A226 CHILD AND PARENT PERCEPTIONS OF FAECAL MICROBIOTA TRANSPLANT (FMT): QUALITATIVE PERSPECTIVES FROM PARTICIPANTS IN A TRIAL OF FMT FOR PEDIATRIC ULCERATIVE COLITIS

Background

Fecal microbiota transplant (FMT) is being increasingly studied across a range of therapeutic indications, including ulcerative colitis (UC). Pediatric patients may have unique responses to microbiome-based therapeutics, given their younger age, fewer comorbidities, and greater susceptibility to medication-related side effects.

Aims

We recently conducted the first pilot RCT of FMT in Canada for the treatment of pediatric ulcerative colitis (PediFETCh Trial) and conducted qualitative interviews post-study of participants and their parents. This study aims to describe the experience and perceptions of children who received FMT, and their parents.

Methods

Patients enrolled in the PediFETCh Trial (ClinicalTrials.gov: NCT02487238) and their parents were invited to participate in face-to-face, semi-structured interviews. Interviews were audiotaped, transcribed, and analyzed using open coding (NVivo 12 Pro).

Results

8 patients and 8 parents were interviewed. Our data has been summarized into 4 domains and 11 composite themes (Table 1). Most patients and parents saw FMT as a natural treatment. Pre-treatment, patients were concerned with receiving “someone else’s poo” and physical discomfort, while parents were concerned with transmission of enteric infections or psychiatric diseases. Both felt their decision to pursue FMT was influenced by frustration with previous lack of response to medications and a fear of medication side effects. Post-treatment, most patients and families expressed no concerns over potential future side effects as a result of the FMT, and all patients reported feeling “completely normal”. Patients were split between preferring FMT or medication, with convenience of medication being an important factor, while others favored FMT for its perceived naturality and symptomatic improvements. For most families, natural therapies and diet played an important role in influencing their decision to pursue FMT; however, several parents reported that alternative healthcare practitioners did not support their desire to pursue FMT.

Conclusions

The study offers valuable insights into pediatric patients’ and parents’ experiences receiving FMT across several themes. Our results suggest a high rate of acceptance and interest in FMT research by pediatric patients and their parents. These findings suggest strategies to improve future delivery of FMT in clinical trials, and should support inclusion of children in FMT-based studies.

Funding Agencies

Hamilton Health Sciences New Investigator Fund (2015, Spring); Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario (HAH-17-002)

A140 UNDERSTANDING PATIENTS’ PERCEPTIONS OF FECAL MICROBIOTA TRANSPLANT

Background

Fecal microbiota transplantation (FMT) is under active investigation as a popular treatment option for a variety of diseases, including ulcerative colitis (UC). Despite increasing evidence for its therapeutic role, the current literature is limited in its scope to assess firsthand patient experiences.

Aims

To exlore perceptions, attitudes, and experiences of patients who chose to pursue FMT and patients who declined FMT in favor of conventional medications.

Methods

Using qualitative descriptive design, eligible patients were invited to participate in face-to-face semi-structured interviews before and after FMT treatment. Interviews were audiotaped, transcribed, and analyzed using thematic analysis.

Results

Main baseline themes across the FMT (n=9) and non-FMT (n=8) groups included: (i) knowledge of FMT, (ii) attitudes around FMT, and (iii) factors contributing to the decision to pursue FMT. Post-FMT themes included: (i) experiences with FMT, and (ii) perceived response to treatment. We found a poor general understanding of FMT across both cohorts, suggesting a need for improving patient education. Non-FMT patients were less likely to have heard or researched FMT in the past due to feelings of “it just sounds weird”. Similar concerns were found across both groups, including fear of transmissible infections, cost of an experimental therapy, and aversion to stool. Expectations varied between the two groups, with feelings of hope and a sense of “last resort” driving patients to pursue FMT. In contrast, the non-FMT cohort felt a need to further research FMT, explore other treatment options before committing to FMT, and were more likely to describe their disease activity as “not at the severe end”. This demonstrates that FMT may be perceived as a “last ditch effort”. Despite initial aversion, the non-FMT group demonstrated interest in learning more about FMT and felt more open to the possibility of pursuing FMT in the future. The FMT group was more likely to harbor a positive view of natural medicine and classify FMT as natural, while the non-FMT cohort expressed “I’m not really into the weird stuff”. Post-FMT, some patients expressed delight in the perceived changes in their symptoms, including improved quality of life, decreased urgency, and less concerns with accidents.

Conclusions

Our results suggest that important motivating factors for pursuing FMT are a perception of naturality and a sense of last resort. With improved education, FMT may pose an acceptable and tolerable treatment option for patients with UC.

Funding Agencies

Canadian IBD (CANIBD) Nursing

A242 EXERCISE AND PHYSICAL ACTIVITY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND RECOMMENDATIONS

Background

Inflammatory bowel disease (IBD) is a chronic life-long condition affecting 0.25% of the North American population. Childhood onset IBD is particularly aggressive, with disease often characterised by poor growth, severe unpredictable abdominal pain and frequent school absences. Treatment involves lifelong medications, which do not always resolve symptoms and carry increased cumulative risks of infections, malignancy, or other adverse effects. Exercise has been suggested as a method of ameliorating some of the symptoms associated with IBD. To date, few studies have investigated the role of exercise and physical activity in paediatric IBD patients.

Aims

We conducted a systematic review assessing the role of exercise and physical activity in paediatric IBD.

Methods

This Level III systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. An electronic database search of Pubmed, Google Scholar, and Cochrane used the search terms “(physical activity or exercise), (Inflammatory Bowel Disease), and (children or paediatric)”. Of the 1458 articles identified during the two rounds of review, only 21 articles met final inclusion criteria.

Results

Three main themes emerged from the review: 1) prescriptive exercise and physical activity ameliorated symptoms IBD and improved physical well-being, 2) patients who actively engage in exercise and physical activity show improved markers of inflammation and decreased future risk of disease, 3) exercise and physical activity improves the mental health and well-being of paediatric IBD patients. The results recommended 30–60 minutes, 6 times per week of mild to moderate aerobic exercise activity. It was noted that vigorous and high intensity exercise was well-tolerated by most IBD patients. Further, exercise prescription should be tailored to individual needs.

Conclusions

Exercise and physical activity improves mental and physical health and well-being of paediatric IBD patients, including decreasing the risk of future disease exacerbation in patients with mild to moderate disease activity. Clinicians and practitioners should consider actively prescribing exercise and physical activity to IBD patients as part of a standard treatment algorithm.

Funding Agencies

None

A120 INFLUENCE OF THE MICROBIOTA ON THE POSTNATAL DEVELOPMENT OF THE ENTERIC NERVOUS SYSTEM IS DEPENDENT ON MOUSE STRAIN

Background

Gastrointestinal function depends on the normal formation of the enteric nervous system (ENS) during fetal and postnatal development. Prior research in an outbred strain of mice (NIH Swiss) has shown that the absence of the gut microbiome in germ-free (GF) mice results in morphological and functional abnormalities of the ENS compared to specific pathogen free (SPF) mice, including an alteration in proportion of nitrergic neurons. Increasing research has been suggesting that the genetic background of the host can impact the host response to the GF state.

Aims

We tested the hypothesis that the absence of the microbiome in an inbred mouse strain (C57BL/6) could influence the development of the ENS during early postnatal life.

Methods

C57BL/6 GF and SPF mice were sacrificed at postnatal day 3 (P3) and P28 (n=4–5 per group). Ileum and colon were collected at P3 and P28 and processed for whole mount preparations. The neuronal network in the myenteric plexus was visualized by immunohistochemistry using antibodies against the pan-neuronal marker PGP9.5. Neuronal cell bodies and nitrergic neurons were identified by immunolabeling with antibodies to the neuronal marker HuC/D and to neuronal nitric oxide (nNOS). Nerve fibre density was quantified by measuring the percentage of PGP9.5-positive pixels (μm2) compared to the whole field using an image analysis program (Volocity; reported as %). Proportions of nitrergic to myenteric neurons were determined by manually counting (blinded) the number of nNOS-positive neurons and dividing by the total number of HuC/D-positive cells per field (reported as %).

Results

We found a significant increase in nerve density at P3 in the GF compared to SPF mice in both ileum (43% vs. 37%; p=0.03) and colon (45% vs. 39%; p=0.03). No significant differences, however, were identified between GF and SPF mice at P28 in either ileum (27% vs. 25%; n.s.) or colon (31% vs. 32%; n.s.). At P3, no significant differences in proportion of nitrergic neurons were seen in the GF compared to SPF ileum (27% vs. 27%; n.s.).

Conclusions

In contrast to earlier observations in the NIH Swiss mice, in which GF mice had decreased nerve density and an increase in nitrergic neurons at P3, our findings reveal an opposite response in nerve density in the C57BL/6 mice and no change in nitrergic neurons. These results suggest that the genetic strain of the mouse model can influence the host response to changes in the microbiome. Further studies are needed to further elucidate potential underlying mechanisms.

Funding Agencies

NSERC

Evaluation of Clinical and Immunological Parameters in Patients with Lichen Ruber Planus Treated with Acupuncture

We have previously shown acupuncture to be effective in the clinical treatment of lichen ruber planus. In this investigation patients with disordered immunological parameters associated with lichen ruber planus were treated with a three week course of daily acupuncture. IgG, IgA, IgM; C3 and C4 complement fractions; α1-antitrypsin and α2-macroglobulin were measured before and after treatment. A return to within normal range was noted in a significant number of cases. We suggest that this is evidence for an immunomodulating effect of acupuncture.

Psoralen and coumarin photochemistry in HSA complexes and DMPC vesicles

The photochemistry and photophysics of several psoralens and coumarins have been examined in human serum albumin (HSA) complexes and dimyristoylphosphatidylcholine (DMPC) vesicles. Fluorescence spectroscopy indicates that there are multiple binding sites with polarities that are intermediate between those of acetonitrile and water for the substrates complexed to HSA. In the case of the 6,7-dimethoxycoumarin-HSA complex, laser flash photolysis experiments provide evidence for the formation of radical cation in addition to triplet. Radical cations are not detected for other coumarin-HSA complexes, either due to a lower yield of formation or to rapid reaction of an initial radical cation with adjacent amino acids. Fluorescence spectra for coumarins indicate that they are primarily solubilized in the polar headgroup region in DMPC vesicles. Consistent with this, radical cations generated by photoionization are detected in transient experiments. For dimethoxycoumarins the radical cation is long-lived, indicating rapid exit from the vesicle and decay in the aqueous phase. However, 4,5',8-trimethylpsoralen and 7-ethoxy-4-hexadecylcoumarin radical cations are much shorter-lived, presumably due to rapid decay by electron recombination in the vesicle. The results for both HSA complexes and vesicles indicate that radical ions may play a role in psoralen and coumarin photochemistry in a cellular environment.

Acute lymphoid changes and ongoing immune activation in SIV infection

Two features of simian immunodeficiency virus (SIV) infection are emphasized: a transitory decrease in CD4 T cells in the first 2 weeks of infection followed by CD8 T-cell rise, and immune cell activation occurring by 4 weeks and persisting throughout the illness. The short-term changes included a fall in CD4 T cells by 2 weeks with partial recovery by 4 weeks and a CD8 rise that starts at 2 weeks. Subsequent characterization of CD4 T cells showed reduced expression of HLA-DR and CD25 (IL-2 receptor alpha chain) antigens later in SIV infection. Immune cell activation is evident in increased serum levels of neopterin and soluble CD8 antigen. Serum beta 2-microglobulin changes are less marked. Activation of CD8 T cells is reflected by increased percentages of cells expressing HLA-DR antigen. The B-cell numbers increased late in the course of SIV infection. Increased expression of the CD78 (Leu 21) activation phenotype was also seen in some monkeys. The immune activation changes (serum neopterin levels) induced by SIV infection in rhesus macaques appear to be associated with duration of illness, although the number of monkeys observed until death were too few for conclusive data. Thus, immune activation as well as T-cell deficiency may reflect significant immunopathogenic processes in SIV-induced disease.

[Cesarean section in elder primiparae]

The frequency and indications for cesarean section for elderly primiparae are presented and compared with those for primiparae aged no more than 29 years and primiparea aged 30 to 34 years. With a mean frequency 1.75% of elderly primiparae, the operation took place in 60% of the cases in the year 1984 and in creased up to 80.95% during 1987. The most frequent indications for cesarean section in this group were: infertility 42.86% preeclampsia 11.43% dynamic dystocia 8.57%. A scheme for management of elderly primiparea that was introduced in obstetrical practice in order to lower the percentage of abdominal delivery, is presented.