Although the cause of inflammatory bowel diseases [IBD] remains unknown, most experts agree that the IBD-associated tissue damage is driven by an excessive immune response against luminal bacteria arising in genetically predisposed individuals as a result of the action of multiple environmental factors.1 These disabling conditions affect millions of individuals and have variable presentations and courses, which, together with the medications used to treat them, can put patients at risk of developing complications and other conditions.2 There is increasing concern regarding the risk that IBD patients being infected with the novel severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]. Indeed, after the initial cases diagnosed in Wuhan [China] in December 2019, coronavirus disease [COVID-19] has rapidly spread to countries where IBD are more prevalent and it is now clear that comorbidities are associated with poorer clinical outcome in patients with COVID-19.3
Why should IBD patients be at an increased risk for SARS-CoV-2-induced infections? Coronaviruses bind to their target cells through angiotensin-converting enzyme 2 [ACE2], a monocarboxypeptidase best known for cleaving several peptides within the renin–angiotensin system and other substrates.4 ACE2 is constitutively expressed by epithelial cells of the lung, intestine, kidney and blood vessels, and is present in the terminal ileum and colon in concentrations that are amongst the highest in the body.5 Analysis of the distribution of SARS-CoV-2 among different biological samples of patients with COVID-19 has shown that up to 50% of fecal samples were positive.6,7 Moreover, more than one-fifth of the patients remained positive in stools after being negative in respiratory samples.7 These findings could explain why some COVID-19 patients experience gastrointestinal symptoms and would imply that SARS-CoV-2 can spread through the fecal route. The expression of ACE2 is increased in the inflamed gut of patients with IBD.8 Moreover, proteomic analysis of tissue samples of IBD patients has revealed a significantly higher expression of ACE2 in Crohn’s disease [CD] than in ulcerative colitis [UC].9 Along with binding to ACE2, a fusion of the coronavirus envelope with host cell membranes is critical for establishing a successful infection. This process is mediated by a specific fusion, or ‘spike’ protein,10 which is activated through a proteolytic cleavage induced by host cell trypsin-like proteases, the activity of which has been reported to be up-regulated in IBD.11 These observations suggest that the inflamed gut of IBD patients represents an optimal doorway through which the virus enters human tissues. However, based on a PubMed search on March 17, 2020, we found no evidence to suggest that COVID-19 occurs more frequently in IBD patients than in the general population. Moreover, so far, no IBD patient with SARS-CoV-2 infection has been reported from the tertiary IBD centers in Wuhan.
How can we interpret these findings? There are two functional and distinct forms of ACE2. The full-length ACE2 contains an extracellular domain, which acts as a receptor for the spike protein of SARS-CoV-2, and a structural transmembrane domain, which anchors the extracellular domain to the plasma membrane.12 In contrast, the soluble form of ACE2 lacks the membrane anchor and circulates in small amounts in the blood.13In Vitro studies have shown that the latter form of ACE2 might act as a competitive interceptor of SARS-CoV-2 by preventing binding of the viral particle to the surface-bound, full-length ACE2.14 Notably, the level of the soluble ACE2 is up-regulated in the peripheral blood of IBD patients,15 raising the possibility that this isoform could contribute to limit SARS-CoV-2 infection.
Although the live SARS-CoV-2 is detectable in feces,7 there is no clear-cut evidence that the content of ACE2 in the ileum and colon influences entry and replication of the virus within the intestinal cells and, hence, facilitates its transmission by an extra-respiratory route. SARS-CoV-2 may require additional and yet unidentified cellular attachment-promoting factors to ensure robust infection of host cells. This is in line with the demonstration that SARS-CoV-2 spreads rapidly through the respiratory route despite the modest ACE2 expression in the upper respiratory tract.16
Another aspect relevant for COVID-19 infection in IBD relates to current therapy, as many patients are taking immune suppressors [e.g. azathioprine, methotrexate] for inducing and maintaining remission as well as for preventing IBD-associated complications. The use of such compounds has been associated with increased risk of infections as they block intracellular signals needed for the host to fight pathogens.17 On the other hand, it is noteworthy that suppression of the effector cytokine driven-inflammatory response in IBD [e.g. using cytokine blockers] could be beneficial not only for dampening the ongoing mucosal inflammation but also for preventing COVID-19-driven pneumonia. Indeed, the profile of cytokines documented in patients with severe COVID-19 resembles that seen in the inflamed intestine of IBD patients and during the ‘cytokine storm’ syndrome, a life-threatening condition characterized by hyper-activation of T cells and massive production of interleukin [IL]-2, IL-6, tumor necrosis factor and interferon-γ.18–20 Consistently, blockers of IL-1 or IL-6 have been used with success in pathologies characterized by cytokine storm syndrome, and preliminary evidence supports the use of IL-6 receptor antagonists in the treatment of COVID-19-driven pneumonia.21
The overall available evidence suggests that IBD patients do not have an increased risk of developing COVID-19 and should stay on IBD medications. Patients receiving immune suppressors should be carefully monitored for the occurrence of symptoms and/or signs suggesting COVID-19. Moreover, those patients over 60 years and/or with comorbidities, who have been reported to have a greater risk for COVID-19-induced pneumonia [e.g. with coronary heart disease, hypertension, diabetes mellitus, lung disease, cerebrovascular diseases], should stay at home and avoid public gatherings
CROHN’S & COLITIS AWARENESS
An Invisable Disease
Crohn’s and colitis are considered invisible illnesses because the diseases aren’t visible on the outside. So, while someone may look fine, their intestines may be inflamed and ulcerated, they may be in excruciating pain, and their immune system is essentially attacking itself.
Because Crohn’s and Colitis are invisible disabilities, some passengers may feel that they will be judged by asking a member of staff for help or having to spend time trying to explain their symptoms.
Imagine suffering from debilitating chronic pain. Every step you take causes discomfort, and it’s perpetually at the forefront of your mind. The internal battle you’re fighting takes mental and physical energy and just going through daily tasks can be debilitating. However, those looking at you may have no indication you’re suffering, let alone that you have a chronic disease. You suffer from an invisible illness.
WHAT IS AN INVISIBLE ILLNESS?
An invisible illness is one that does not exhibit externally visible signs or symptoms. Those with invisible illnesses and disabilities may have symptoms such as pain, fatigue, dizziness, weakness, or mental health disorders. Many of these conditions deeply impact the people suffering, but show no obvious signs to an outside observer.
By 2020, the US Department of Health and Human Services estimates that 157 million Americans will be afflicted with a chronic illness and the US Census Bureau estimates 96% of chronic illnesses are invisible. Invisible illnesses disproportionately impact women and many are not yet well understood by health care providers or the general public. This lack of understanding inevitably contributes to feelings of isolation and hopelessness for those suffering from such conditions.
CHALLENGES OF LIVING WITH AN INVISIBLE ILLNESS
In addition to the various symptoms of a chronic and invisible illness, people suffering from these illnesses can also experience frustration, guilt, exhaustion, and embarrassment.
For those diagnosed with an illness at a young age, the common stereotype that younger populations are supposed to be healthy makes it especially difficult. For those diagnosed later in life, many feel guilty they are unable to more actively participate in the lives of their families and be active with their children and grandchildren.
Invisible illnesses impact people in all aspects of their lives, personally and professionally. They can severely impact the ability to routinely work and may lead to social isolation and depression.
Nearly all of those experiencing an invisible illness have to deal with common misconceptions regarding their condition. Here are just a few of those most frequently dealt with.
- The way a person looks reflects how they’re feeling physically. Someone may look healthy, but that doesn’t mean they are.
- Invisible illnesses are ‘all in the person’s head.’ Keeping stress at a minimum may reduce symptoms of a chronic illness, but it doesn’t mean the root cause of the disease is psychological.
- Resting up will make people feel better. Just as people not suffering from chronic or invisible illness are unable to bank sleep (rest for a long period of time in order to recoup or “make-up” sleep or to expend extra energy), neither are those with chronic illnesses. The same amount of rest leading up to different events, on different days, may not yield the same results, as symptoms ebb and flow, often unpredictably.
- If a person suffering from a chronic illness is enjoying themselves, they must feel ok. Don’t assume a person who’s enjoying themselves, laughing, and participating in activities is symptom-free. Many people have learned to cope with their symptoms to participate in important events and activities, but that does not mean they are feeling well.
- Stress reduction techniques are a cure for chronic pain and illness. While these techniques may assist with symptom relief, they are not a cure-all.
- Being home all day is a dream lifestyle. Being home all day, but in constant pain and suffering from an invisible illness does not make for a dream lifestyle, regardless of location. Many people are often couch-bound or bed-bound due to extreme pain. They also experience boredom, as not being able to actively participate in the world around them can be frustrating and disappointing.
- Those in chronic pain are ‘drug seekers’. People in chronic pain are often misunderstood and mistreated by the medical community. They get labeled as “drug seekers” in emergency rooms and, as a result, are denied much-needed pain medication.
HOW TO SUPPORT OTHERS WITH INVISIBLE ILLNESSES
If you know someone with an invisible illness, there are several things you can do to support them. It’s important to remember everyone wants to enjoy life and no one wants to be a burden; however, people suffering from chronic and invisible illnesses do appreciate your support and understanding.
- Accept you are powerless to make them better. Your love and understanding are what they need.
- Take time to talk to them and learn about their illness. Ask questions about symptoms and treatments, and be patient. The more you learn, the better you’ll be able to understand and show empathy.
- Be with them when they need it and give them space when they want it. Many chronic illnesses become socially isolating, as people are house-bound or lose companions due to the lack of understanding around invisible illnesses. Being around and access may be one of the best support methods available.
- Try not to get frustrated. One of the biggest challenges associated with invisible illnesses is you get sick and then you continue to get sick, the cycle does not stop. At times, this may get frustrating to caregivers and it’s important for them to realize it’s normal for people suffering this way to be emotionally needy, distant, angry, or sad.
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Crohns Disease and bad weather
We know that Crohn’s disease can equal big gastrointestinal problems, but we don’t fully know what causes this condition. Genetics and the environment are thought to play roles, along with your body’s unique response to bacteria in your intestines. Another theory is a possible link between Crohn’s and the weather or climate where you live.
Researchers at Massachusetts General Hospital, who collected information on 175,912 women 15 to 30 years old, found that the incidence of Crohn’s disease increased significantly among those living in more northern latitudes. This was especially true for women in the older age range.
Experts aren’t sure what it is about Crohn’s and weather that could cause more cases up north, but one possible explanation is that there’s less sunlight or UVB radiation exposure in these areas, which in turn means that your body makes less vitamin D and doesn’t get as strong an immunity boost as it does in sunnier climes.
Another theory relates to health issues delineated by geography. “Generally areas farther from the equator are more developed countries, with lower incidences of gastrointestinal infections and parasites,” says Ghassan T. Wahbeh, MD, director of the Inflammatory Bowel Disease Program at Seattle Children’s Hospital and an associate professor of pediatrics and gastroenterology at the University of Washington School of Medicine. The theory is that in warmer areas closer to the equator, exposure to common GI bugs may mean the immune system is better able to fight off Crohn’s, “ in contrast to the unexposed gut immune system in cleaner environments,” he says.
Crohn’s and Weather: Putting the Forecast in Your Favor
Just as there’s no “one size fits all” nutrition plan for managing Crohn’s, there’s no ideal Crohn’s climate or geographic region that can rule out Crohn’s flares for everyone. Visit the online Crohn’s Forum, for example, and you’ll see that people’s experiences vary wildly, with some describing worse symptoms in winter and others saying summer heat causes them problems.
Individual experiences aside, however, there are some important warm weather Crohn’s tips to keep in mind, whether you live in the sun year-round or are planning a vacation escape.
“Staying in warmer climates mandates proper hydration, more so for patients with active disease and symptoms who are at risk of dehydration,” says Dr. Wahbeh. Kidney stones can also be a concern for people with inflammatory bowel disease and another reason to stay on top of your beverage consumption. On average, you should be drinking 80 or more ounces every day to stay hydrated.
Keep in mind that whether you’re experiencing bouts of diarrhea from Crohn’s disease or excessive sweating because of warm or hot weather, you’ll need to drink more water. Fever and vomiting can also contribute to dehydration. Signs to watch out for include dry mouth or mucous membranes, little or no urine or urine that’s dark yellow in color, a lack of tears, sunken eyes, and lethargy. There’s also the risk for coma in very serious cases.
People with an inflammatory bowel disease also have a greater than normal risk for skin cancer, according to Wahbeh. Experts aren’t certain how much of the risk is due to the disease itself and how much can be attributed to the side effects of the medications used to treat it. However, there’s no doubt that you should religiously apply a broad spectrum sunscreen and double up on sun protection by wearing wide-brimmed hats, sunglasses, and even clothing that can block UVA and UVB rays.
Living with Crohn’s disease has its challenges, but taking into account Crohn’s and weather factors, as well as following warm weather Crohn’s tips, living and playing in hot weather is certainly possible and perhaps even more pleasurable.
Wrap up stay safe and warm its going to be along 2021
all the best
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