This study quantified and characterised changes to a species level for aerobic and anaerobic bacteria from colonic biopsies of acute ulcerative colitis (UC) comparing them with that of a normal control group. Fresh endoscopic biopsies of the recto–sigmoid region were obtained during flexible sigmoidoscopy from 10 patients suffering an acute attack of UC and a similar number of healthy controls. Quantitative estimation was carried out on selective media for total aerobic, anaerobic, Bacteroides , Bifidobacterium and Lactobacillus spp. (Miles–Misra). Species identification involved gram stain, indole, catalase tests and commercially validated anaerobic, gram-positive and non-enteric fermenting enzyme hydrolysis kits. There was a significant quantitative decrease in growth of Lactobacillus spp. in colitic biopsies (p<0.05). Total aerobic speciation revealed 32 different sub-species with 18 of these found only in UC biopsies. Anaerobic speciation revealed 41 different sub-species with a mean 6.7 species in normal and 4.7 in UC patients. Bacteroides thetaiotaomicron was isolated in significantly increased frequency in UC biopsies (8:10) in comparison with normal (4:10). Our data are consistent with the possibility that a reduction in mucosally associated Lactobacillus bacteria in UC permits proliferation of a large number of potentially pathogenic aerobic species and anaerobic predominance of B. thetaiotaomicron . Keywords: ulcerative colitis, intestinal flora, Lactobacillus , B. thetaiotaomicron .
Mucosal healing is the desired therapeutic endpoint for clinical trials in ulcerative colitis (UC). However, conventional white light endoscopy may fall short of capturing the full spectrum of inflammatory change; and virtual electronic chromoendoscopy (VEC) can show ongoing disease activity even when Mayo scores suggest healing (Iacucci et al. Endoscopy 2015 and 2017). Applicability of VEC scoring requires determination outside the expert setting; thus, our aim was to provide external validation among trainees, consultant gastroenterologists and colorectal surgeons, practicing across six general and specialist centres.
Method
15 participants reviewed a computerised training module outlining HD and i-Scan modes. Anchor points for the VEC score indicated mucosal changes (crypt distortion, 0 [A–C]; microerosions, I [1–3]; erosions, II [1–3]; and ulceration, III [1–3]) and vascular alterations (non-dilated vessels, 0 [A–C]; dilated/crowded vessels, I [1–3]; mucosal bleeding, II [1–3]; and intraluminal bleeding, III [1–3]). Performance accuracy was tested using a video library pre-/post-training (n=30). Agreement between raters was tested for the Mayo score, UCEIS and VEC score, and results correlated with histology (New York Mount Sinai system).
Results
The inter-rater agreement was very good for the Mayo score, UCEIS scoring erosions/ulcers and overall, and for VEC scoring mucosal patterns in both modules (Table 1). For the vascular components of UCEIS agreement was only moderate, and did not improve post-training; unlike the agreement for VEC vascular patterns which improved significantly to very good. Correlation between histology and VEC score was highly significant for mucosal and vascular scoring (Spearman’s ρ: 0.910, p<0.001; and 0.907, p<0.001; respectively, Figure 1). This was superior to the Mayo score (0.876, p<0.001) and UCEIS (0.887, p<0.001).
Conclusion
The VEC score demonstrates very good inter-observer agreement across all levels of experience and provides excellent correlation with histology. Unlike UCEIS, the VEC score does not have subjective elements (e.g. mucosal erythema, incidental/contact friability) and may better delineate vascular changes due to filter technology. Given the ability to define subtle endoscopic features, VEC may be applied to further stratify treatment paradigms for patients with UC.
Disclosure of Interest
P. Trivedi Conflict with: Received funding from the National Institute for Health Research (NIHR), Conflict with: This article presents independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health, S Ghosh: None Declared, M Iacucci: None Declared
Background Simulation via Instant Messaging - Birmingham Advance (SIMBA) aimed to improve clinicians’ confidence in managing various clinical scenarios during the COVID-19 pandemic. Methods Five SIMBA sessions were conducted between May and August 2020. Each session included simulation of scenarios and interactive discussion. Participants’ self-reported confidence, acceptance, and relevance of the simulated cases were measured. Results Significant improvement was observed in participants’ self-reported confidence (overall n = 204, p<0.001; adrenal n = 33, p<0.001; thyroid n = 37, p<0.001; pituitary n = 79, p<0.001; inflammatory bowel disease n = 17, p<0.001; acute medicine n = 38, p<0.001). Participants reported improvements in clinical competencies: patient care 52.0% (n = 106/204), professionalism 30.9% (n = 63/204), knowledge on patient management 84.8% (n = 173/204), systems-based practice 48.0% (n = 98/204), practice-based learning 69.6% (n = 142/204) and communication skills 25.5% (n = 52/204). Conclusion SIMBA is a novel pedagogical virtual simulation-based learning model that improves clinicians’ confidence in managing conditions across various specialties.
Introduction Helicobacter pylori is a Gram-negative bacterium, which infects over 50% of the population worldwide. However, only a subset of these infections result in gastrointestinal diseases, such as peptic ulceration (10%) and gastric cancer (2%). Several epidemiological studies have revealed that people who carry H. pylori are at a decreased risk of developing IBD. However, a mechanistic understanding of the association between H. pylori infection and IBD is still unknown. Unlike any other microbial species, once H. pylori colonises its gastric niche, it is able to dominate the gastric microbiome, representing 90%–95% of the total microbial population. Therefore, we hypothesised that the presence of H. pylori in the upper gastrointestinal (GI) tract prevents the colonisation of the lower GI tract with microbial species associated with the pathogenesis of IBD. Method To test this, we collected stool samples from IBD patients (comprising Ulcerative Colitis and Crohn’s disease patients) and determined their H. pylori status using a stool antigen test. We then characterised the intestinal microbiota of H. pylori positive (n=9) and negative IBD patients (n=18), by amplifying the V4 hyper-variable region of the 16S rRNA gene from faecal DNA. To determine the predominant phyla, these products were sequenced using the Illumina MiSeq and data analysis was performed using the QIIME pipeline and GreenGenes database. Results Interestingly, bacterial community structure revealed that there is a strong trend towards a decrease of Proteobacteria and an increase of Bacteroidetes in H. pylori positive IBD patients. Of note, IBD is generally characterised by an increase in Proteobacteria and a decrease in Bacteroidetes. Furthermore, using PICRUSt to investigate the functional composition of the metagenomes, we found that the H. pylori positive IBD patients displayed significant functional differences, including decreased bacterial motility and chemotaxis (p= Conclusion Our preliminary data suggests that the presence of H. pylori infection may promote a less pathogenic intestinal microbiome in patients with established IBD. This data provides the rationale to extend our studies with increased patient numbers and healthy controls to determine the mechanistic basis for the negative association of H. pylori infection and IBD. Disclosure of Interest None Declared
BACKGROUND: Although corticosteroids are recognised as the most efficacious treatment for bronchial asthma, their mode of action remains unclear. A placebo controlled trial was undertaken of the effect of inhaled corticosteroids on physiological and immmunopathological parameters in asthmatic patients in whom the correlations between these indices were tested after treatment. METHODS: Sixteen patients (two women) with asthma entered a double blind, placebo controlled, parallel study during which they inhaled either budesonide 800 micrograms twice daily or matching placebo for six weeks. Spirometric parameters and bronchial reactivity to histamine and terbutaline were measured and endobronchial biopsy samples were taken before and after treatment. Patients recorded morning and evening flow rates during the treatment period. The biopsy samples were subjected to immunohistological analysis to determine the disposition of inflammatory cells within the bronchial wall. RESULTS: Treatment with budesonide resulted in a significant improvement in the 25-75% forced expiratory flow (FEF25-75) from a mean of 133 l/min before treatment to 169 l/min after treatment, and in the morning peak expiratory flow rate (PEFR) from a mean of 384 l/min before treatment to 415 l/min after treatment. No changes were seen in the placebo group. Comparison between the changes in the immunopathological indices after six weeks of treatment with placebo or budesonide showed a significant reduction in the numbers of mast cells (0.5/unit area to 0.2/ unit area), activated eosinophils, and the expression of HLA-DR antigens (relative density -1.9 before to 1.02 after treatment) on inflammatory cells in response to treatment with budesonide. Although reductions in the numbers of other inflammatory cells within the bronchial wall were recorded using immunohistological analysis, these changes were not statistically significant. Significant correlations were found between changing immunological indices and lung physiology. CONCLUSIONS: This controlled study shows that inhaled corticosteroids cause improvement in physiological and immunopathological parameters in patients with stable asthma that are not seen with placebo, and that cause and effect relationships may exist between these two measures of disease status.
In response to COVID-19, the delivery of medical education has largely transitioned from face-to-face teaching to virtual platforms. Simulation-based learning is a useful teaching modality to develop clinicians' knowledge and skills, while protecting patients from harm.[1][1] While simulation has
Objective To provide a framework that is able to categorise whether patients are able to adapt to and lead a ‘normal’ life with ulcerative colitis (UC) and to detail the factors that influence this. Design Qualitative research study using in-depth semi-structured interviews. Setting Four clinical sites in the West and East Midlands regions of England. Participants 28 adult patients diagnosed with UC for years between 1 and 22. Results Medication was rarely sufficient for patients to adapt to UC and live as ‘normal’ a life as possible. Virtually all patients tested and adopted non-medical adaptation methods to improve physical and psychological well-being, to help them carry on working and to prevent embarrassment. In addition, some patients benefited from outside support providing them with practical, emotional and/or financial help. In conjunction with adaptation strategies and the time to adapt, this meant that some patients with severe clinical disease were able to maintain a sense of normality in life. Patients reported that clinicians were not always receptive to discussion of the broader context of life with UC. Conclusions Patients’ experience of UC and their ability to adapt in order to maintain a sense of normality in life is a complex interplay of symptoms, adaptation strategies and outside support. Over time patients test out a variety of non-medical adaptation strategies. Awareness of this may help clinicians and researchers to understand patients’ views on the role of medical and other therapies. Further research around the utility of this framework in clinical practice and research is now required. Trial registration number ISRCTN56523019 , results.
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