examine the relationship between disease symptoms and disease phenotype in a large Canadian cohort of persons with Crohn’s disease

Methods Adults (n=1515) with Crohn’s disease from 14 Canadian centres participated in the Mind And Gut Interactions Cohort (MAGIC) between 2018-2023. Disease activity was measured using the 24-item IBD Symptom Inventory-Short-Form (IBDSI-SF). We compared the symptoms commonly associated with active versus inactive disease, and explored symptoms patterns in relation to disease phenotype, based on the Montreal Classification. To assess psychological status the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were used.

Results Mean disease duration was 15.6±11.8 years. The 5 most common symptoms were similar for those with active disease, although at higher prevalence (89-98%) versus those with inactive disease (47-79%), and included fatigue, diarrhea, gas, bloating, and urgency. The intensity of symptoms was higher in those with active than inactive IBDSI-SF scores. The rank order and relative distribution of the symptoms and intensity of the symptoms reported were similar between those with different disease phenotypes B1, B2 and B3 and L1, L2 and L3. Persons with active IBDSI-SF had a higher prevalence of anxiety (24.6%) and depression (38/2%) versus persons with inactive IBDSI-SF (6.3% and 8%, respectively)

Conclusions Individuals with Crohn’s disease with active and inactive disease by IBDSI, experience similar symptoms, but the prevalence of symptoms and their intensity is greater in persons with active IBDSI. Persons with inactive IBDSI report many symptoms. There was no difference in symptom reporting by disease behavior or location.

 

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Bernstein CN, Panaccione R, Nugent Z, Marshall DA, Kaplan GG, Vanner S, Dieleman LA, Graff LA, Otley A, Jones J, Buresi M, Murthy S, Borgaonkar M, Bressler B, Bitton A, Croitoru K, Sidani S, Fernandes A, Moayyedi P. Crohn's Disease Phenotypes and Associations With Comorbidities, Surgery Risk, Medications and Nonmedication Approaches: The MAGIC in IMAGINE Study.  Inflammatory Bowel Diseases 2025 Jan 6;31(1):113-122.

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Background: We aimed to establish a cohort of persons with Crohn's disease enrolled from 14 Canadian centers to describe the contemporary presentation of Crohn's disease in Canada.

Methods: All enrollees were at least 18 years old and underwent chart review for phenotype documentation by Montreal Classification at time of enrollment, comorbidities, IBD and other surgeries, and use IBD and other therapies.

Results: Of 2112 adults, 59% were female, and the mean age was 44.1 (+/-14.9SD) years. The phenotype distribution was B1 (inflammatory)= 50.4%, B2 (fibrostenotic)= 22.4%, B3 (penetrating)= 17.3%, and missing information = 9.9%. Perineal disease was present in 14.2%. Pertaining to disease location, 35.2% of patients had disease in L1 (ileal only), 16.8% in L2 (colonic only), 48% in L3 (ileocolonic), and 0.4% in L4 (upper gastrointestinal). There was no difference in phenotype by gender, anxiety score, depression score. Disease duration was significantly different depending on disease behavior type (B1 = 12.2 ± 10.1; B2 = 19.4 ± 12.9; B3 = 18.9 ± 11.8, P < .0001). Isolated colonic disease was much less likely to be fibrostenotic or penetrating than inflammatory disease. Penetrating disease was more likely to be associated with ileocolonic location than other locations. Perineal disease was most commonly seen in persons with B3 disease behavior (24%) than other behaviors (11% B1; 20% B2 disease, P < .0001) and more likely to be seen in ileocolonic disease (L3;19%) vs L2 (17%) and L1 (11%; P < .0001). Surgery related to IBD occurred across each behavior types at the following rates: B1 = 23%, B2 = 64%, and B3 = 74%. Inflammatory bowel disease-related surgery rates by location of disease were L1 = 48%, L2 = 21%, and L3 = 51%.

Conclusions: In exploring this large contemporary Crohn’s disease cohort we have determined that inflammatory disease is the main Crohn’s disease phenotype in Canada and that Crohn’s disease-related surgery remains very common.

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Marshall DA, MacDonald KV, Kao D, Bernstein CN, Kaplan GG, Jijon H, Hazlewood G, Panaccione R, Nasser Y, Raman M, Moayyedi P, on behalf of the IMAGINE Network.  Patient Preferences for Active Ulcerative Colitis Treatments and Fecal Microbiota Transplantation. Therapeutic Advances in Chronic Diseases 2024; Mar 26; 15:20406223241239168.

 

Background: Fecal microbiota transplantation (FMT) is a promising treatment for active ulcerative colitis. Understanding patient preferences can identify treatment features that may impact treatment decisions, improve shared decision-making, and contribute to patient-centered care, which is especially important in the context of novel treatments like FMT.

Objectives: We aimed to quantify preferences for active ulcerative colitis treatments, specifically FMT and biologics, and identify patient characteristics associated with different preference patterns.

Design: This is a cross-sectional survey study.

Methods: We administered a discrete choice experiment survey to elicit preferences in a sample of Canadian adults with ulcerative colitis. Discrete choice experiment data were analyzed using a main-effects mixed logit model and used to predict uptake of hypothetical scenarios reflecting alternative combinations of treatment features. Latent class modeling identified heterogeneity in patient preference patterns.

Results: Participants' (n = 201) mean age was 47.1 years (SD: 14.5 years), 58% were female, and most (84%) had at least some post-secondary education. Almost half were willing to undergo FMT. When considering treatments for active ulcerative colitis, the most important attributes were chance of remission and severity of rare unknown side effects. All else equal, participants were most likely to uptake treatment that involves oral capsules/pills. Participants in the class with the highest utility for chance of remission were younger, had more severe disease, and 58% indicated that they would be willing to undergo FMT.

Conclusion: We identified characteristics of ulcerative colitis patients who are more likely to be interested in FMT using preference elicitation methods. Patient-centered care can be enhanced by knowing which patients are more likely to be interested in FMT, potentially improving satisfaction with and adherence to treatments for active ulcerative colitis to maximize the effectiveness of treatment while considering heterogeneity in patient preferences.

 

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Furer P, Graff LA, Jackson GL, Kredenster M, Anderson S, Dirkse D, Pryor T, Bernstein CN.  Development of an Internet-delivered Cognitive Behavioral Program for Inflammatory Bowel Disease: A Pilot Study. Journal of Depression and Anxiety Disorders 2022; 4(1):106-114.

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Background: It is well established that individuals with IBD have significantly higher rates of anxiety and depression than the general population. Persistent high levels of stress predict worsening IBD symptoms, which in turn increases the risk of developing chronic anxiety and depression. This pilot study examined a new internet-delivered cognitive behavior therapy program (iCBT) for anxiety, depression and/or stress in adults with inflammatory bowel disease (IBD). The iCBT intervention tailored for adults with IBD to address stress, anxiety and/or depression included 9 core modules and 1 optional module. Modules took approximately 1-2 hours each to complete and included text, patient videos illustrating learning points, and practice exercises to complete between modules.

Methods: Adults were recruited from the Manitoba sample of the Inflammation, Microbiome, and Alimentation: Gastro-Intestinal and Neuropsychiatric Effects (IMAGINE) study, a large cohort of Canadian patients with physician-confirmed IBD. Eighteen of 21 participants completed the 9-module program. Measures of anxiety, depression, and stress were administered at baseline, and at 6-, 12-, and 24-weeks post-baseline.

Results: Compared to baseline, there was a significant reduction in anxiety (HADS-A) and in stress (PSS-4) over time. There were no statistically significant changes in depression scores (HADS-D). However, inspection of average depression scores over time suggests a trend for a decrease in scores at the 6- and 12-week points, with a subsequent increase at 24 weeks.Participant satisfaction on the CSQ-8 ranged from 18 to 28 with a mean of 23.65 reflecting good satisfaction with the online intervention.

​Conclusion: The results of this pilot study suggest it is a promising clinical intervention and support further investigation of this online CBT intervention for adults with IBD. Clinically meaningful reductions in anxiety and stress were achieved with this relatively low-resource intensity and accessible intervention. Participant engagement was high, with an excellent completion rate.

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Moayyedi P, MacQueen G, Bernstein CN, Vanner S, Bercik P, Madsen KL, Surette M, Rioux JD, Dieleman LA, Verdú E, de Souza RJ, Otley A, Targownik L, Lavis J, Cunningham J, Marshall DA, Zelinsky S, Fernandes A. IMAGINE NETWORK’s Mind And Gut Interactions Cohort (MAGIC) Study: a protocol for a prospective observational multicentre cohort study in inflammatory bowel disease and irritable bowel syndrome. BMJ Open. 2020 Oct 21;10(10):e041733. 

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Gut microbiome and diet may be important in irritable bowel syndrome (IBS), IBD and comorbid psychiatric conditions, but the mechanisms are unclear. We will create a large cohort of patients with IBS, IBD and healthy controls, and follow them over time, collecting dietary and mental health information and biological samples, to assess their gastrointestinal and psychological symptoms in association with their diet, gut microbiome and metabolome.

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This 5-year observational prospective cohort study is recruiting 8000 participants from 15 Canadian centres. Persons with IBS who are 13 years of age and older or IBD who are at least 5 years will be recruited. Healthy controls will be recruited from the general public and from friends or relatives of those with IBD or IBS who do not have GI symptoms. Participants answer surveys and provide blood, urine and stool samples annually. Surveys assess disease activity, quality of life, physical pain, lifestyle factors, psychological status and diet. The main outcomes evaluated will be the association between the diet, inflammatory, genetic, microbiome and metabolomic profiles in those with IBD and IBS compared with healthy controls using multivariate logistic regression. We will also compare these profiles in those with active versus quiescent disease and those with and without psychological comorbidity. Approval has been obtained from the institutional review boards of all centres taking part in the study. We will develop evidence-based knowledge translation initiatives for patients, clinicians and policymakers to disseminate results to relevant stakeholders. Trial registration number: NCT03131414.