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Background Both the Crohn’s disease exclusion diet combined with partial enteral nutrition (CDED+PEN) and exclusive enteral nutrition (EEN) can induce remission in mild-to-moderate pediatric Crohn’s disease and are associated with a marked decrease in fecal kynurenine levels. This suggests a link between clinical outcome of dietary therapy and changes in tryptophan metabolism pathways. Here, we characterize the changes in several fecal tryptophan metabolites induced by CDED+PEN or EEN and their association with remission. Methods A total of 21 tryptophan metabolites were quantified in fecal samples from a 12-week prospective randomized trial with CDED+PEN or EEN for induction of remission in mild to moderate pediatric Crohn’s disease. Tryptophan metabolites at week 0 (W0), W6, and W12 of 73 samples were quantitatively measured by liquid chromatography coupled with triple quadrupole mass spectrometry, and data were analyzed according to clinical groups of baselines (W0), induced remission at W6, no remission, sustained remission at W12, and nonsustained remission. Results Reduction in components of the kynurenine pathway, such as kynurenine and quinolinic acid, were strongly associated with induced remission with both CDED+PEN and EEN, which were maintained in sustained remission. Specific serotonin pathway metabolites, such as melatonin, N-acetylserotonin, and 5-OH-tryptophan, were significantly increased in fecal samples from patients maintaining remission at W12 with both CDED+PEN and EEN. Importantly, in samples from patients failing to sustain remission, no changes were observed. Remission induction with EEN differs from CDED+PEN, particularly the moderate effects on indole pathway metabolites. The ratios of kynurenine and melatonin and quinolinic acid and melatonin perform well as markers for sustained remission. Conclusions The reduction in specific kynurenine pathway compounds and the increase in serotonin pathway compounds are associated with diet-induced and sustained remission. Further studies are warranted to assess causality and the association of these metabolites with specific diet and lifestyle factors, affecting sustained clinical remission.

Persistent inflammation can trigger altered epigenetic, inflammatory, and bioenergetic states. Inflammatory bowel disease (IBD) is an idiopathic disease characterized by chronic inflammation of the gastrointestinal tract, with evidence of subsequent metabolic syndrome disorder. Studies have demonstrated that as many as 42% of patients with ulcerative colitis (UC) who are found to have high-grade dysplasia, either already had colorectal cancer (CRC) or develop it within a short time. The presence of low-grade dysplasia is also predictive of CRC. Many signaling pathways are shared among IBD and CRC, including cell survival, cell proliferation, angiogenesis, and inflammatory signaling pathways. Current IBD therapeutics target a small subset of molecular drivers of IBD, with many focused on the inflammatory aspect of the pathways. Thus, there is a great need to identify biomarkers of both IBD and CRC, that can be predictive of therapeutic efficacy, disease severity, and predisposition to CRC. In this study, we explored the changes in biomarkers specific for inflammatory, metabolic, and proliferative pathways, to help determine the relevance to both IBD and CRC. Our analysis demonstrated, for the first time in IBD, the loss of the tumor suppressor protein Ras associated family protein 1A (RASSF1A), via epigenetic changes, the hyperactivation of the obligate kinase of the NOD2 pathogen recognition receptor (receptor interacting protein kinase 2 [RIPK2]), the loss of activation of the metabolic kinase, AMP activated protein kinase (AMPKα1), and, lastly, the activation of the transcription factor and kinase Yes associated protein (YAP) kinase, that is involved in proliferation of cells. The expression and activation status of these four elements are mirrored in IBD, CRC, and IBD-CRC patients and, importantly, in matched blood and biopsy samples. The latter would suggest that biomarker analysis can be performed non-invasively, to understand IBD and CRC, without the need for invasive and costly endoscopic analysis. This study, for the first time, illustrates the need to understand IBD or CRC beyond an inflammatory perspective and the value of therapeutics directed to reset altered proliferative and metabolic states within the colon. The use of such therapeutics may truly drive patients into remission.

Background and aims Nutritional therapy with the Crohn’s Disease Exclusion Diet + Partial Enteral Nutrition [CDED+PEN] or Exclusive Enteral Nutrition [EEN] induces remission and reduces inflammation in mild-to-moderate paediatric Crohn’s disease [CD]. We aimed to assess if reaching remission with nutritional therapy is mediated by correcting compositional or functional dysbiosis. Methods We assessed metagenome sequences, short chain fatty acids [SCFA] and bile acids [BA] in 54 paediatric CD patients reaching remission after nutritional therapy [with CDED + PEN or EEN] [NCT01728870], compared to 26 paediatric healthy controls. Results Successful dietary therapy decreased the relative abundance of Proteobacteria and increased Firmicutes towards healthy controls. CD patients possessed a mixture of two metabotypes [M1 and M2], whereas all healthy controls had metabotype M1. M1 was characterised by high Bacteroidetes and Firmicutes, low Proteobacteria, and higher SCFA synthesis pathways, and M2 was associated with high Proteobacteria and genes involved in SCFA degradation. M1 contribution increased during diet: 48%, 63%, up to 74% [Weeks 0, 6, 12, respectively.]. By Week 12, genera from Proteobacteria reached relative abundance levels of healthy controls with the exception of E. coli. Despite an increase in SCFA synthesis pathways, remission was not associated with increased SCFAs. Primary BA decreased with EEN but not with CDED+PEN, and secondary BA did not change during diet. Conclusion Successful dietary therapy induced correction of both compositional and functional dysbiosis. However, 12 weeks of diet was not enough to achieve complete correction of dysbiosis. Our data suggests that composition and metabotype are important and change quickly during the early clinical response to dietary intervention. Correction of dysbiosis may therefore be an important future treatment goal for CD.

ObjectiveWe aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn’s disease [CD].MethodsWe formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained.ResultsWe established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone.ConclusionsWe present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.

Background Accumulating evidence suggests that the metabolic effects of metformin and fermentable fibers are mediated, in part, through diverging or overlapping effects on the composition and metabolic functions of the gut microbiome. Pre-clinical animal models have established that the addition of fiber to metformin monotherapy improves glucose tolerance. However, possible synergistic effects of combination therapy (metformin plus fiber) have not been investigated in humans. Moreover, the underlying mechanisms of synergy have yet to be elucidated. The aim of this study is to compare in adolescents with obesity the metabolic effects of metformin and fermentable fibers in combination with those of metformin or fiber alone. We will also determine if therapeutic responses correlate with compositional and functional features of the gut microbiome. Methods This is a parallel three-armed, double-blinded, randomized controlled trial. Adolescents (aged 12–18 years) with obesity, insulin resistance (IR), and a family history of type 2 diabetes mellitus (T2DM) will receive either metformin (850 mg p.o. twice/day), fermentable fibers (35 g/day), or a combination of metformin plus fiber for 12 months. Participants will be seen at baseline, 3, 6, and 12 months, with a phone follow-up at 1 and 9 months. Primary and secondary outcomes will be assessed at baseline, 6, and 12 months. The primary outcome is change in IR estimated by homeostatic model assessment of IR; key secondary outcomes include changes in the Matsuda index, oral disposition index, body mass index z-score, and fat mass to fat-free mass ratio. To gain mechanistic insight, endpoints that reflect host-microbiota interactions will also be assessed: obesity-related immune, metabolic, and satiety markers; humoral metabolites; and fecal microbiota composition, short-chain fatty acids, and bile acids. Discussion This study will compare the potential metabolic benefits of fiber with those of metformin in adolescents with obesity, determine if metformin and fiber act synergistically to improve IR, and elucidate whether the metabolic benefits of metformin and fiber associate with changes in fecal microbiota composition and the output of health-related metabolites. This study will provide insight into the potential role of the gut microbiome as a target for enhancing the therapeutic efficacy of emerging treatments for T2DM prevention. Trial registration ClinicalTrials.gov NCT04578652. Registered on 8 October 2020.

Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder of the gastrointestinal tract with numerous genetic and environmental risk factors. Patients with Crohn’s disease (CD) or ulcerative colitis (UC) often demonstrate marked disruptions of their gut microbiome. The intestinal microbiota is strongly influenced by diet. The association between the increasing incidence of IBD worldwide and increased consumption of a westernized diet suggests host nutrition may influence the progression or treatment of IBD via the microbiome. Several nutritional therapies have been studied for the treatment of CD and UC. While their mechanisms of action are only partially understood, existing studies do suggest that diet-driven changes in microbial composition and function underlie the diverse mechanisms of nutritional therapy. Despite existing therapies for IBD focusing heavily on immune suppression, nutrition is an important treatment option due to its superior safety profile, potentially low cost, and benefits for growth and development. These benefits are increasingly important to patients. In this review, we will describe the clinical efficacy of the different nutritional therapies that have been described for the treatment of CD and UC. We will also describe the effects of each nutritional therapy on the gut microbiome and summarize the strength of the literature with recommendations for the practicing clinician.

Background: As the microbiome plays an important role in instigating inflammation in ulcerative colitis (UC), strategies targeting the microbiome may offer an alternative therapeutic approach. The goal of the pilot trial was to evaluate the potential efficacy and feasibility of a novel UC exclusion diet (UCED) for clinical remission, as well as the potential of sequential antibiotics for diet-refractory patients to achieve remission without steroids. Methods: This was a prospective, single-arm, multicenter, open-label pilot study in patients aged 8–19, with pediatric UC activity index (PUCAI) scores &gt, 10 on stable maintenance therapy. Patients failing to enter remission (PUCAI &lt, 10) on the diet could receive a 14-day course of amoxycillin, metronidazole and doxycycline (AMD), and were re-assessed on day 21. The primary endpoint was intention-to-treat (ITT) remission at week 6, with UCED as the only intervention. Results: Twenty-four UCED treatment courses were given to 23 eligible children (mean age: 15.3 ± 2.9 years). The median PUCAI decreased from 35 (30–40) at baseline to 12.5 (5–30) at week 6 (p = 0.001). Clinical remission with UCED alone was achieved in 9/24 (37.5%). The median fecal calprotectin declined from 818 (630.0–1880.0) μg/g at baseline to 592.0 (140.7–1555.0) μg/g at week 6 (p &gt, 0.05). Eight patients received treatment with antibiotics after failing on the diet, 4/8 (50.0%) subsequently entered remission 3 weeks later. Conclusion: The UCED appears to be effective and feasible for the induction of remission in children with mild to moderate UC. The sequential use of UCED followed by antibiotic therapy needs to be evaluated as a microbiome-targeted, steroid-sparing strategy.

Background Canadian-born children of South Asian [SA] ethnicity develop inflammatory bowel disease [IBD] at similar rates to those among Caucasian children. We evaluated the variation in phenotypic spectrum of IBD in SA and Caucasian children in a national paediatric inception cohort of new-onset IBD. Methods Patients aged Results Of 1156 children enrolled over 2014 to 2019, 623 were Caucasian [98% and 88% parents Canadian born] and 114 SA [79% Canadian born, 87% parents SA born]. Fewer SAs have a first-degree relative with IBD, 6% vs 19% in Caucasians, p = 0.002. SAs present at a younger age, median age 11.4 years (interquartile range [IQR] 9.2–14.3) vs 13 years [IQR 10.9-15 years], p = 0.03 and more commonly with a UC/IBD-U [ulcerative colitis/IBD-unclassified] subtype [ratio of UC/IBD-U to CD 1.2:1 vs 1:1.8 for Caucasians, p Conclusions The phenotypic spectrum of new-onset IBD in SA children differs from that of Caucasian children, but treatment and clinical course are similar within phenotypic subgroups.

Background The incidence of childhood-onset inflammatory bowel disease (IBD) diagnoses is increasing in Canada; therefore, more patients will need to transition from pediatric into adult care. The literature on transition in IBD patients has focused mainly on preparation and while transition success is often referenced, it is not clearly defined. Prior research on IBD transition success has only focused on the perspectives of the health care providers. Taking into consideration that transition is a process that greatly relies on patient involvement, patient perspectives should be represented in defining its success. Aims The primary aim is to understand patients’ perspectives on the outcomes that characterize a successful transition from pediatric to adult care. Methods This study paired a theoretical position of naturalistic inquiry with the method of qualitative description. Purposive sampling was used to recruit patients from IBD clinics at the University of Alberta and the University of Calgary. Inclusion criteria included transition within the last two years, diagnoses with IBD for at least a year prior to transitioning, and absence of comorbidities. Virtual semi-structured interviews were conducted using an established interview guide. Interviews were transcribed verbatim and then analyzed concurrently with data collection by latent content analysis using NVivo computer software. Participant recruitment and data analysis continued until no further themes emerged from the data, which signaled that thematic saturation was achieved. Results Thematic saturation was achieved after 17 interviews. Among participants, 58.8% were female; 47% had a diagnosis of Crohn’s, 47% of ulcerative colitis, and one individual was diagnosed with both. The median age at diagnosis was 15 years (IQR, 3.5). The majority (94%) of participants viewed their transition as being successful. Overall, the major themes that emerged from the data were: 1. relationship with one’s adult care team, characterized predominantly as the patient being comfortable with their new team; 2. health outcomes, characterized by disease remaining stable, and medication adherence; 3. independence in one’s care, characterized by making and attending appointments on their own, asking questions and in general having an awareness about your health and disease; 4. care stability, characterized by no drop off in care, and regular contact and follow up by their provider. Conclusions Young adults with IBD define pediatric transition success in four themes: relationship with care team, health outcomes, independence in one’s care, and care stability. Through understanding what transition success looks like from the patients’ perspectives, health care providers can help patients achieve success as they define it. Funding Agencies None

Infliximab (IFX) is administered intravenously using weight-based dosing (5 mg/kg) in inflammatory bowel disease (IBD) patients. Our hypothesis is that especially young children need a more intensive treatment regimen than the current weight-based dose administration. We aimed to assess IFX pharmacokinetics (PK), based on existing therapeutic drug monitoring (TDM) data in IBD patients p p n = 29) in YP vs. 58% (n = 45) in OP; p = 0.56).Conclusion: Intensification of the induction scheme is suggested for PIBD patients aged What is Known? •Infliximab trough levels of paediatric IBD patients are influenced by several factors as dosing scheme, antibodies and inflammatory markers.•In 4.5–30% of the paediatric IBD patients, infliximab treatment was stopped within the first year. What is New? •The majority of young PIBD (

Background The last decade has seen increasing calls for patient and public involvement in health-related research due to an ideological shift toward more equitable methods of knowledge development and an effort to increase the usability and relevance of knowledge by improving outcomes in clinical practice. Patient engagement includes simply informing patients to offering complete decision-making autonomy to individuals, groups, communities, caregivers, friends, and families who have personal experience and knowledge of a health issue. Despite the use of patient engagement methods in research, evaluation has lagged, resulting in a knowledge gap that makes it difficult to foster capacity and sustainability for patients and researchers alike since little is known about how effective patient collaborations in research are built, maintained, or improved. This study centers on pediatric functional constipation, a common condition that affects children and families. Since parents play a pivotal role in treatment, they are an optimal group to engage in improving the resources and support available to them. Objective This study aims to use patient-engagement methods to establish a research collaboration with parents to cocreate a digital knowledge translation tool for parents caring for a child with functional constipation and formally evaluate the patient engagement processes within this project to build the science of patient engagement in research. Methods Members of the parent collaborator group will be recruited from previous participants who expressed interest in the development of a digital knowledge translation tool. The group will collaborate with the research team to create a tool to address patients’ support and information needs when caring for a child with functional constipation. The parent collaborator group will then be evaluated in a multimethod study design. Data will be digitally and anonymously collected from all members of the parent collaborator group, using the validated Public and Patient Engagement Evaluation Tool (PPEET) patient questionnaire. Descriptive statistics will be used to report group characteristics and question responses. Qualitative analysis will be used to understand open-ended question responses. Specifically, directed content analysis will be used to assess themes of the Patient Engagement in Research (PEIR) Framework with a combination of deductive and inductive analyses. Findings will be integrated into the discussion if there are sufficient commonalities and inter-relationships. The final manuscript will include reporting of each element as described by the Good Reporting of a Mixed Methods Study criteria. Results Recruitment is planned for June 2020. Data collection for the evaluation of patient engagement processes will occur upon completion of the digital knowledge translation tool. The results of this study are expected to be published by the end of 2020. Conclusions This study will provide valuable information about parents’ experiences participating in child-health research and is a fundamental step in building the science of patient engagement in research. International Registered Report Identifier (IRRID) PRR1-10.2196/19108

Background The etiology of inflammatory bowel diseases (IBD) remains unknown, although gut microorganisms and diet have been implicated. Dietary fibers pass through the bowel undigested and are fermented within the intestine by microbes, promoting gut health. However, many IBD patients describe experiencing sensitivity to fibres. Interestingly, fiber receptors on immune cells are able to interact with fibers typically found on the surface of fungal cells (which share properties with dietary fibers), for example, resulting in a paradoxical pro-inflammatory response. Aims As an altered microbial composition is a hallmark of IBD, we hypothesized that the loss of fiber fermenting-microbes populating the IBD gut could lead to dietary fibers not being efficiently broken down into their beneficial biproducts, resulting in binding of intact fibers to pro-inflammatory host cell receptors. This can ultimately drive pro-inflammatory responses and a microenvironment that promotes continued dysbiosis and increased pathogenicity of select microbes, as observed in IBD. Methods Fiber receptor expression gut was examined using immunohistochemistry and flow cytometry and demonstrated elevated receptor expression due to increased presence of immune cells in IBD patient biopsies. Cytokine secretion, in response to fiber (5mg/mL) or pre-fermented fibers, cultured with microbes of interest, was measured by ELISAs in cell lines in vitro and biopsy tissues cultured ex vivo. Results Whole-fibers induced pro-inflammatory cytokine production in macrophage, monocytes, and neutrophils. Specific microbes were capable of fermenting fiber, measured by gas chromatography. Pre-fermentation of fibers by these microbes reduced inflammatory cytokine production. The fiber oligofructose increased IL-1β in pediatric CD (n=44) and UC (n=29) biopsies cultured ex vivo but not in non-IBD (n=25). The increase was greater in patients with more severe disease. Pre-fermentation of oligofructose by bacteria reduced this secretion of IL-1β. Whole-microbe intestinal washes from severe IBD patients were unable to ferment oligofructose or reduce fiber-associated inflammation in macrophage cells compared to remission or non-IBD children. Statistical analysis of food frequency questionnaire (FFQ) data on fiber consumption demonstrated that fiber-associated inflammation in patient biopsies cultured ex vivo (ELISA and qPCR) correlated with fiber avoidance (FFQ). Conclusions Comparing in vitro findings to our patient FFQs, intestinal washes (microbe abundance), and detailed patient history will better define the relationship between microbes, dietary fibers, and gut inflammation in IBD. This will allow for tailored dietary intervention through dietary recommendations, prebiotic, and/or probiotic therapies. Funding Agencies CCCWeston Foundation, WCHRI

Background The incidence rates of inflammatory bowel diseases (IBD), Crohn disease (CD) and ulcerative colitis (UC) are increasing in children. Although the etiology of IBD is poorly understood, factors such as urban lifestyle, diet, increased hygiene, and reduced microbial biodiversity have been implicated as risk factors. Compositional changes and reduced microbial biodiversity have been linked to therapy failure in pediatric IBD. Non-digestible dietary carbohydrates, such as fiber, must undergo fermentation by gut microbiota within the large bowel, producing short chain fatty acids (SCFAs). Animal studies have shown that dietary fibers can inhibit IBD-associated inflammation, and clinical trials have demonstrated that SCFAs can prevent intestinal atrophy and allow for tissue recovery in IBD patients. In disease settings with altered gut microbes, fermentation of dietary fibers may be greatly affected. Unfermented fibers interact with receptors on host immune cells and can induce proinflammatory immune response, production of oxygen species and inflammation, or an inhibition of proinflammatory receptors. Aims Based on this rationale, we hypothesize that dysbiosis in the IBD gut leads to decreased fiber fermenting microbes, resulting in reduced SCFA production. This contributes to increased inflammatory responses both in in vitro cell lines, as well as ex vivo patient biopsies. Because intact fibers can bind to host cell receptors, this promotes inflammatory response and continued dysbiosis. Methods To assess effects of intact fiber on immune cells, macrophage and T-cell in vitro cultures were used to measure cytokine response to inulin (5mg/mL) and oligofructose (5mg/mL) through ELISAs/qPCR. These cell lines and ex vivo patient biopsies were treated with whole fibers and IL-1β secretion was measured. Fibers were also pre-fermented with microbes of interest or whole microbe patient intestinal washes and used to treat cell lines and patient biopsies. Results Whole fibers induced a pro-inflammatory response in macrophage cells but not T-cells, and this pro-inflammatory response was mitigated by pre-fermenting the fibers. Intestinal washes from severe IBD patients were unable to successfully ferment oligofructose or reduce fiber-associated inflammation in macrophage cell lines, whereas washes from remission or non-IBD samples reduced IL-1β. Oligofructose was found to increase IL-1β secretion in UC and CD patient biopsies, but not in non-IBD specimens. This increase was also correlated with disease severity. Conclusions These results indicate that a lack of fiber-fermenting microbes and presence of whole fibers can lead to pro-inflammatory responses, both in cell lines and patient biopsies. However, the presence of appropriate fermenting microbes can reduce fiber-associated inflammation. Funding Agencies CCCWCHRI, Weston Foundation

Background Persistent inflammation can trigger altered epigenetic, inflammation and bioenergetics states. Inflammatory bowel disease (IBD) is a heterogeneous disease with an abnormal inflammatory state and subsequent metabolic syndrome disorder. Current IBD therapeutics are directed to inhibit inflammatory pathways, such as inflammation of the epithelial cells in the colonic crypts. We hypothesize that in order to achieve mucosal healing and to keep patients in remission we must (i) inhibit inflammatory mediators and (ii) resolve secondary effects of inflammation such a reset of metabolic dysfunction. Aims The aims of this study are to explore correlations between inflammation/metabolic markers and the severity of the disease to uncover emerging new therapeutic players. Methods More than one hundred patients were recruited and underwent colonoscopy. In order to explore how biomarkers change with disease and time, all patients had IBD for more than 10 years or less than 5 years. Those diagnosed with cancer, celiac sprue, or diabetes were excluded. The activity of key metabolic markers (such as AMPK) was tracked using phospho-specific antibodies. Immunohistochemistry and immunoblotting were carried out, as described by Gordon et al., PLOSone 2013. All patients were consented under our IBD ethics protocol (Pro00001523 and Pro00077868). Results Using intestinal biopsies from non-IBD, UC and CD patients, we explored the expression/activation levels of markers of inflammation (such as obligate NOD2 kinase RIPK2) and metabolism (AMPK) in order to gain insight into correlations with clinical severity of the disease. We confirm that the loss in the activity of AMPK occurs with a gain of activity of RIPK2 that drives the inflammatory phenotype of the gut in patients with long-standing IBD (>10 years). (If inflammation is inhibited in a mouse model of IBD, metabolic reset occurs to regain AMPK and promote mucosal healing). However, RIPK2 remains elevated in patients that are currently on IBD therapeutics. Conclusions Therapeutics inhibiting inflammation (RIPK2) and stimulating metabolic (AMPK) drivers of the disease may be a useful combination therapy to completely eliminate inflammation, reset abnormal metabolism and achieve full remission in IBD patients with longstanding disease. Funding Agencies None

Background and AimsIncidence of paediatric inflammatory bowel disease [IBD] in Canada is among the highest worldwide, and age of onset may be decreasing. In a multicentre nationwide inception cohort study, we examined variation in phenotype of IBD throughout the paediatric age spectrum.MethodsChildren aged ≥2 years [y] and ResultsAmong 1092 children (70% Caucasian; 64% Crohn’s disease [CD], 36% ulcerative colitis/inflammatory bowel disease unclassified [UC/IBD-U]; median age 13 y, interquartile range [IQR] 11–15 y), 210 [19%] were diagnosed before the age of age 10 y [Paris A1a] and 43 [4%] before age 6 y (very-early-onset [VEO-IBD]). CD was less common in younger children [42%, 56%, 66%, respectively, of VEO-IBD, A1a; A1b]. Colon-only IBD [UC/IBDU or CD-colon] was present in 81% of VEO-IBD and 65% of A1a; ileal disease increased progressively, reaching plateau at age 10 y. CD location was ileocolonic [L3] in 53% overall. Ileitis [L1] increased with age [6% of VEO-IBD; 13% of A1a; 21% of A1b], as did stricturing/penetrating CD [4% of A1a; 11% of A1b]. At all ages UC was extensive [E3/E4] in >85%, and disease activity moderate to severe according to Physician’s Global Assessment [PGA] and weighted Paediatric Crohn’s Disease Activity Index/Paediatric Ulcerative Colitis Activity Index [wPCDAI/PUCAI] in >70%. Heights were modestly reduced in CD [mean height z score -0.30 ± 1.23], but normal in UC/IBD-U.ConclusionsParis classification of age at diagnosis is supported by age-related increases in ileal disease until age 10 years. Other phenotypic features, including severity, are similar across all ages. Linear growth is less impaired in CD than in historical cohorts, reflecting earlier diagnosis.

BACKGROUND: Inflammatory bowel diseases (IBD), including Crohn disease and ulcerative colitis, are chronic and severely debilitating gastrointestinal disorders, with rising prevalence, especially in children. While the etiology of IBD remains poorly understood, gut microorganisms and diet have been implicated in IBD pathogenesis. Interestingly, dietary fibers pass through the small bowel undigested and are fermented within the large intestine by specific gut microbes, promoting gut health by altering the gut microenvironment, modulation of the immune system, and altered energy metabolism. Our previous work indicates an altered balance between commensal and pathobiont microbes in IBD, suggesting one opportunity for the misregulation of fiber fermentation within the IBD gut. Interestingly, specific carbohydrate receptors on the surface of immune cells interact with fibers, such as those expressed by certain species of fungi, driving an inflammatory response. AIMS: Here we hypothesize that the altered microbiota in IBD causes significant changes in fiber fermentation, ultimately driving intestinal inflammation. METHODS: Bacterial growth rates in response to specific fibers were examined by OD600 growth curves. Bacterial fiber fermentation patterns were evaluated by mass spectrometry of SCFAs. The effects of specific fibers on bacterial pathogenicity when co-cultured with human HT29 epithelial cells was measured by gentamicin protection assays and visualized by microscopy. Immunohistochemistry of biopsy tissues collected from pediatric IBD (n=14) and control patients (n=7) was utilised to examine expression levels of fiber receptors expressed on human cells. RESULTS: We have demonstrated that commensal microorganism, isolated live from IBD patients, display a different pattern of fiber fermentation compared to pathobiont species. Specific fibers also increase the invasive potential of these pathobionts. Preliminary immunohistochemistry suggests that there is increased expression of specific carbohydrate receptors in IBD, suggesting an increased sensitivity to unfermented dietary fibers in these patients. CONCLUSIONS: These results suggest that some patients may display a sensitivity to specific dietary fibers due to a lack of appropriate fiber fermenting microbes in their gut. Profiling the patient specific microbiota of IBD patients may allow us to make more specific dietary recommendations to assist in reducing intestinal inflammation in IBD. Comparing in vitro findings to our readily available patient food frequency questionnaires (FFQs) and detailed patient history will allow us to define key disease features of IBD and also identify new and improved treatment options, such as microbe-altering treatments, and tailored nutritional recommendations. FUNDING AGENCIES: CCCCCFC

BACKGROUND: Inflammatory bowel diseases (IBD), including Crohn disease (CD) and ulcerative colitis (UC), affect 1 in 150 Canadians, and 25% of new cases are diagnosed in children. IBD manifests with chronic gastrointestinal inflammation and an altered intestinal microbiome. Dietary changes impact IBD, as shown by the effective pediatric CD therapy exclusive enteral nutrition (EEN), which entails exclusive intake of liquid meal-replacement for 6–8 weeks. EEN adherence can be challenging and costly to families; biomarkers to more accurately predict response to EEN would allow for individualized therapy. Previous diet impacts microbes and has been shown to affect response to dietary therapy in mice. Therefore, we hypothesized that previous diet would impact EEN success (and suggest mechanisms of microbial involvement), and that the effects of EEN are mediated through an altered intestinal microbiome in response to dietary or bacterial secreted metabolites. AIMS: To establish predictors for EEN success and elucidate the metabolic mechanism by which an altered intestinal microbiome mediates patient response to dietary intake. METHODS: Pre-diagnosis food frequency questionnaire (FFQ) data were used to identify predictors of EEN outcomes. These were then correlated with metabolomics to identify metabolites that may link diet with response to therapy. Metabolites suspected to be involved in response to EEN were then assessed in vitro by measuring effects on bacterial invasion, epithelial barrier integrity, and inflammation. RESULTS: Pilot FFQ analysis correlated intake of simple carbohydrate and processed meat with EEN failure and success, respectively. Exposure to sterile IBD patient intestinal washes increased invasion of Enterohemorrhagic Escherichia coli into Caco-2 cells in gentamicin protection assays. Metabolomic analysis of the content showed increased succinate in IBD patient intestinal washes. Results were replicated in vitro with gentamicin protection assays showing that succinate increased bacterial invasion into HT29 cells. IBD patient isolated bacterial strains have also shown increased invasion compared to identical species isolated from non-IBD controls; both exhibited increased invasion in the presence of succinate. CONCLUSIONS: We have shown that previous diet predicts response to therapy, metabolites can alter bacterial invasion, and the IBD microbiome may house more invasive strains of bacteria. Understanding the interactions between diet and the microbiome in pediatric IBD can guide novel dietary or metabolite-focused therapies and facilitate identification of patients likely to respond to dietary therapies such as EEN. FUNDING AGENCIES: CCCCCFA

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer that is associated with significantly high mortality. In spite of advances in IBC diagnoses, the prognosis is still poor compared to non-IBC. Due to the aggressive nature of the disease, we hypothesize that elevated levels of inflammatory mediators may drive tumorigenesis and metastasis in IBC patients. Utilizing IBC cell models and patient tumor samples, we can detect elevated NF-&kappa, B activity and hyperactivation of non-canonical drivers of NF-&kappa, B (nuclear factor kappaB)-directed inflammation such as tyrosine phosphorylated receptor-interacting protein kinase 2 (pY RIPK2), when compared to non-IBC cells or patients. Interestingly, elevated RIPK2 activity levels were present in a majority of pre-chemotherapy samples from IBC patients at the time of diagnosis to suggest that patients at diagnosis had molecular activation of NF-&kappa, B via RIPK2, a phenomenon we define as &ldquo, molecular inflammation&rdquo, Surprisingly, chemotherapy did cause a significant increase in RIPK2 activity and thus molecular inflammation suggesting that chemotherapy does not resolve the molecular activation of NF-&kappa, B via RIPK2. This would impact on the metastatic potential of IBC cells. Indeed, we can demonstrate that RIPK2 activity correlated with advanced tumor, metastasis, and group stage as well as body mass index (BMI) to indicate that RIPK2 might be a useful prognostic marker for IBC and advanced stage breast cancer.

Cancer is a multifaceted condition, in which a senescent cell begins dividing in an irregular manner due to various factors such as DNA damage, growth factors and inflammation. Inflammation is not typically discussed as carcinogenic; however, a significant percentage of cancers arise from chronic microbial infections and damage brought on by chronic inflammation. A hallmark cancer-inducing microbe is Helicobacter pylori and its causation of peptic ulcers and potentially gastric cancer. This review discusses the recent developments in understanding microbes in health and disease and their potential role in the progression of cancer. To date, microbes can be linked to almost every cancer, including colon, pancreatic, gastric, and even prostate. We discuss the known mechanisms by which these microbes can induce cancer growth and development and how inflammatory cells may contribute to cancer progression. We also discuss new treatments that target the chronic inflammatory conditions and their associated cancers, and the impact microbes have on treatment success. Finally, we examine common dietary misconceptions in relation to microbes and cancer and how to avoid getting caught up in the misinterpretation and over inflation of the results.

Article first published online 29 April 2015., Inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis, are poorly understood disorders affecting the intestinal tract. The current model for disease suggests that genetically susceptible patients develop intolerance to gut microflora, and chronic inflammation develops as a result of environmental insults. Although interest has mainly focused on studying genetic variants and gut bacterial flora, little is known about the potential of viral infection to contribute to disease. Accordingly, we conducted a metagenomic analysis to document the baseline virome in colonic biopsy samples from patients with IBD in order to assess the contribution of viral infection to IBD. Libraries were generated from colon RNA to create approximately 2 GB sequence data per library. Using a bioinformatic pipeline designed to detect viral sequences, more than 1000 viral reads were derived directly from tissue without any coculture or isolation procedure. Herein, we describe the complexity and abundance of viruses, bacteria/bacteriophage, and human endogenous retroviral sequences from 10 patients with IBD and 5 healthy subjects undergoing surveillance colonoscopy. Differences in gut microflora and the abundance of mammalian viruses and human endogenous retroviruses were readily detected in the metagenomic analyses. Specifically, patients with herpesviridae sequences in their colon demonstrated increased expression of human endogenous viral sequences and differences in the diversity of their microbiome. This study provides a promising metagenomic approach to describe the colonic microbiome that can be used to better understand virus–host and phage–bacteria interactions in IBD.

BACKGROUND: Several studies support a role for gut microorganisms in the development of the common and severely debilitating chronic inflammatory bowel diseases (IBD), Crohn disease (CD) and ulcerative colitis (UC). To date, most studies have examined only samples from stool or inflamed areas, limiting the ability to differentiate between cause and effect. Our recent work examined the uninflamed terminal ileum (TI) in pediatric UC, and showed changes in diversity and composition of bacteria, suggesting that microbes proximal to diseased areas may drive inflammation distally. AIMS: As immunoglobulin (Ig)G is increased in IBD and has been shown to bind more selectively to pathogens than its counterpart, IgA, we hypothesized that IgG is formed in response to invasive microbes, and could be used to identify specific taxa involved in IBD pathogenesis. To test this, we isolated IgG-bound intestinal bacteria, identified by 16S rDNA sequencing, and tested their virulence in vitro. METHODS: TI luminal washes were collected during endoscopy of pediatric IBD patients and non-IBD controls. IgG bound (IgG+) and unbound (IgG-) bacteria were separated and collected using FACS and DNA was extracted for 16S rDNA sequencing (Ilumina MiSeq platform). Virulence of specific IgG-bound bacteria was tested in-vitro via gentamycin protection assay, microscopy and qPCR for markers of immune response. RESULTS: Species diversity and microbial composition were reduced in UC compared to non-IBD. Furthermore, the ratio of IgG+/IgG- bacteria increased in CD and UC patients by 2 and 1.5 fold, respectively. Although total abundance of Burkholderia cepacia, was comparable in IBD and non-IBD, there was a 2.5 and 4.1 fold increase in the ratio of IgG+/IgG- binding to B. cepacia in remission/mild or moderate/severe UC, respectively, compared to non-IBD. B. cepacia was previously identified in the ileum of IBD cohorts however, it is not typically recognized as an intestinal pathogen. B. cepacia displays pro-inflammatory effects and invasive potential in an in-vitro model, supporting its pathobiont potential and further supporting the use of IgG as a marker of pathobionts in IBD. CONCLUSIONS: We have demonstrated the ability of IgG-binding to selectively identify previously unrecognized mucosa-associated pathobionts, validated in-vitro. Elucidating the role of specific bacterial species in UC pathogenesis will underpin new strategies to improve our ability to direct therapies to those patients most likely to respond. FUNDING AGENCIES: CCCCCFA

BACKGROUND: Inflammatory bowel diseases (IBD) are chronic inflammatory conditions of the intestines likely induced by abnormal immune response to resident intestinal bacteria in genetically susceptible hosts. Probiotics, prebiotics and dietary fibres alter the gut microbiota and improve its function, thus potentially counteracting the development of inflammation. Although the role of these compounds in the prevention and management of IBD is relatively understudied, anecdotal evidence suggests widespread, undocumented use of these supplements by patients. Investigating the use of probiotics and prebiotics by IBD patients and association with disease severity may allow for optimization of therapy and improved clinical outcomes. AIMS: To assess if the self-motivated intake of probiotics, prebiotics and dietary fibre supplements is associated with the disease severity in patients with IBD. METHODS: We conducted a cross-sectional study of patients with a diagnosis of IBD in the University of Alberta IBD clinic. Using a 20-item questionnaire we collected data from patients on demographics, disease characteristics and knowledge and use of probiotics, prebiotics and dietary fibre supplements. We used a chart review to ascertain the occurrence of flares, disease duration and objective markers of inflammation such as fecal calprotectin (FCP) as indicators of disease severity. RESULTS: In this study, 100 participants (45% females) with a known diagnosis of IBD (47% Crohn’s disease, 34% ulcerative colitis, 19% IBD-unclassified) completed questionnaires. Large proportions of participants were knowledgeable about probiotics (88%) and dietary fibres (76%), but less about prebiotics (42%). The majority of users had Crohn’s disease (42% CD vs. 35% UC, p=0.33). 66% of surveyed patients had used these products as an alternate therapy. Disease flares in the last two years did not have an effect on usage (73% users vs. 71% non-users, p=0.8). The use of alternative therapies was higher in patients with longer history of IBD (77% in those with a duration >5 years vs. 22% in those with a duration 250 µg/g (an indicator of acute disease) during the preceding six months reported supplement use, compared to 52% with FCP values below this value (P=0.11). CONCLUSIONS: This study shows that a large proportion of IBD patients are interested in alternative therapies for IBD. Increased flare frequency and objective markers of inflammation did not have an effect on usage. However, longer disease history was the main factor influencing the search for a “cure” by the patients. These microbiota-altering strategies have the ability to affect disease outcomes, therefore clinicians and researchers should identify and document their use. FUNDING AGENCIES: CIHR

BACKGROUND: With the rise of inflammatory bowel disease (IBD) in pediatric patients, transition is a process that occurs more every day. In a prior study, we identified that an interactive IBD transition website was needed to assist pediatric patients with IBD make the transition from pediatric to adult gastroenterology care. This interactive website can be used to assess the transition skills of patients around the time of transfer of care. AIMS: To assess the transition skills of young adults with IBD around the time of transfer of care, before and after using the newly developed IBD Transition Website. METHODS: Participants between the ages of 16–18 years were recruited in the pediatric and adult IBD clinics at the Stollery and University of Alberta Hospitals. Written consent was obtained and participants were directed to the transition.ibdclinic.ca website and instructed to complete a short website assessment. After the participants complete the assessment, they are prompted to re-take the assessment after 30 days to assess if there is any change in these transition skills. Transition skills assessed include: 1) knowledge (IBD-Kid), 2) medication adherence, and 3) transition readiness (TRAQ). RESULTS: To date, 21 patients recruited and 8 have completed the initial assessment. Demographic data of those completing the initial assessment: 75% female; 75% have Crohn’s Disease; median age of 17.5. Results of the baseline transition skills assessments are shown in Table 1; scores are compared to results to literature values. 30-day post-website access scores are not yet available. CONCLUSIONS: In IBD patients transitioning from pediatric to adult care in Edmonton appear to have good knowledge and medication adherence, however show significant deficits in transition readiness skills. It is not yet known, if an IBD website intervention is able to improve these deficits. FUNDING AGENCIES: CEGIIR

BACKGROUND: Nod-like receptor protein-3 (NLRP3) inflammasomes have been linked to various inflammatory conditions such as inflammatory bowel diseases (IBD). Conditions associated with the inflammasomes are typically characterized by an overabundance of interleukin (IL)-1β with the exception of IBD, where its dysregulation results in hypoproduction. The mouse pathogen Citrobacter rodentium, which causes IBD-like colitis, is used to understand the dynamic relationship between pathogens, the inflammasome and the epithelial barrier. We have recently shown that ATP-activated macrophages increase clearance of C. rodentium in vitro. Our hypothesis is that inflammasome activation will increase macrophage recruitment and facilitate protection of the epithelial barrier. AIMS: The aim was to determine the role the inflammasome plays during macrophage-epithelial interaction during C. rodentium infection METHODS: Mouse colonic epithelial cells (CMT-93) were seeded on the bottom of collagen coated transwells until tight junctions were formed using transepithelial electrical resistance (TEER). The CMT-93 cells were infected with C. rodentium on the apical membrane. ATP and LPS were used to activate the inflammasome in macrophages with YVAD as an inhibitor and added to the basolateral membrane, with tight junction permeability measured using TEER. Immunofluorescence was done using confocal microscopy looking at tight junction proteins ZO-1, occluding and claudin 1. Adherence of C. rodentium to the epithelial barrier was assessed using serial dilutions and plating on LB agar at 37°C overnight. RESULTS: ATP-activated macrophages were increased at the apical membrane during C. rodentium infection of epithelial cells. Tight junction proteins Claudin-1, Occludin, and ZO-1 were found on macrophages using immunofluorescence. The presence of epithelial ZO-1 rings were observed during C. rodenitum infection through immunofluorescence. C. rodentium adherence was found to be significantly reduced, together with an increase in epithelial TEER recovery; this was inhibited using YVAD. CONCLUSIONS: These data suggest that the inflammasome is an important mediator for pathogen clearance by macrophages. Some individuals with Crohn Disease that have a decreased ability to produce IL-1β may be more susceptible to infection, as they cannot clear a pathogen. Furthermore, the role of the epithelial cell in this relationship is critical to understanding why the epithelial barrier in IBD patients is disrupted. FUNDING AGENCIES: CCCCCA