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Background and Objective\ud \ud To determine the population prevalence and associated health impairment of disorders of gut-brain interaction (DGBI) across Great Britain, and the emphasis placed upon them within medical education.\ud \ud \ud \ud Methods\ud \ud An Internet-based cross-sectional health survey was completed by 1906 general population adults across Great Britain without self-reported organic GI disease. The survey enquired for demographics, symptom-based criteria for Rome IV DGBI, healthcare use, non-GI somatic symptoms, and quality of life. As a separate analysis, we evaluated which DGBI are considered core knowledge at undergraduate medical school level and post-graduate specialization level for Gastroenterologists and General Practitioners.\ud \ud \ud \ud Results\ud \ud The overall prevalence of DGBI across Great Britain was 37%, being similar for England (37%), Scotland (33%), and Wales (36%); p = 0.66. There was no difference between English regions (range 33%–43%, p = 0.26). The prevalence of DGBI was highest in those aged 18–40 years (40%), then 40–64 years (37%), and least amongst those ≥65 years (29%); p < 0.001. The most common DGBI were bowel disorders (30%), followed by gastroduodenal (10.5%), anorectal (8.1%) and oesophageal disorders (6.2%). Individuals with DGBI were significantly more likely than those without DGBI to have increased GI-related healthcare visits, medication use, surgical interventions, non-GI somatic symptoms, and reduced quality of life. One-in-three people with DGBI had multiple GI organ regions involved and this correlated with increased health impairment (p < 0.001).\ud \ud \ud \ud The only DGBI mentioned across all medical training curricula is irritable bowel syndrome, while the General Practitioner and Gastroenterology Curricula also recognise the outdated term non-ulcer dyspepsia (as opposed to functional dyspepsia). The 2010 Gastroenterology Curriculum also includes functional constipation and disordered defecation, with the incoming 2022 iteration adding in functional upper GI syndromes, functional abdominal pain, and opioid-induced GI disturbances.\ud \ud \ud \ud Conclusion\ud \ud Disorders of gut-brain interaction are common across Great Britain and incur substantial health impairment. However, they are generally under-taught within the British medical education system. Increasing awareness and education of disorders of gut-brain interaction might improve patient outcomes.

There is an abundance of outcomes research for clinical hypnosis showing promising results, however, hypnosis is still underutilized in clinical care. For a behavioral intervention to enter mainstream clinical care, efficacy needs to be demonstrated with exceptionally high quality of evidence. Furthermore, the reporting of these studies also needs to be complete and sufficiently clear to show quality of evidence, and to enable replication and clinical use. The Task Force for Establishing Efficacy Standards for Clinical Hypnosis conducted a review of best practice guidelines in outcomes research, including a review of the CONSORT statement, TIDieR checklist, and the Cochrane Handbook for Systematic Reviews of Interventions. The present article provides best practice guidelines specific to conducting clinical hypnosis research. The guidelines comprise recommendations for planning, conducting, and reporting research in this field. The recommendations are presented in two tiers. Tier I recommendations include essential best practices, such as a call for the use of detailed research and intervention manuals, plans for and reporting of participant-education about hypnosis, the use of hypnotizability scales with good psychometric properties, and clear reporting of the hypnotizability measurement. They also instruct for sharing of intervention scripts and manuals, and the clear reporting of the induction procedure, the labeling of the intervention for participants, and the definition of hypnosis used. Tier II includes preferred recommendations, calling for measurement of adherence to home practice, measurement of hypnotizability by someone other than the interventionist, the use of hypnotizability scales with both subjective and behavioral measures of responsiveness, and the involvement pf participants from the full hypnotizability spectrum. They also recommend the assessment of response expectancy, therapeutic relationship, and other variables related to proposed mechanisms of action, and the reporting of participants prior hypnosis experiences, and the relationship of expectancies and treatment outcomes.This list of recommendations will be useful for researchers, reviewers, and journal editors alike when conducting, reporting, or evaluating studies involving clinical applications of hypnosis.

Background Past research suggests that patient-provider relationships play a crucial role in patient satisfaction with their medical care. However, the essential relationship elements responsible for this effect have not been elucidated and were examined in this study. Methods Patients in six gastroenterology clinics at a major medical center completed an anonymous, secure Internet survey about their medical care after a clinic visit. The survey included the validated Satisfaction With Care Scale-37 (SAT-37) and Patient-Physician Relationship Scale (PPRS). Correlations between those scales were calculated, and exploratory factor analysis (EFA) followed by regression analysis was used to create a PPRS Short Form (PPRS-SF) specifically to account for satisfaction with care. Key results 173 patients (114 females and 59 males; mean age 49.2 years) completed the survey. A range of specific patient-doctor relationship aspects on the PPRS substantially influenced the patients' satisfaction scores. These are grouped into five EFA-derived patient perception factors about their physicians: Competence, Connection, Professionalism, Considerateness, and Willingness/ability to make needed outside referrals. A brief 12-item PPRS-SF questionnaire was constructed that explained 63% of the variance in patients' satisfaction with their care. In contrast, the patients' clinical and demographic characteristics had little explanatory value regarding their satisfaction. Conclusions & inferences Our findings strongly support the notion that the patient-physician relationship's quality is the principal driver of gastroenterology patients' satisfaction with their care. The new PPRS-SF is a convenient tool for clinicians and healthcare systems to assess the essential relationship factors that ensure satisfied patients.

ObjectiveGibraltar is a unique densely populated multicultural British Overseas Territory for which no population data on disorders of gut–brain interaction have existed.We aimed to provide the first-ever assessment of prevalence of irritable bowel syndrome and functional dyspepsia in Gibraltar in relation to their diagnostic recognition and healthcare burden.DesignAn internet survey was carried out in Gibraltar in 2019–2020. The study survey included demographic questions, the Rome IV diagnostic questions for functional dyspepsia and irritable bowel syndrome, relevant medical history, previous surgeries, medication use, healthcare visit frequency and a quality-of-life questionnaire.Results888 individuals (3.5% of all Gibraltar adults) completed the survey anonymously. Irritable bowel syndrome prevalence was 5.2% (95% CI 3.7% to 6.6%). Functional dyspepsia prevalence was 9.9% (95% CI 7.9% to 11.9%). The two conditions overlapped substantially. Women had higher mean prevalence than men of both disorders. People meeting criteria for either or both disorders were prone to surgeries, had more frequent healthcare visits, higher medication use and lower quality-of-life scores compared with people without these disorders. Diagnostic recognition by healthcare providers was low, leaving 58.3% of irritable bowel syndrome and 96.9% of functional dyspepsia individuals undiagnosed.ConclusionThis first-ever population-based study of Rome IV defined irritable bowel syndrome and functional dyspepsia in Gibraltar indicates that the prevalence rates of these disorders are similar to the recently reported data for the UK and Spain, but they remain poorly recognised despite substantially affecting the quality of life of individuals who have them in the Gibraltar community.

Post-traumatic headache (PTH) is common after traumatic brain injury (TBI), especially among active-duty service members (SMs), affecting up to 35% of patients with chronic TBI. Persistent PTH is disabling and frequently unresponsive to treatment and is often migrainous. Here, we describe a trial assessing whether dietary modifications to increase n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and reduce n-6 linoleic acid (LA), will alter nociceptive lipid mediators and result in clinical improvements in persistent PTH.This prospective, randomized, controlled trial tests the efficacy, safety, and biochemical effects of targeted, controlled alterations in dietary n-3 and n-6 fatty acids in 122 adult SMs and military healthcare beneficiaries with diagnosed TBI associated with actively managed persistent frequent (8 /month) PTH with migraine. Following a 4-week baseline, participants are randomized to one of two equally intensive dietary regimens for 12 additional weeks: 1) increased n-3 EPA + DHA with low n-6 LA (H3L6); 2) usual US dietary content of n-3 and n-6 fatty acids (Control). During the intervention, participants receive diet arm-specific study oils and foods sufficient for 75% of caloric needs and comprehensive dietary counseling. Participants complete daily headache diaries throughout the intervention. Clinical outcomes, including the Headache Impact Test (HIT-6), headache hours per day, circulating blood fatty acid levels, and bioactive metabolites, are measured pre-randomization and at 6 and 12 weeks. Planned primary analyses include pre-post comparisons of treatment groups on clinical measures using ANCOVA and mixed-effects models. Similar approaches to explore biochemical and exploratory clinical outcomes are planned.gov registration: NCT03272399.

Background Infections are well-known adverse effects of tumor necrosis factor inhibitors (TNFi) and increased hospitalization rates due to infections have also been reported. To our knowledge, this is the first study to report the effect of TNFi initiation on outpatient antimicrobial prescription patterns. Objectives To investigate the use of antimicrobial agents (antibacterials, antifungals and antivirals; excluding antimycobacerials) in patients with rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis in relation to the initiation of the first TNFi in biologic-naive patients. Methods All patients with inflammatory arthritides who are treated with biologic DMARDs in Iceland are registered in ICEBIO, a nationwide registry. On February 1st 2016, ICEBIO contained information on 1058 individuals. The Icelandic Directorate of Health operates the Icelandic Medicine Database (IMD), a registry that includes over 95% of all filled drug prescriptions in Iceland. From the IMD, filled antimicrobial prescriptions were extracted two years before and two years after the initiation of first-line TNFi therapy for all patients in ICEBIO with rheumatoid arthritis (RA; n=366), psoriatic arthritis (PsA; n=250) and axial spondyloarthritis (AS; n=218). As controls, five individuals, age and sex matched, for the same calendar time were randomly selected. Antimicrobial use was determined from defined daily dose per 1000 capita (DID). Results The use of antimicrobials prior to TNFi treatment was greater in the patient group when compared to controls (mean 43 DID vs 21 DID; p Conclusion Patients with active chronic arthritidies use statistically significantly more antimicrobials two years antedating TNFi treatment compared to controls. TNFi treatment further increases antimicrobial use in this patient population, especially in patients with PsA and AS. Meanwhile, antifungal use increased in RA and antiviral use increased in both RA and PsA. Further analysis needs to be done on the effect of co-medicines such as glucocorticoids, DMARDs and disease activity. Disclosure of Interests Aron H Bjornsson: None declared, Kristin P Sigurbjornsdottir: None declared, Olafur Palsson: None declared, Thorvardur Jon Love Consultant for: Received reimbursment from Celgene for speaking about guidelines for the treatment of psoriatic arthritis, Petur S Gunnarsson: None declared, Mar Kristjansson: None declared, Bjorn Gudbjornsson: None declared

Background TNFα-inhibitor therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for treatment of pain and stiffness in inflammatory arthritides and are the first treatment line in axial spondyloarthritis. Objectives To study the prescriptions of NSAIDs in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) registered in ICEBIO and matched controls, and explore their relationship with disease activity measures. In addition, to explore the impact of initial TNFα-inhibitor therapy on NSAID prescription rates. Methods All patients receiving biologic DMARD therapy in Iceland for rheumatic diseases are registered in a nationwide database; ICEBIO. The Icelandic Directorate of Health operates a prescription database that includes over 90% of all drug prescriptions in Iceland. On February 1st2016 we extracted data for all patients with RA, PsA and AS from ICEBIO along with all filled prescriptions for NSAIDs made two years before and after the initiation of TNFα-inhibitor therapy. We then extracted NSAID prescriptions for five randomly selected individuals matched on age, sex, and calendar time of TNF inhibition for each patient. Results Data from 366 patients with RA, 218 with AS, 251 with PsA and 4760 controls was included. Control group was prescribed a mean of 23 defined daily doses (DDD) of NSAIDs per year. In total the ICEBIO patients were prescribed 6.7 times more DDDs of NSAIDs than the controls or a mean of 149 per year. After initiation of TNFα-inhibitor therapy the use of NSAIDs was reduced to a mean of 85 DDD per year, or 3.9 times that of the controls. Among the patients with RA, consumption was reduced by 43% (mean 148 to 85 DDD/year), 47% in the AS group (154 to 83 DDD/year) and 43% in the PsA group (157 to 90 DDD/year). The 20% of patients who used the largest amounts of NSAIDs over the 4 year period reported worse visual analogue scale (VAS) pain scores (mean±SD 65±20 to 60±23), VAS global health scores (70±19 to 65±23), and HAQ scores (1.19±0.64 to 1.03±0.67) when TNFα-inhibitor therapy was initiated compared to the rest of the ICEBIO group (p Conclusion Patients with inflammatory arthritidies requiring TNFα-inhibitor therapy use more NSAIDs than general population controls, but consumption is significantly reduced following the initiation of the first-line biologic drug. The patients with the highest NSAID use have worse patient reported outcome measures but physician outcome measures are similar, which may suggest a non-inflammatory etiology of the pain. Disclosure of Interests Olafur Palsson: None declared, Johan K Wallman Consultant for: Consultant for AbbVie, Celgene, Eli Lilly, Novartis, and UCB Pharma., Thorvardur Jon Love Consultant for: Received reimbursment from Celgene for speaking about guidelines for the treatment of psoriatic arthritis, Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Bjorn Gudbjornsson: None declared

Background The course of rheumatoid arthritis (RA) has become milder during the last decades, which could at least partly be attributed to major advances in the pharmacological treatment of the disease and the implementation of “treat to target”-strategies (1,2). It has also been suggested that RA is already milder at presentation (3) Objectives To investigate whether the clinical status, markers of inflammation, functional status, and patient and evaluator reported disease activity measures in patients with newly diagnosed RA, have improved over the recent decades. Methods Baseline data on all DMARD-naive patients with early RA ( Results A total of 6559 early RA patients were included. Over the study period of 23 years the majority of the patients were women (68%), and the mean age at inclusion increased from 57,4 to 59,1 years. Results are summarised in Table 1. Mean CRP, ESR, TJC and SJC all decreased significantly between the two time periods compared, which was also the case for HAQ. In contrast, mean pain, PtGA and EGA increased significantly between the time periods. Furthermore, time from symptom onset to inclusion was shorter 2011-2014. Conclusion In Swedish patients with early RA, baseline joint counts and inflammatory markers improved over the last three decades. This could partly be explained by shorter symptom duration at diagnosis but also suggests that, at onset, RA might be an inherently milder disease today. However, pain and patient’s global assessment and evaluator’s global assessment of disease activity increased over the same period of time, possibly indicating changes in both patients’ and evaluators’ expectations for management of early RA today References [1] Gwinnutt, et al. Arthritis Rheumatol. 2017; 69:1566–75. [2] Matsumoto, et al. J Rheumatol. 2017; 44:1575–82. [3] Diffin, et al. J Rheumatol. 2014; 41:1590–9. Disclosure of Interests Jon Einarsson: None declared, Tor Olofsson: None declared, Olafur Palsson: None declared, Johan K Wallman Consultant for: Consultant for AbbVie, Celgene, Eli Lilly, Novartis, and UCB Pharma., Meliha C Kapetanovic: None declared

Background:TNFα-inhibitor (TNFi) therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain in patients with arthritis. Opioids are often prescribed for chronic pain, a common issue in inflammatory joint disease.Objectives:To explore the impact of the initiation of TNFi therapy as a first-line biologic disease-modifying anti-rheumatic drug (DMARD) on the prescription rates of opioids in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA) in Iceland.Methods:All patients receiving biologic DMARD therapy for rheumatic diseases in Iceland are registered in a nationwide database (ICEBIO). The Icelandic Directorate of Health operates a Prescription Medicines Register that includes over 90% of all drug prescriptions in Iceland. The study group included patients with RA, PsA, AS, and UA registered in ICEBIO and for each of them five randomly selected comparators from the general population matched on age, sex, and calendar time. On February 1st2016 we extracted data on all filled opioid analgesic prescriptions two years before and two years after the date of TNFi initiation.Results:Data from 359 RA, 217 AS, 251 PsA and 113 UA patients and 4700 comparators were collected. In total, 75% of patients compared to 43% of comparators received ≥1 opiate prescription during the study period. The proportion of patients using opioids (regardless of dose) two years prior to TNFi initiation was 41%, increasing to 49% the following year. After TNFi initiation the proportion returned to 40% (Figure 1). Despite this, the mean yearly opiate dose used by the patients followed a rising trajectory throughout the study period (Figure 2). In total, patients were prescribed nearly 6 times more opioids than the comparators, corresponding to a bootstrapped mean (95% CI) dose of 818 (601-1073) mg MED per patient and year compared to 139 (111-171) mg for comparators.Figure 1.Percental distributions of opioid analgesic use by dose (according to dispensed prescriptions) among patients with inflammatory arthritis (A) and matched comparators (B). All doses are oral morphine equivalent dose (MED) in milligrams.Figure 2.Bootstrapped mean oral morphine equivalent dose per person per year for patients with inflammatory arthritis (above) and age and sex matched comparators (below). Box edges represent 25-75thpercentiles and whiskers 95% confidence intervals.Conclusion:Three out of four patients with inflammatory arthritis in Iceland use opioid analgesics in the two years prior to and/or after the initiation of TNFi therapy and the mean doses were significantly higher than in matched comparators. The proportion of patients receiving opioids increased before TNFi therapy and then decreased again to the previous level. The initiation of the first-line TNFi did not reduce opioid consumption by dose at the group level. On the contrary, there was a trend towards increasing doses over time in both patients and comparators, possibly reflecting the development of opiate tolerance.Table 1.Baseline demographic data. Mean ± SD unless specified. * defined from diagnosis to baselAll patientsRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisUndifferentiated arthritisTotal n (%)940 (100)359 (38)251 (27)217 (23)113 (12)Age (years)49 ± 1453 ± 1449 ± 1343 ± 1344 ± 15Disease duration (years)*7.8 ± 8.58.2 ± 8.27.4 ± 7.88.3 ± 10.26.3 ± 6.6Female58%73%59%34%52%Disclosure of Interests:Olafur Palsson: None declared, Thorvardur Love: None declared, Johan K Wallman Consultant of: Consultant for AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma., Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

Gout is a disabling and common arthritis with increasing prevalence. Without treatment the disease can cause permanent joint damage. It is commonly associated with the metabolic syndrome but can also be related to a number of life-threatening diseases and their treatments. Gout is often misdiagnosed and its long-term management is suboptimal despite the availability of effective treatments. Recently The American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) released common guidelines for the diagnosis of gout and EULAR updated their guidelines for management. There is increased emphasis on preventive treatment, both with lifestyle modifications and pharmacotherapy. It is important to educate patients about the disease and the existence of effective treatment options, how to manage an acutely inflamed joint and why it is important to lower serum urate. When a patient is diagnosed with gout he should be screened for associated comorbidities. It is important to treat-to-target and lower serum urate over a long period of time to induce permanent remission of gouty arthritis.