Expert Opinion: Place in Therapy of Probiotics in Infertility and Recurrent Implantation Failure

Infertility is a widespread medical condition, affecting a notable percentage of couples globally, with a rising prevalence in India. While assisted reproductive technologies (ART) provide hope, recurrent implantation failure (RIF) continues to challenge approximately one in 10 couples undergoing in-vitro fertilization (IVF). This expert opinion document intends to highlight the promise of probiotics, particularly from Lactobacillus, as a therapeutic approach for improving fertility and treating RIF. In India, on June 29-30, 2024, a physical expert meeting was organized involving 14 specialists from gynecology, obstetrics, and fertility fields. The role of probiotics in reproductive health was discussed in the meeting with an emphasis on infertility and RIF. All experts agree that microbial dysbiosis characterized by an imbalance among the dominant Lactobacillus species is associated with RIF leading to increased inflammation hence poor reproductive outcomes. Probiotics have emerged as possible therapies that restore microbial equilibrium while reducing inflammation and enhancing the intactness of the genital epithelium barrier. All experts have strongly supported the use of Lactobacillus-based oral probiotic supplementation particularly for preventing miscarriages and maintaining pregnancy. All the experts unanimously agreed that oral probiotic supplementation, particularly Lactobacillus-based, should be considered as a potential method to prevent miscarriages and aid in maintaining pregnancy. They recommend oral probiotic use prior to embryo transfer to enhance implantation and pregnancy rates. This expert opinion emphasizes the value of probiotics as a safe and non-invasive approach to treating infertility and RIF. By fostering a balanced microbiome, probiotics may increase the likelihood of successful pregnancies.

Maintenance treatment with vedolizumab in paediatric inflammatory bowel disease (VEDOKIDS): 54-week outcomes of a multicentre, prospective, cohort study

BACKGROUND

Infliximab and adalimumab are the only biologics thus far approved for paediatric patients with inflammatory bowel disease (IBD), so other biologics, such as vedolizumab, are prescribed off-label. Despite its frequent use, prospective data for vedolizumab treatment in children are available only for short-term induction outcomes. We aimed to evaluate the long-term efficacy and safety of maintenance therapy with vedolizumab in paediatric patients with IBD.

METHODS

In this multicentre, prospective, cohort study (VEDOKIDS), children younger than 18 years with Crohn's disease, ulcerative colitis, or IBD unclassified (analysed with the ulcerative colitis group) who had initiated intravenous vedolizumab were enrolled from 17 centres in six countries (Israel, the USA, Italy, Ireland, Denmark, and Slovenia). Patients initiating vedolizumab to prevent postoperative recurrence were excluded. Vedolizumab dose or schedule were not standardised, and concomitant treatment with any other medication was permitted. Patients were prospectively followed up for 54 weeks, with repeated biosampling. The primary outcome was complete remission at week 54, defined as clinical remission (weighted Paediatric Crohn's Disease Activity Index [wPCDAI] of <12·5 points in Crohn's disease and Paediatric Ulcerative Colitis Activity Index [PUCAI] of <10 in ulcerative colitis) without the need for surgery, exclusive enteral nutrition for children with Crohn's disease, or steroids (steroid-free and exclusive enteral nutrition-free clinical remission) plus CRP concentration lower than 1·5 times the upper limit of normal (ULN) of 0·5 mg/dL. In cases of missing data on CRP, ESR was used instead (concentrations <1·5 times the ULN, which was 25 mm/h). Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT02862132.

FINDINGS

Between May 19, 2016, and April 1, 2022, we enrolled 142 patients. Five children who had received only one or two infusions of their three-infusion induction before switching drugs due to COVID-19 pandemic-related reasons were excluded, leaving 137 children (64 [47%] with Crohn's disease, 64 [47%] with ulcerative colitis, and nine [7%] with IBD unclassified; 63 [46%] male and 74 [54%] female; age range of 0·7-17·6 years) in the intention-to-treat population. The median wPCDAI score in children with Crohn's disease decreased from 35 (IQR 18 to 49) at baseline to 13 (0 to 25; median of differences -14 [95% CI -33 to 0]) at week 54, and the median PUCAI score in children with ulcerative colitis decreased from 25 (IQR 15 to 50) at baseline to 5 (0 to 25) at week 54 (median of difference -10 [-30 to 0]). Improvements in disease activity were significant by week 6, with no further significant changes between visits. At week 54, 16 (25%) of 64 children with Crohn's disease and 34 (47%) of 73 with ulcerative colitis or IBD unclassified were in complete remission. 38 vedolizumab-related adverse events were recorded in 29 (21%) of 137 children, the most common being headache (n=7), myalgia (n=4), and fever (n=4), and none were serious.

INTERPRETATION

Vedolizumab maintenance seems safe and efficacious in children, with a higher efficacy in those with ulcerative colitis than in those with Crohn's disease.

FUNDING

The European Crohn's and Colitis Organisation, the European Society for Paediatric Gastroenterology Hepatology and Nutrition, and Takeda.

Comparative Whole Metagenome Analysis in Lesional and Nonlesional Scalp Areas of Patients with Psoriasis Capitis and Healthy Individuals

Psoriasis is an immune-mediated inflammatory disorder, where the majority of the patients suffer from psoriasis capitis or scalp psoriasis. Current therapeutics remain ineffective to treat scalp lesions. In this study, we present a whole-metagenome characterization of the scalp microbiome in psoriasis capitis. We investigated how changes in the homeostatic cutaneous microbiome correlate with the condition and identified metagenomic biomarkers (taxonomic, functional, virulence factors, antimicrobial resistance genes) that could partly explain its emergence. Within this study, 83 top and back scalp samples from healthy individuals and 64 lesional and nonlesional scalp samples from subjects with untreated psoriasis capitis were analyzed. Using qPCR targeting the 16S and 18S ribosomal RNA genes, we found a significant decrease in microbial load within scalp regions affected by psoriasis compared with that in their nonlesional counterparts. Metagenomic analysis revealed that psoriatic lesions displayed significant lower Cutibacterium species (including C. modestum, C. namnetense, C. granulosum, C. porci), along with an elevation in Staphylococcus aureus. A heightened relative presence of efflux pump protein-encoding genes was detected, suggesting potential antimicrobial resistance mechanisms. These mechanisms are known to specifically target human antimicrobial peptides (including cathelicidin LL-37), which are frequently encountered within psoriasis lesions. These shifts in microbial community dynamics may contribute to psoriasis disease pathogenesis.

Quorum Sensing: Not Just a Bridge Between Bacteria

The study of quorum sensing (QS) has gained critical importance, offering insights into bacterial and microorganism communication. QS, regulated by autoinducers, synchronizes collective bacterial behaviors across diverse chemical signals and target genes. This review highlights innovative approaches to regulating QS, emphasizing the potential of quorum quenching and QS inhibitors to mitigate bacterial pathogenicity. These strategies have shown promise in aquaculture and plant resistance, disrupting QS pathways to combat infections. QS also provides opportunities for developing biosensors for early disease detection and preventing biofilm formation, which is critical to overcoming antimicrobial resistance. The applications of QS extend to cancer therapy, with targeted drug delivery systems utilizing QS mechanisms. Advancements in QS regulation, such as the use of nanomaterials, hydrogels, and microplastics, provide novel methods to modulate QS systems. This review explores the latest developments in QS, recognizing its significance in controlling bacterial behavior and its broad impacts on human health and disease management. Integrating these insights into therapeutic strategies and diagnostics represents a pivotal opportunity for medical progress.

After Surgically Induced Remission, Ileal and Colonic Mucosa-Associated Microbiota Predicts Crohn's Disease Recurrence

BACKGROUND & AIMS

Investigating the tissue-associated microbiota after surgically induced remission may help to understand the mechanisms initiating intestinal inflammation in Crohn's disease.

METHODS

Patients with Crohn's disease undergoing ileocolic resection were prospectively recruited in 6 academic centers. Biopsy samples from the neoterminal ileum, colon, and rectosigmoid were obtained from colonoscopies performed after surgery. Microbial DNA was extracted for 16S rRNA gene sequencing. Microbial diversity and taxonomic differential relative abundance were analyzed. A random forest model was applied to analyze the performance of clinical and microbial features to predict recurrence. A Rutgeerts score ≥i2 was deemed as endoscopic recurrence.

RESULTS

A total of 349 postoperative colonoscopies and 944 biopsy samples from 262 patients with Crohn's disease were analyzed. Ileal inflammation accounted for most of the explained variance of the ileal and colonic mucosa-associated microbiota. Samples obtained from 97 patients who were in surgically induced remission at first postoperative colonoscopy who went on to develop endoscopic recurrence at second colonoscopy showed lower diversity and microbial deviations when compared with patients who remained in endoscopic remission. Depletion of genus Anaerostipes and increase of several genera from class Gammaproteobacteria at the 3 biopsy sites increase the risk of further recurrence. Gut microbiome was able to predict future recurrence better than clinical features.

CONCLUSIONS

Ileal and colonic mucosa-associated microbiome deviations precede development of new-onset ileal inflammation after surgically induced remission and show good predictive performance for future recurrence. These findings suggest that targeted microbial modulation is a plausible modality to prevent postoperative Crohn's disease recurrence.

Global trends in surgically based treatment of anal fistula in Crohn's disease: a bibliometric and visualization analysis

BACKGROUND

Crohn's disease (CD) is a chronic, recurrent gastrointestinal disorder characterized by a complex etiology. Among its perianal complications, anal fistulas represent a challenging comorbidity. With the increase of surgical options, a comprehensive bibliometric analysis was deemed necessary to consolidate the vast array of research in this field.

METHODS

We extracted 1608 articles spanning from 1 January 1994, to 1 May 2024, from the Web of Science Core Collection. Using VOSviewer, CiteSpace, and Scimago Graphica for visual analytics, we synthesized key trends across multiple bibliometric indicators, encompassing geographic and institutional contributions, individual authorship, journal prominence, citation metrics, and thematic prevalence.

RESULTS

From the delineated corpus, we identified publications from 325 countries and 5110 research institutions, with the US and UK at the forefront of publication volume and academic impact. The data indicated a leading role for institutions like the Cleveland Clinic and Imperial College London. "Diseases of the Colon and Rectum" emerged as a central journal due to its high publication and citation frequency. Distinctly, the analysis uncovered trending keywords, signifying the field's prioritization on surgical intervention, biologic therapy, imaging modalities, and emerging biological treatments.

CONCLUSION

Our findings elucidate a trajectory toward prominent advancements in CD fistula research. This analysis underscores the field's shift towards integrative treatment strategies, spotlighting the pressing need for comprehensive comparative studies of surgical approaches. It underscores the imperative for robust clinical trials to standardize treatments and extend care to a broader CD patient population.

Pharmacological treatment for metabolic dysfunction-associated steatotic liver disease and related disorders: Current and emerging therapeutic options

Metabolic dysfunction-associated steatotic liver disease (MASLD; formerly known as nonalcoholic fatty liver disease) is a chronic liver disease affecting over a billion individuals worldwide. MASLD can gradually develop into more severe liver pathologies, including metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, and liver malignancy. Notably, although being a global health problem, there are very limited therapeutic options against MASLD and its related diseases. While a thyroid hormone receptor agonist (resmetirom) is recently approved for MASH treatment, other efforts to control these diseases remain unsatisfactory. Given the projected rise in MASLD and MASH incidence, it is urgent to develop novel and effective therapeutic strategies against these prevalent liver diseases. In this article, the pathogenic mechanisms of MASLD and MASH, including insulin resistance, dysregulated nuclear receptor signaling, and genetic risk factors (eg, patatin-like phospholipase domain-containing 3 and hydroxysteroid 17-β dehydrogenase-13), are introduced. Various therapeutic interventions against MASH are then explored, including approved medication (resmetirom), drugs that are currently in clinical trials (eg, glucagon-like peptide 1 receptor agonist, fibroblast growth factor 21 analog, and PPAR agonist), and those failed in previous trials (eg, obeticholic acid and stearoyl-CoA desaturase 1 antagonist). Moreover, given that the role of gut microbes in MASLD is increasingly acknowledged, alterations in the gut microbiota and microbial mechanisms in MASLD development are elucidated. Therapeutic approaches that target the gut microbiota (eg, dietary intervention and probiotics) against MASLD and related diseases are further explored. With better understanding of the multifaceted pathogenic mechanisms, the development of innovative therapeutics that target the root causes of MASLD and MASH is greatly facilitated. The possibility of alleviating MASH and achieving better patient outcomes is within reach. SIGNIFICANCE STATEMENT: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide, and it can progress to more severe pathologies, including steatohepatitis, cirrhosis, and liver cancer. Better understanding of the pathogenic mechanisms of these diseases has facilitated the development of innovative therapeutic strategies. Moreover, increasing evidence has illustrated the crucial role of gut microbiota in the pathogenesis of MASLD and related diseases. It may be clinically feasible to target gut microbes to alleviate MASLD in the future.

Effectiveness and safety of thiopurines in inflammatory bowel disease patients with NUDT15 polymorphism: a real-world retrospective study

BACKGROUND

Thiopurine S-methyltransferase (TPMT) and Nudix hydrolase (NUDT15) polymorphisms predispose to thiopurine-related leukopenia.

METHODS

Retrospective evaluation of inflammatory bowel disease (IBD) patients harboring NUDT15 polymorphisms and exposed to thiopurines. We report the frequency of NUDT15 polymorphism, frequency of leukopenia, the tolerated dose of azathioprine, and the clinical efficacy of thiopurines.

RESULTS

Of 1440 patients, 118 (8.2%) had NUDT15 polymorphism. Among 51 with complete details, 46 were heterozygous (90.2%), and 5 homozygous (9.2%) for NUDT15. Twenty (43.5%) heterozygous and all homozygous patients developed leukopenia. Leukopenia was significantly more in NUDT15 heterozygous group compared to controls (43.45% vs 7.8%, Odds ratio: 9, 95% CI 3.57-22.9). The maximum tolerated dose of azathioprine was lower in NUDT15 heterozygous group (1.1 ± 0.4 mg per kg vs 1.7 ± 0.7 mg per kg, p = 0.002). The mean time to leukopenia was earlier in the heterozygous group vs controls (19 ± 56 weeks vs 70 ± 53 weeks, p-value 0.002). Seven (35%) of 20 heterozygous patients who developed leukopenia, could be maintained at a lower dose of thiopurine. Twenty-five maintained clinical remission while on thiopurines.

CONCLUSION

Thiopurines should be avoided in NUDT15 homozygous but can be used cautiously at lower dosages with frequent monitoring among heterozygous patients.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Efficacy of hemostatic powder monotherapy versus conventional endoscopic treatment for nonvariceal GI bleeding: a meta-analysis and trial sequential analysis

BACKGROUND AND AIMS

Hemostatic powder (HP) is a novel hemostasis modality for nonvariceal GI bleeding. This meta-analysis was performed to evaluate the efficacy of HP monotherapy versus conventional endoscopic treatment (CET) for nonvariceal GI bleeding.

METHODS

PubMed, EMBASE, and Cochrane Library databases were systematically searched from inception to October 16, 2023. The primary outcomes were the initial hemostatic rate and the 30-day recurrent bleeding rate. After the meta-analysis, a trial sequential analysis (TSA) was also conducted to decrease the risk of random errors and validate the result.

RESULTS

The meta-analysis included 8 studies, incorporating 653 patients in total. Given significant heterogeneity, all analyses were segregated into malignancy-related and nonmalignancy-related GI bleeding lesions. For the former, HP monotherapy significantly improved the initial hemostasis rate and 30-day recurrent bleeding rate compared with CET (relative risk [RR], 1.50; 95% confidence interval [CI], 1.28-1.75; P < .001; RR, .32; 95% CI, .12-.86; P = .02, respectively), and TSA supported the results. For nonmalignancy-related GI bleeding, HP monotherapy and CET have similar initial hemostasis and 30-day recurrent bleeding rates (RR, 1.08; 95% CI, .98-1.19; P = .11; RR, 1.15; 95% CI, .46-2.90; P = .76, respectively), but the TSA failed to confirm the results.

CONCLUSIONS

HP monotherapy surpassed CET in terms of the initial hemostasis rate and 30-day recurrent bleeding rate for patients with malignancy-related GI bleeding. However, their relative efficacy for nonmalignancy-related GI bleeding remains unresolved.

Is stapled Kono-S anastomosis a protective factor against postoperative endoscopic recurrence in Crohn disease? A single-center, retrospective cohort study

BACKGROUND

Handsewn Kono-S anastomosis is safe and associated with a reduction in postoperative recurrence (POR) in Crohn disease (CD). This study aimed to investigate the advantages of stapled Kono-S anastomosis in patients with CD who underwent intestinal anastomosis.

METHODS

Patients with CD who underwent intestinal anastomosis were reviewed via a prospectively maintained database. Patients who underwent conventional stapled side-to-side anastomosis were classified into the conventional group, and those who underwent stapled Kono-S anastomosis were classified into the Kono-S group. The primary endpoint was modified endoscopic recurrence (mER; ≥i2b). Other endpoints were endoscopic recurrence (ER; ≥i2); severe ER (i3 and i4); intra- and postoperative outcomes, including morbidity and hospital stay; and cross-sectional parameters. Multivariate logistic regression analysis was performed to assess the independent risk factors for mER.

RESULTS

Between 2020 and 2023, 199 patients (63 in the Kono-S group) were included in this study. After matching the 63 patients in each group, the overall rates of mER, ER, and severe ER were 19.0%, 24.6%, and 8.7%, respectively. The mER, ER, and severe ER rates were lower in the Kono-S group than in the conventional group (12.7% vs 25.4% [P =.07], 20.6% vs 28.6% [P =.30], and 6.3% vs 11.1% [P =.34], respectively). Multivariate analysis indicated that stapled Kono-S anastomosis (odds ratio [OR], 0.35; 95% CI, 0.12-0.98; P =.047) was an independent protective factor for mER, whereas male gender (OR, 7.75; 95% CI, 1.50-40.00; P =.01) and BMI of <18.5 kg/m2 (OR, 3.27; 95% CI, 1.11-9.67; P =.03) were independent risk factors for mER.

CONCLUSION

Stapled Kono-S anastomosis is safe for patients with CD. However, stapled Kono-S anastomosis may not be a protective factor against POR compared with conventional stapled side-to-side anastomosis.

A phase 1b clinical trial to determine the safety, tolerability and immunogenicity of simian adenovirus and poxvirus vectored vaccines against a Mycobacterium avium complex subspecies in patients with active Crohn's disease

BACKGROUND

Crohn's Disease (CD) is a chronic, debilitating condition hypothesised to be associated with Mycobacterium avium ssp paratuberculosis (MAP) infection. It is the causative pathogen of the granulomatous inflammatory enteritis in ruminants, Johne's Disease. A developing treatment approach is utilising heterologous prime-boost viral vectored vaccines. We report a Phase 1b dose-escalation trial to determine the safety, tolerability and immunogenicity of candidate recombinant ChAdOx2 and MVA vectored vaccines against MAP in patients with CD.

METHODS

28 patients with mild to moderate CD, aged 18-50, were randomly allocated into 5 groups. Group 1 and 2 were vaccinated with ChAdOx2 HAV, Groups 3 and 4 with MVA HAV and Group 5 with both vaccines in a prime-boost regimen. A 112-day follow-up period assessed safety and tolerability by recording adverse events (AEs) and serious adverse events (SAEs). Secondary objectives of immunogenicity were assessed by ELISpot (enzyme-linked immunosorbent spot) and clinical response by Crohn's Disease Activity Index (CDAI) and Simple Endoscopic Score for Crohn's Disease (SES-CD).

FINDINGS

28 participants received either a single dose of ChAdOx2 HAV (n = 12), a single dose of MVA HAV (n = 6) or a prime dose of ChAdOx2 HAV (n = 10) followed by an MVA HAV (n = 9) boost. Solicited AEs were 196 in all participants, one AE was graded as severe but resolved within 24 h. The majority of solicited AEs were graded as mild (149/196; 76%, 95% CI 69%-82%) or moderate (45/196; 23%, 95% CI 17%-29%). ELISpot responses increased in Groups 1 and 2 and significantly more after boosting with MVA HAV.

INTERPRETATION

Candidate vaccines ChAdOx2 HAV and MVA HAV were safe, well-tolerated and immunogenic in patients with active CD. A heterologous prime-boost schedule induces a T cell-mediated immune response. Further studies are required to determine the efficacy and optimal regime of the vaccines.

FUNDING

HAV Vaccines Limited funded the trial and acted as trial sponsor. The Sponsor was involved in protocol development, trial conduct, including data monitoring and analysis, and the preparation of this manuscript in line with the Medicines for Human Use (Clinical Trials) Regulations 2004 and amendments.

Early-life gut inflammation drives sex-dependent shifts in the microbiome-endocrine-brain axis

Despite recent advances in understanding the connection between the gut microbiota and the adult brain, significant knowledge gaps remain regarding how gut inflammation affects brain development. We hypothesized that gut inflammation during early life would negatively affect neurodevelopment by disrupting microbiota communication to the brain. We therefore developed a novel pediatric chemical model of inflammatory bowel disease (IBD), an incurable condition affecting millions of people worldwide. IBD is characterized by chronic intestinal inflammation, and is associated with comorbid symptoms such as anxiety, depression and cognitive impairment. Notably, 25% of patients with IBD are diagnosed during childhood, and the effects of chronic inflammation during this critical developmental period remain poorly understood. This study investigated the effects of early-life gut inflammation induced by DSS (dextran sulfate sodium) on a range of microbiota, endocrine, and behavioral outcomes, focusing on sex-specific impacts. DSS-treated mice exhibited increased intestinal inflammation and altered microbiota membership, which correlated with changes in microbiota-derived circulating metabolites. The majority of behavioral measures were unaffected, with the exception of impaired mate-seeking behaviors in DSS-treated males. DSS-treated males also showed significantly smaller seminal vesicles, lower circulating androgens, and decreased intestinal hormone-activating enzyme activity compared to vehicle controls. In the brain, DSS treatment led to chronic, sex-specific alterations in microglial morphology. These results suggest that early-life gut inflammation causes changes in gut microbiota composition, affecting short-chain fatty acid (SCFA) producers and glucuronidase (GUS) activity, correlating with altered SCFA and androgen levels. The findings highlight the developmental sensitivity to inflammation-induced changes in endocrine signalling and emphasize the long-lasting physiological and microbiome changes associated with juvenile IBD.

Hormonal birth control is associated with altered gut microbiota β-diversity in physically active females across the menstrual cycle: a pilot trial

Understanding changes to gut microbiota composition in response to hormonal birth control (HBC) may provide insight into the microbial mechanisms underlying the metabolic effects of HBC, for example, altered short-chain fatty acid (SCFA) production. Athletes' unique physiological demands may interact with these microbial mechanisms in distinct ways; however, there is limited research on HBC and gut microbiota diversity and composition across different menstrual cycle phases in physically active females. A pilot cohort of physically active females using HBC (oral contraceptives, hormone-based intrauterine devices, or arm implants) and a control group not using HBC (n = 12 per group; 22 ± 2 yr, 24 ± 4 kg/m2 vs. 22 ± 4 yr, 23 ± 4 kg/m2; Ps ≥ 0.496) provided fecal samples alongside self-reported menstrual phase and circulating sex hormones. α-diversity (microbial richness and evenness) was assessed using the Shannon index whereas β-diversity (microbial composition differences) was analyzed using PERMANOVA based on Bray-Curtis dissimilarity. Circulating estrogen and luteinizing hormone increased from early (days 1-5) to mid-cycle (days 12-17) in both groups (time effect Ps ≤ 0.01), with greater changes in Control (Ps ≤ 0.046) than HBC (Ps ≥ 0.231). Although no menstrual phase effect was observed on either diversity measure (Ps ≥ 0.473), β-diversity differed between Control and HBC groups (P = 0.015), reflecting distinct gut microbiota profiles irrespective of menstrual phase. Seven taxa linked to SCFA production were less abundant in the HBC group (unadjusted Ps ≤ 0.046), though significance was lost after adjusting for multiple comparisons. These findings suggest that in physically active females, hormonal contraception influences gut microbial composition, which may have downstream effects on metabolism and performance.NEW & NOTEWORTHY This study is the first to investigate interactions between hormonal contraception and the gut microbiota in a cohort of physically active young females across the menstrual cycle. Our findings suggest that hormonal contraception may influence gut microbiota composition, potentially through a reduced relative abundance of short-chain fatty acid-producing taxa. Experimental studies are needed to confirm these associations and explore their potential implications for metabolism, health, and performance.

A guide to germ-free and gnotobiotic mouse technology to study health and disease

The intestinal microbiota has major influence on human physiology and modulates health and disease. Complex host-microbe interactions regulate various homeostatic processes, including metabolism and immune function, while disturbances in microbiota composition (dysbiosis) are associated with a plethora of human diseases and are believed to modulate disease initiation, progression and therapy response. The vast complexity of the human microbiota and its metabolic output represents a great challenge in unraveling the molecular basis of host-microbe interactions in specific physiological contexts. To increase our understanding of these interactions, functional microbiota research using animal models in a reductionistic setting are essential. In the dynamic landscape of gut microbiota research, the use of germ-free and gnotobiotic mouse technology, in which causal disease-driving mechanisms can be dissected, represents a pivotal investigative tool for functional microbiota research in health and disease, in which causal disease-driving mechanisms can be dissected. A better understanding of the health-modulating functions of the microbiota opens perspectives for improved therapies in many diseases. In this review, we discuss practical considerations for the design and execution of germ-free and gnotobiotic experiments, including considerations around germ-free rederivation and housing conditions, route and timing of microbial administration, and dosing protocols. This comprehensive overview aims to provide researchers with valuable insights for improved experimental design in the field of functional microbiota research.

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Approach to anaemia in gastrointestinal disease: A position paper by the ESPGHAN Gastroenterology Committee

Anaemia is a frequent consequence of many gastrointestinal (GI) diseases in children and it can even be the initial presenting symptom of underlying chronic GI disease. The definition of anaemia is age and gender-dependent and it can be classified based on pathophysiology, red cell morphology, and clinical presentation. Although nutritional deficiencies, including GI malabsorption of nutrients and GI bleeding, play a major role, other pathophysiologic mechanisms seen in chronic GI diseases, whether inflammatory (e.g., inflammatory bowel disease) or not (e.g., coeliac disease and dysmotility), are causing anaemia. Drugs, such as proton pump inhibitors, mesalamine, methotrexate and sulfasalazine, are also a potential cause of anaemia. Not uncommonly, due to a combination of factors, such as iron deficiency and a chronic inflammatory state, the underlying pathophysiology may be difficult to decipher and a broad diagnostic work-up is required. The goal of treatment is correction of anaemia by supplementation of iron and vitamins. The first therapeutic step is to treat the underlying cause of anaemia including bleeding control, restoration of intestinal integrity and reduction of inflammatory burden. The route of iron and vitamin supplementation is guided by the severity of anaemia.

Vitamin D and its analogs in immune system regulation

Vitamin D was discovered as the cure for nutritional rickets, a disease of bone growth arising from inadequate intestinal calcium absorption, and for much of the 20th century, it was studied for its critical role in calcium homeostasis. However, we now recognize that the vitamin D receptor and vitamin D metabolic enzymes are expressed in numerous tissues unrelated to calcium homeostasis. Notably, vitamin D signaling can induce cellular differentiation and cell cycle arrest. Moreover, the vitamin D receptor and the enzyme CYP27B1, which produces the hormonal form of vitamin D, 1,25-dihydroxyvitamin D (1,25D), are expressed throughout the immune system. In addition, CYP27B1 expression in immune cells is regulated by physiological inputs independent of those controlling its expression in calcium homeostatic tissues. These observations have driven the development of 1,25D-like secosteroidal analogs and nonsecosteroidal analogs to separate the effects of vitamin D on cell differentiation and function from its calcemic activities. Notably, some of these analogs have had considerable success in the clinic in the treatment of inflammatory and immune-related disorders. In this review, we described in detail the mechanisms of vitamin D signaling and the physiological signals controlling 1,25D synthesis and catabolism, with a focus on the immune system. We also surveyed the effects of 1,25D and its analogs on the regulation of immune system function and their implications for human immune-related disorders. Finally, we described the potential of vitamin D analogs as anticancer therapeutics, in particular, their use as adjuncts to cancer immunotherapy. SIGNIFICANCE STATEMENT: Vitamin D signaling is active in both the innate and adaptive arms of the immune system. Numerous vitamin D analogs, developed primarily to minimize the dose-limiting hypercalcemia of the active form of vitamin D, have been used widely in preclinical and clinical studies of immune system regulation. This review presents a description of the mechanisms of action of vitamin D signaling, an overview of analog development, and an in-depth discussion of the immunoregulatory roles of vitamin D analogs.

Unraveling the immunological landscape and gut microbiome in sepsis: a comprehensive approach to diagnosis and prognosis

BACKGROUND

Comprehensive and in-depth research on the immunophenotype of septic patients remains limited, and effective biomarkers for the diagnosis and treatment of sepsis are urgently needed in clinical practice.

METHODS

Blood samples from 31 septic patients in the Intensive Care Unit (ICU), 25 non-septic ICU patients, and 18 healthy controls were analyzed using flow cytometry for deep immunophenotyping. Metagenomic sequencing was performed in 41 fecal samples, including 13 septic patients, 10 non-septic ICU patients, and 18 healthy controls. Immunophenotype shifts were evaluated using differential expression sliding window analysis, and random forest models were developed for sepsis diagnosis or prognosis prediction.

FINDINGS

Septic patients exhibited decreased proportions of natural killer (NK) cells and plasmacytoid dendritic cells (pDCs) in CD45+ leukocytes compared with non-septic ICU patients and healthy controls. These changes statistically mediated the association of Bacteroides salyersiae with sepsis, suggesting a potential underlying mechanism. A combined diagnostic model incorporating B.salyersia, NK cells in CD45+ leukocytes, and C-reactive protein (CRP) demonstrated high accuracy in distinguishing sepsis from non-sepsis (area under the receiver operating characteristic curve, AUC = 0.950, 95% CI: 0.811-1.000). Immunophenotyping and disease severity analysis identified an Acute Physiology and Chronic Health Evaluation (APACHE) II score threshold of 21, effectively distinguishing mild (n = 19) from severe (n = 12) sepsis. A prognostic model based on the proportion of total lymphocytes, Helper T (Th) 17 cells, CD4+ effector memory T (TEM) cells, and Th1 cells in CD45+ leukocytes achieved robust outcome prediction (AUC = 0.906, 95% CI: 0.732-1.000), with further accuracy improvement when combined with clinical scores (AUC = 0.938, 95% CI: 0.796-1.000).

INTERPRETATION

NK cell subsets within innate immunity exhibit significant diagnostic value for sepsis, particularly when combined with B. salyersiae and CRP. In addition, T cell phenotypes within adaptive immunity are correlated with sepsis severity and may serve as reliable prognostic markers.

FUNDING

This project was supported by the National Key R&D Program of China (2023YFC2307600, 2021YFA1301000), Shanghai Municipal Science and Technology Major Project (2023SHZDZX02, 2017SHZDZX01), Shanghai Municipal Technology Standards Project (23DZ2202600).

Nonfistulizing Perianal Crohn's Disease

Perianal Crohn's disease (CD) includes a wide range of nonfistulizing sequela, including fissures and ulcers, skin tags, anal stricture, and anal cancer. Symptoms related to perianal manifestations of CD are often disabling and have a significant impact on patients' quality of life. They include pain, drainage, bleeding, difficulty with hygiene and may cause secondary difficulties with sexual and defecatory dysfunction. The care of patients with perianal CD requires a thoughtful approach, including detailed history taking, physical examination, and often multidisciplinary care teams to maximize quality of life and ameliorate symptoms.

Italian validation of the IBD-disk tool for the assessment of disability in inflammatory bowel diseases: A cross-sectional multicenter study

INTRODUCTION

IBD-Disk is a simple, easy-to-use, and self-administered analogue visual tool for assessing disability in patients with Inflammatory Bowel Disease (IBD). However, it has not yet been validated in Italian. This study aims to validate IBD-Disk in an Italian cross-sectional multicentre study.

METHODS

This study was conducted in eight IBD centres from February 2023 to October 2023. After forward-backwards translation of IBD-Disk into Italian, patients consecutively completed IBD-Disk (at baseline and after 7 days), IBD-Disability Index (IBD-DI) and IBDQ-32 for quality of life.

RESULTS

We enrolled 767 patients (377, 49,2% CD; 390, 50,8% UC) who completed the IBD-Disk [median score of 30 (IQR=11-52)]. Internal consistency was excellent, with Cronbach's α of 0.92 (95%CI=0.92-0.92). To evaluate the validity, the IBD-Disk was compared with the IBD-DI and IBDQ-32, revealing a significant positive correlation of 0.70 (95% CI=0.66-0.73; p<0.001) and 0.83 (r=0.83, 95% CI=0.80-0.85; p<0.001), respectively. The intraclass correlation coefficient (ICC) was 0.84 (95% CI=0.82-0.86) for test-retest. Female gender, clinically active IBD and the presence of extraintestinal manifestations led to higher IBD-Disk scores.

CONCLUSION

This study validated the IBD-Disk in a large cohort of Italian IBD patients, demonstrating that it is a valid, reliable and responsive tool for quantifying IBD-related disability. This validation facilitates its integration into the daily clinical management of IBD patients.

Clinical effectiveness and safety of ustekinumab in youth with refractory inflammatory bowel disease: A retrospective cohort study

BACKGROUND

Inflammatory bowel disease (IBD) incidence and prevalence has been increasing worldwide. Limited data exists on the effectiveness of ustekinumab (UST) in children. We aimed to describe the effectiveness and safety of UST in pediatric patients with IBD.

METHODS

A single-center retrospective study was conducted between January 2017 and February 2022. The study included patients ≤16 years of age who were treated with UST and followed up for ≥1 year. Clinical remission was defined as a score of the Pediatric Crohn's Disease (CD) and Pediatric Ulcerative Colitis (UC) Activity Indices ≤10 at week 52.

RESULTS

Thirteen patients who had failed anti-tumor necrosis factor-α (anti-TNFα) therapy were included, eight (61.5%) with CD and five (38.5%) with UC. The median age was 13 years (interquartile range [IQR]: 11.5 to 14). UST treatment was initiated at a median age of 3 years (IQR: 2.3 to 7) after diagnosis. Ten patients (76.9%) achieved clinical remission. There were no statistically significant differences in characteristics between patients who achieved and did not achieve clinical remission. Biochemical remission (BioR) was achieved in six patients (46.2%). Body mass index (BMI) significantly improved, C-reactive protein (CRP) significantly decreased, and the need for corticosteroids significantly decreased in the remission group. Endoscopy conducted post-treatment in seven patients confirmed remission in six patients. Adverse events included two cases of infection and one of headache.

CONCLUSIONS

UST was effective as a secondary biologic therapy for the induction and maintenance of remission in patients with anti-TNFα refractory IBD. At one year, 84% of patients remained on UST with no severe adverse reactions reported.

Bowel preparation for small bowel capsule endoscopy: standard regimen with 2 L polyethylene glycol versus 1 L polyethylene glycol plus ascorbate

BACKGROUND/AIMS

Optimization of bowel preparation for small bowel capsule endoscopy (SBCE) is debated. Guidelines recommend 2 L of iso-osmolar polyethylene glycol (PEG) to improve SBCE visibility. We compared the efficacy of the standard 2 L PEG solution with a 1 L PEG plus ascorbate (PEG-ASC) preparation, which has already been established for large-bowel preparation.

METHODS

Between October 2020 and February 2022, patients undergoing SBCE were assigned to receive 2 L PEG or 1 L PEG-ASC bowel preparation on an even- or odd-day basis. Bowel cleanliness was evaluated using the small bowel mucosal visibility scoring system (SBMVSS).

RESULTS

Following propensity score matching using a random forest method, two comparable populations of patients treated with 2 L PEG (n=74, male 41%, 53±17 years) and 1 L PEG-ASC (n=74, male 42%, 55±21 years) were obtained from the original cohort of 221 consecutive SBCE patients. Our results showed a trend towards more frequent adequate mucosal visibility with 1 L PEG-ASC compared to 2 L PEG (small bowel mucosal visibility ≥2 in all three small bowel tertiles, p=0.07), as per the SBMVSS score. No significant differences were observed in the diagnostic yield (p=1.00), visibility score=9 (p=0.85), SBCE completeness (p=0.33), or adequate mucosal visibility in each tertile (p=0.61, p=0.74, and p=0.70 for the first, second, and third tertiles, respectively).

CONCLUSIONS

Our study suggests the non-inferiority of the 1 L PEG-ASC solution over the standard 2 L PEG for SBCE preparation.

Improving the Real-Time Classification of Disease Severity in Ulcerative Colitis: Artificial Intelligence as the Trigger for a Second Opinion

INTRODUCTION

Endoscopic classification of ulcerative colitis (UC) shows high interobserver variation. Previous research demonstrated that artificial intelligence (AI) can match the accuracy of central reading in scoring still images. We now extend this assessment to longer colon segments and integrate AI into clinical workflows, evaluating its use for real-time, video-based classification of disease severity, and as a support system for physicians.

METHODS

We trained a convolutional neural network with the Mayo Endoscopic Subscores (MESs) of 2,561 images and 53 videos from 645 patients. The model differentiated scorable from unscorable endoscopy sections through open-set recognition. Validation involved 140 video clips from 44 patients with UC. Six inflammatory bowel disease (IBD) experts and 16 nonexperts rated these videos, with expert scores as the gold standard. We assessed the model's performance and the value as a supporting system. Last, the model underwent an alpha test on a real-world patient as a real-time endoscopic support.

RESULTS

The model achieved an accuracy of 82%, with no significant differences between the experts and the AI. When used as a supporting system, it improved non-IBD experts' performance by 12% and disagreed with the primary physician in 20%-39% of cases. During the alpha test, it was successfully integrated into clinical practice, accurately distinguishing between MES 0 and MES 1, consistent with endoscopists' assessments.

DISCUSSION

Our innovative AI model shows significant potential for enhancing the accuracy of UC severity classification and improving the proficiency of non-IBD experts. It is designed for clinical use and has proven feasible in real-world testing.

Efficacy and Safety of Etrasimod in Patients With Moderately to Severely Active Ulcerative Colitis Stratified by Baseline Modified Mayo Score: A Post Hoc Analysis From the Phase 3 ELEVATE UC Clinical Program

BACKGROUND

Etrasimod is an oral, once daily, selective sphingosine 1-phosphate (S1P)1,4,5 receptor modulator for the treatment of moderately to severely active ulcerative colitis (UC). This post hoc analysis of the ELEVATE UC clinical program describes etrasimod efficacy and safety by patients' baseline disease activity.

METHODS

Predefined efficacy endpoints were assessed at week 12 in patients with moderately (modified Mayo score [MMS] 5-7) or severely (MMS 8-9) active UC using pooled data from ELEVATE UC 52 and ELEVATE UC 12. Descriptive statistics with 95% CI were calculated.

RESULTS

Of 743 patients analyzed, 525 (70.7%) had moderately active and 218 (29.3%) had severely active disease at baseline. At week 12, patients treated with etrasimod showed larger mean percentage reductions (95% CI) in MMS vs placebo, regardless of baseline disease activity (-48.4% [-52.3, -44.4] vs -27.0% [-32.2, -21.7] for moderately active disease and -46.4% [-51.2, -41.5] vs -29.8% [-37.2, -22.3] for severely active disease). Similar proportions of patients with moderately or severely active disease treated with etrasimod vs placebo achieved clinical response at week 12 (61.3% vs 39.8% for moderately active disease and 64.5% vs 30.3% for severely active disease). Incidence of treatment-emergent adverse events were similar between disease activity subgroups.

CONCLUSIONS

At week 12, etrasimod showed greater reductions in disease activity and higher rates of clinical response vs placebo in patients with either moderately or severely active disease at baseline. The safety profile of etrasimod was consistent with the overall trial population and was unimpacted by baseline disease activity.

CLINICALTRIALS.GOV

NCT03945188; NCT03996369.

Postbiotic potential of Lactococcus lactis CNCM I-5388 in alleviating visceral pain in female rat through GABA production: The innovative concept of the "active-GAD bag"

Irritable bowel syndrome (IBS) is a multifactorial disorder of the gut-brain axis, characterized by visceral hypersensitivity (VH). Psychobiotics, through GABA synthesis, are good candidates to alleviate gastrointestinal discomfort. Here, we analyzed the GABA-producer Lactococcus lactis CNCM I-5388 as an active-enzyme postbiotic to relieve VH mediated by psychological stress. L. lactis CNCM I-5388 was inactivated by ethanol while maintaining its glutamate decarboxylase (GAD) activity. This EtOH-treated nonviable form was given daily orally for 1, 5, or 10 days to female Wistar rats in comparison with viable L. lactis CNCM I-5388 or vehicle. Visceral sensitivity was measured by electromyography before and after partial restraint stress (PRS). GABA was quantified in the stomach collected from rats and in the gastric compartment of TIM-1 human gut model in fed state. A daily treatment for 5 and 10 days by L. lactis CNCM I-5388 both in its viable and nonviable forms counteracted VH promoted by PRS. However, only viable L. lactis CNCM I-5388 tended to reduce VH after a single administration. After 5-day treatment, only under PRS conditions, the production of GABA within the stomach was enhanced in rats treated with viable or nonviable L. lactis CNCM I-5388. This increase was confirmed by using the TIM-1 human gut model. We found that a postbiotic with an active-GAD enzyme of L. lactis CNCM I-5388, similarly to its viable psychobiotic form, exerts anti-VH properties in an IBS-like rat model. These effects are associated with GABA production in the stomach where the low pH promotes GAD activity.

Assessment and management for latent tuberculosis before advanced therapies for immune-mediated inflammatory diseases: A comprehensive review

Tuberculosis (TB), caused by Mycobacterium tuberculosis , is the most significant infectious cause of mortality across the globe. While TB disease can prey on immunocompetent individuals, it is more likely to occur in immunocompromised individuals. Immune-mediated inflammatory diseases (IMIDs) are a group of diseases (rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis, psoriasis, hidradenitis suppurativa, autoimmune blistering diseases, and others) where there may be a need for systemic immunosuppression to control the disease manifestations, treat symptoms and improve long term outcomes. Immunosuppression may predispose them to active TB either from recent infection or reactivation of Latent TB (LTB). The major determinants of reactivation include the type of therapy (highest risk with TNF inhibitors and JAK inhibitors) and the underlying TB endemicity. The strategy to avoid TB reactivation includes the detection of LTB using tests that detect immunoreactivity to TB antigens (interferon-gamma release assays or tuberculin skin test) and treating LTB before or with initiation of IMID therapies. Available diagnostic tests have deficiencies in diagnostic sensitivity to detect LTB and even worse capability in predicting reactivation of TB. In addition to immunological tests, more stringent testing strategy utilizing one or many LTB equivalents may point towards subclinical TB. LTB equivalents include clinical (past history of TB, recent exposure to TB) and radiological criteria (use of chest roentgenogram, computed tomography, or, sometimes positron emission tomography - computed tomography). The present review summarizes the risk factors for TB reactivation in patients initiated on advanced therapies, geographically appropriate strategies for LTB testing, and treatment of LTB.

Micro-fragmented adipose tissue-An innovative therapeutic approach: A narrative review

Subcutaneous adipose tissue provides distinct advantages as a source of mesenchymal stem cells due to its accessibility and the ease of isolating stem cells. Human adipose stem cells, located in the stromal-vascular fraction, can be harvested using mechanical methods to produce microfragmented adipose tissue (MFAT). Local injections of MFAT have shown potential in promoting natural tissue regeneration. This review introduces the concept of MFAT, highlights its clinical applications, and explores its potential in regenerative medicine, offering insights into its role as an innovative therapeutic approach.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.

Azathioprine and 6-mercaptopurine for maintenance of remission in ulcerative colitis

BACKGROUND

Maintenance of remission is essential in inflammatory bowel disease (IBD) in terms of disease course and long-term prognosis. The thiopurines azathioprine and 6-mercaptopurine have longstanding merit in ulcerative colitis, but more therapeutic options have been developed. This review is an update and extension of a review last published in 2016.

OBJECTIVES

To assess the effectiveness and safety of azathioprine and 6-mercaptopurine in monotherapy or combined therapy regimens compared to placebo or active controls for the maintenance of remission in ulcerative colitis.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (until May 2023), ClinicalTrials.gov (until May 2023), Embase (until August 2022), MEDLINE (until May 2023), and WHO ICTRP (until May 2023). We checked reference lists of the included studies and, if needed, contacted the authors to request more data or information.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of at least 24 weeks' duration comparing azathioprine or 6-mercaptopurine with placebo or any other medication, or comparing different treatment modalities of azathioprine or 6-mercaptopurine, in persons of any age with quiescent ulcerative colitis were eligible. We only considered studies with mixed IBD populations or with a preceding induction period if separate results on participants with ulcerative colitis in remission were available or could be calculated. The primary outcome was failure to maintain clinical or endoscopic remission (relapse). Secondary outcomes included change in disease activity, quality of life, hospitalization, need for surgery, days off work, adverse events, and withdrawal due to adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data using standard forms, resolved any disagreements by consensus, and assessed study quality using the Cochrane risk of bias tool (RoB 2). We conducted separate analyses by type of control, calculated pooled risk ratios (RRs) or risk differences (RDs) using the fixed-effect model unless heterogeneity was likely, and assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies in the review, including 468 adult participants with ulcerative colitis. The risk of bias across these was low for most outcomes, but we considered some outcomes to have some concerns or high risk of bias due to insufficient information on concealment of allocation and outcome measurement. Based on five placebo-controlled studies, azathioprine or 6-mercaptopurine may reduce the risk of failing to maintain remission. In the thiopurine group, 45% (64/143) of participants failed to maintain remission compared to 67% (96/143) of participants receiving placebo (RR 0.66, 95% confidence interval (CI) 0.54 to 0.82; 5 studies, 286 participants; low-certainty evidence). Three studies reported withdrawals due to adverse events. Among participants on azathioprine, 4% (3/80) withdrew due to adverse events compared to 0% (0/82) of placebo participants (RD 0.04, 95% CI -0.02 to 0.09; 3 studies, 162 participants; low-certainty evidence). The evidence is of low certainty when comparing 6-mercaptopurine to 5-aminosalicylate. Based on one three-armed trial, 27% (3/11) of 6-mercaptopurine participants failed to maintain remission compared to 100% (2/2) of 5-aminosalicylate participants (RR 0.35, 95% CI 0.13 to 0.97; 1 study, 13 participants; low-certainty evidence). This trial also involved an induction phase; we only included the results for participants in remission. The single trial comparing 6-mercaptopurine to 5-aminosalicylate did not report separate data on adverse events and withdrawals due to adverse events for the subgroup with successful induction of remission, so we could not analyze these outcomes for this comparison.

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that azathioprine or 6-mercaptopurine therapy may be more effective than placebo for the maintenance of remission in ulcerative colitis. More research is needed to evaluate the value of therapeutic drug monitoring and the effects of various treatment modalities on long-term safety.

Recent Advances in the Etiology, Diagnosis, and Treatment of Marmoset Wasting Syndrome

One of the primary challenges encountered in managing captive callitrichids is a group of gastrointestinal disorders that are collectively known as Marmoset Wasting Syndrome (MWS). Unfortunately, MWS is still not well understood. It is suggested that MWS has a multifactorial etiology; stress, infection, malnutrition, malabsorption, and enteritis or colitis may be associated with MWS. Usually, animals demonstrate more than one of the following clinical signs: progressive weight loss, alopecia, chronic diarrhea, muscle atrophy, hypoproteinemia, and anemia. Recent advances in diagnostics, mostly noninvasive fecal and urine tests, yielded promising results. Good treatment results have been achieved with the administration of glucocorticoids and tranexamic acid, although no cure has been found yet. Probiotics and gel diets also demonstrated to be potentially useful. However, once animals are affected by MWS, treatments eventually become ineffective, and animals will inevitably require euthanasia to prevent further suffering. Preventative measures should be aimed at reducing stress and optimizing housing, husbandry, and diets. More research is warranted to elucidate the pathogenesis of MWS in captive callitrichids and to refine diagnostic and treatment methods.

Efficacy and safety of two-step acupuncture therapy for symptom relief in adults with mild to moderate ulcerative colitis: rationale and design of the TSA-UC randomised controlled trial

INTRODUCTION

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterised by episodes of symptoms including rectal bleeding, increased stool frequency and abdominal pain, impacting quality of life significantly. Conventional treatments often come with potential side effects and may not be sufficient. Acupuncture is increasingly recognised for its potential benefits in UC. This study aims to assess the efficacy and safety of acupuncture for symptom relief in mild to moderate UC.

METHODS AND ANALYSIS

This single-centre, parallel-arm, randomised, sham-controlled, the two-step acupuncture (TSA)-UC trial, will involve 64 adults with mild to moderate UC, randomly assigned in a 1:1 ratio to either the acupuncture or sham acupuncture group. Participants will receive 20 sessions of two-step acupuncture or sham acupuncture therapy over 8 weeks. Blinding will be applied to participants, outcome assessors and statisticians. The primary outcome measure is the change in Patient-Reported Outcome 2 (PRO2) from baseline at week 8. Secondary outcomes include changes from baseline in the following scales: PRO2 at other time points, weekly average Numeric Rating Scale (NRS) for bowel urgency, weekly average NRS for abdominal pain (both associated and not associated with bowel movement), the 32-item Inflammatory Bowel Disease Questionnaire, Work Productivity and Activity Impairment Questionnaire-IBD, Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale. The Patient Global Impression of Change will also be assessed. Long-term effects of acupuncture will be explored. Adverse events and additional treatments will be monitored throughout the study. The modified intention-to-treat population including participants who complete baseline assessments and receive at least one treatment session will be analysed.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Ethics Committee of Guang'anmen Hospital, China Academy of Chinese Medical Sciences (2024-190-KY). The results will be published in a peer-reviewed medical journal.

TRIAL REGISTRATION NUMBER

NCT06615765.

Preoperative Optimization for Elective Surgery in Crohn's Disease: A Narrative Review

Crohn's disease is a chronic inflammatory bowel disease and, despite an increase in the available drug treatments, many patients will still require surgery at some point in their disease course. Stricturing and penetrating phenotypes of Crohn's disease are less likely to respond to our current medical treatment and, therefore, surgical intervention may be required. This is most commonly elective, planned surgery, thereby affording the opportunity to optimize medications, nutritional and inflammatory status, and steroid use. Poor nutritional status and previous surgery increase the risk of postoperative complications. Preoperative optimization has three main goals: reduction of postoperative complications; reduction of reoperation rates; and reduction of postoperative recurrence rates. A literature search was completed using PubMed, Embase, and Ovid using the search term "preoperative optimization in Crohn's disease", and it included both adult and pediatric studies, excluding those for perianal Crohn's disease. In this narrative review, we examine the role of nutritional intervention, medical optimization pre and postoperatively, and the role of personalized prehabilitation in the reduction of postoperative complications. We demonstrate that these may all yield better postoperative outcomes for patients with Crohn's disease undergoing elective surgery, although the evidence is somewhat limited and there is a requirement for more prospective randomized controlled trials to implement their role into standard practice or guidelines.

Impact of Ligilactobacillus salivarius Li01 on benzo[a]pyrene-induced colitis, based on host-microbiome interactions in Mongolian gerbils

Background

Probiotics supplementations have been regarded as an effective strategy for colitis treatment. However, the effect of Ligilactobacillus salivarius Li01 on benzo[a]pyrene (BaP)-induced colitis in Mongolian gerbils remains unclear. In this study, we leverage a BaP-induced model of colitis that exhibits significant remission following Ligilactobacillus salivarius Li01 intervention, to conduct an animal experiment that integrates histopathological assessment, inflammatory cytokines, 16S rRNA sequencing, targeted metabolomic profiling to investigate the relationship between Ligilactobacillus salivarius Li01, gut microbiota, and colitis.

Results

We demonstrated that the improvements in colon histopathological assessment and inflammatory cytokines by Ligilactobacillus salivarius Li01 supplementation are accompanied by alterations in gut microbiota structure marked by increased abundance of strains with probiotic potential belonging to Bifidobacterium and Eubacterium_coprostanoligenes. Targeted metabolomic profiling analysis showed that Ligilactobacillus salivarius Li01 supplementation increases the concentration of acetic, propionic, butyric, and valeric acid. Correlation analysis showed that the alteration in the indicators associated with colitis is closely correlated to the changed microbial taxa and short-chain fatty acids (SCFAs).

Conclusion

These data highlighted that Ligilactobacillus salivarius Li01 supplementation ameliorated the BaP-induced colitis, probably via modulating the structure of gut microbiota and promoting the production of SCFAs. Our findings provide preliminary evidence for a possible therapeutic strategy for the treatment of colitis based on host-microbiome interactions.

The Role of Calprotectin in the Diagnosis and Treatment of Inflammatory Bowel Disease

The management of inflammatory bowel disease (IBD), which is characterized by immunodeficiency, has attracted increasing attention, highlighting the necessity for more precise and streamlined diagnostic approaches in clinics. Calprotectin, an immune cell-derived protein with inherent anti-inflammatory and antimicrobial properties, plays a pivotal role in immune regulation and intestinal homeostasis. Its expression levels are intricately linked to IBD activity, enabling differentiation between inflammatory and non-inflammatory states while predicting recurrence risks. As a non-invasive biomarker, fecal calprotectin (FC) and serum calprotectin (SC) analysis offers high reproducibility and clinical utility, facilitating both IBD diagnosis and real-time disease monitoring. Beyond its diagnostic specificity in distinguishing IBD from other gastrointestinal disorders, calprotectin also emerges as a promising therapeutic target, due to its dual role in modulating inflammatory pathways and interacting with the gut microbiota. With collaborative advancements in standardized detection protocols and innovative research methodologies, it is anticipated that calprotectin-based strategies will be integrated into mainstream clinical practice for IBD.

Clinical observation of probiotics combined with mesalazine and Yiyi Baitouweng Decoction retention enema in treating mild-to-moderate ulcerative colitis

Objective

The purpose of this article was to unravel the clinical efficacy of probiotics combined with mesalazine and Yiyi Baitouweng Decoction retention enema in the treatment of mild-to-moderate ulcerative colitis (UC).

Methods

Eighty-six mild-to-moderate UC patients were selected as study subjects and randomized into the control group (treated with mesalazine enteric-coated tablets [Salofalk]) and the observation group (treated with mesalazine enteric-coated tablets, Bifidobacterium Tetravaccine Tablets, and Yiyi Baitouweng Decoction retention enema). The clinical efficacy, colonoscopy score, serum levels of inflammatory factors, and the incidence of adverse reactions were compared.

Results

The clinical efficacy of patients in the observation group was better in contrast to the control group. After 8 weeks of treatment, the colonoscopy score, and levels of TNF-α, IFN-γ, CRP, and ESR were lower, while IL-10 levels were higher in patients of both groups than those before treatment; lower colonoscopy score and levels of TNF-α, IFN-γ, CRP, and ESR and higher IL-10 levels were observed in the observation group versus the control group.

Conclusion

Probiotics combined with mesalazine and Yiyi Baitouweng Decoction retention enema have remarkable clinical effects in treating mild-to-moderate UC.

Progressing advanced therapies for inflammatory bowel disease: Current status including dual biologic therapy and discontinuation of biologics

INTRODUCTION

Advanced therapies (ADT) that encompass biological agents and small molecules have been approved for the treatment of inflammatory bowel disease (IBD), broadening the spectrum of available treatment options. Nevertheless, a substantial proportion of patients fail to achieve satisfactory responses, necessitating surgical intervention. Treatment objectives have evolved beyond clinical remission, reduction of inflammation, and mucosal healing, shifting focus toward enhancing the quality of life, acknowledging the profound impact of IBD on physical and mental well-being.

AREA COVERED

This comprehensive review describes the current landscape of ADT for IBD, including dual biologic therapy (DBT), which involves the combination of two biologics or a single biologic with a small-molecule compound, as well as considerations surrounding the discontinuation of biologics.

EXPERT OPINION

ADT is the standard treatment for moderate to severe IBD, while DBT appears promising for specific subsets of patients, including those with refractory disease or extraintestinal manifestations. However, these approaches may increase the risk of adverse effects, including malignancy. To optimize individualized treatment strategies in patients with refractory IBD, further trials are needed to refine ADT's predictive value, establish DBT's safety and indications, define biologic discontinuation criteria, and evaluate emerging biomarkers, artificial intelligence, and bowel ultrasound in patient management.

Very long-term remission in behcet's disease following withdrawal of anti-TNF treatment exceeds relapses: a reappraisal of an outcome study

BACKGROUND

Introduction of anti-TNF treatment has greatly improved prognosis of Behcet's disease (BD). Withdrawal of anti-TNF treatment in chronic inflammatory arthritis or bowel disease has been associated with sustained remission in subsets of patients. Herein, we examined the probability of very long-term quiescence after withdrawal of TNF inhibitors in BD.

METHODS

Retrospective longitudinal outcome single-center study focusing on BD patients who discontinued successful ant-TNF treatment since 2001. Endpoint was their proportion with sustained clinical remission for 5 years after withdrawal.

RESULTS

Thirty-three patients with severe BD refractory to non-biologic treatment (mean age 47.5 ± 11.5 years, 55% men) achieved TNF inhibitor-induced remission for a median of 2 years (IQR [1-2.6]). TNF inhibitors had been given for sight-threatening disease (28/33, 82%), for mucocutaneous (3/33), central nervous system (2/33) and gastrointestinal involvement (1/33). After withdrawal, BD remained in remission in 15/33 patients for 6.6 to 20.6 years (mean 13.5 ± 3.8). Conversely, 18/33 patients relapsed after a median of 9.5 months [IQR 8-12, range 4-32] following withdrawal but retreatment with TNF inhibitors was effective in 13/18. Of them, 9/13 discontinued for a second time and achieved again the study's endpoint, remaining in remission for median of 7.4 years ([IQR 5-9.3, range 5-15 years). Study's end-point was met by 24/33 patients (73%); 17and 7 patients remain any-drug free or on azathioprine only, respectively.

CONCLUSION

Discontinuation of successful anti-TNF treatment is frequently associated with durable very long-term remission in severe BD. Additional studies are needed since relapses not responding to anti-TNF re-treatment may occur.

Artificial intelligence to revolutionize IBD clinical trials: a comprehensive review

Integrating artificial intelligence (AI) into clinical trials for inflammatory bowel disease (IBD) has potential to be transformative to the field. This article explores how AI-driven technologies, including machine learning (ML), natural language processing, and predictive analytics, have the potential to enhance important aspects of IBD trials-from patient recruitment and trial design to data analysis and personalized treatment strategies. As AI advances, it has potential to improve long-standing challenges in trial efficiency, accuracy, and personalization with the goal of accelerating the discovery of novel therapies and improve outcomes for people living with IBD. AI can streamline multiple trial phases, from target identification and patient recruitment to data analysis and monitoring. By integrating multi-omics data, electronic health records, and imaging repositories, AI can uncover molecular targets and personalize trial strategies, ultimately expediting drug development. However, the adoption of AI in IBD clinical trials encounters significant challenges. These include technical barriers in data integration, ethical concerns regarding patient privacy, and regulatory issues related to AI validation standards. Additionally, AI models risk producing biased outcomes if training datasets lack diversity, potentially impacting underrepresented populations in clinical trials. Addressing these limitations requires standardized data formats, interdisciplinary collaboration, and robust ethical frameworks to ensure inclusivity and accuracy. Continued partnerships among clinicians, researchers, data scientists, and regulators will be essential to establish transparent, patient-centered AI frameworks. By overcoming these obstacles, AI has the potential to enhance the efficiency, equity, and efficacy of IBD clinical trials, ultimately benefiting patient care.

Small Molecules in the Treatment of Acute Severe Ulcerative Colitis: A Review of Current Evidence

Ulcerative colitis (UC) is an inflammatory bowel disease in which one-quarter of patients are at risk of developing a severe form of the disease known as acute severe UC (ASUC). This condition exposes patients to serious complications, including toxic megacolon, surgical intervention, and even death. The current therapeutic strategy relies on time-dependent, multi-step algorithms that integrate systemic corticosteroids, calcineurin inhibitors, and biologic agents (specifically infliximab) as medical therapy aimed at avoiding colectomy. Despite this approach, a significant proportion of patients fail to respond to either corticosteroids or infliximab and may require alternative therapeutic options if there is no urgent surgical necessity. These alternatives include other biologics or emerging small molecules, although the evidence supporting these treatments remains extremely low, even considering their well-documented and promising efficacy and safety in moderate-to-severe UC. Conversely, it is necessary to investigate whether infliximab can be effectively replaced or surpassed by other approved biological agents and small molecules as first-line therapy after steroid resistance. This review aims to summarise the available evidence on small molecules, specifically Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators.

Fluorescent Nanocomposite Materials with Synergistic Effects for Enhanced Fenelidone Delivery in Diabetic Nephropathy Treatment

In this study, we designed and synthesized a novel thio-purine analog, compound 1, which exhibits significant fluorescence properties due to its extended conjugated system, heteroatom incorporation (O, S, N), and rigid three-dimensional molecular framework, enabling its use as a fluorescence probe for real-time drug tracking and release monitoring. To enhance the solubility, biocompatibility, and therapeutic efficacy of compound 1, we synthesized a copper(II)-based coordination polymer (CP1) via hydrothermal methods, featuring a three-dimensional framework formed by 1,4-ttb and auxiliary ligand 4,4'-bpdc, as confirmed by comprehensive characterization techniques. Leveraging the synergistic therapeutic effects of compound 1 and fenelidone, we developed a composite drug delivery system, mPEG-PSU@CP1@1@fenelidone, which combines an amphiphilic mPEG-PSU shell with a CP1 core co-encapsulating both drugs. Notably, the fluorescence properties of compound 1 allow for real-time monitoring of drug release, as its fluorescence is quenched when encapsulated in CP1 and restored upon release. This system optimizes controlled drug release while enhancing the synergistic effects of compound 1 and fenelidone in reducing inflammation and renal fibrosis, as demonstrated in diabetic nephropathy (DN) model mice. Overall, the composite system integrates real-time fluorescence monitoring with improved therapeutic efficacy, offering a promising strategy for diabetic nephropathy treatment.

Effectiveness of biologics for endoscopic healing in patients with isolated proximal small bowel Crohn's disease

BACKGROUND

Endoscopic healing (EH) is a key therapeutic target in Crohn's disease (CD). Proximal small bowel (SB) lesions in patients with CD are associated with a significant risk of strictures and bowel resection. Assessing SB in patients with CD is necessary because of its significant therapeutic implications. The advent of biologic therapies, including infliximab, ustekinumab, and vedolizumab, has significantly altered CD treatment. However, data on the efficacy of biologics in achieving EH, specifically in the proximal SB of patients with CD, remain limited.

AIM

To assess the effectiveness of biologics for EH in patients with jejunal and/or proximal ileal CD.

METHODS

Between 2017 and 2023, we retrospectively included 110 consecutive patients with isolated proximal SB CD, identified through baseline balloon-assisted enteroscopy. These patients completed 1-year of treatment with infliximab, ustekinumab, or vedolizumab, and underwent a second balloon-assisted enteroscopy at 1 year. Complete EH was defined as a modified Simple Endoscopic Score for CD (SES-CD) of < 3, while EH of the jejunum and proximal ileum was defined as a segmental modified SES-CD of 0.

RESULTS

In total, 64 patients were treated with infliximab, 28 with ustekinumab, and 18 with vedolizumab. The complete EH rate at 1 year was 20.9% (23/110), with 29.6% (19/64) for infliximab, 10.7% (3/28) for ustekinumab, and 5.5% (1/18) for vedolizumab. The median modified SES-CD significantly decreased compared to baseline [5 (2-8) vs 8 (6-9), P < 0.001]. The jejunal and proximal ileal EH rates at 1 year were 30.8% (12/39) and 15.5% (16/103), respectively. Multiple logistic regression analysis showed that stricturing or penetrating disease [odds ratio (OR) = 0.261, 95%CI: 0.087-0.778, P = 0.016], prior exposure to biologics (OR = 0.080, 95%CI: 0.010-0.674, P = 0.020), and moderate-to-severe endoscopic disease (OR = 0.277, 95%CI: 0.093-0.829, P = 0.022) were associated with a lower likelihood of achieving EH at 1 year.

CONCLUSION

Only 20.9% of patients with isolated proximal SB CD achieved complete EH after 1 year of biologic therapy.

Differences in diversity and composition of mucosa-associated colonic microbiota in colorectal cancer and non-colorectal cancer in Indonesia

BACKGROUND

Colorectal cancer is the third most common malignancy and the fourth leading cause of cancer-related deaths worldwide. Several studies have shown an association between gut microbiota and colorectal cancer. Gut microbiota is unique and can be influenced by geographic factors and habits. This study aimed to determine the diversity and composition of colonic mucosal microbiota in patients with and without colorectal cancer.

AIM

To determine the diversity and composition of colonic mucosal microbiota in patients with and without colorectal cancer in Indonesia.

METHODS

This case-control study included 59 subjects (35 colorectal cancer patients and 24 non-colorectal cancer patients indicated for colonoscopy at Dr. Cipto Mangunkusumo Gastrointestinal Endoscopy Center and Fatmawati Hospital. Microbiota examination was performed using 16S rRNA sequencing. Bioinformatics analysis was performed using the wf-metagenomics pipeline from EPI2Me-Labs (Oxford Nanopore Technologies platform).

RESULTS

Patients with colorectal cancer had a higher median index value on the Shannon index (3.28 vs 2.82, P > 0.05) and a lower value on the Simpson index (0.050 vs 0.060, P > 0.05). Significant differences in beta diversity were observed at the genus (P = 0.002) and species levels (P = 0.001). Firmicutes, Proteobacteria, Bacteroidetes, and Fusobacteria were the dominant phyla. The genera Bacteroides, Campylobacter, Peptostreptococcus, and Parvimonas were found more frequently in colorectal cancer, while Faecalibacterium, Haemophilus, and Phocaeicola were more frequently found in non-colorectal cancer. The relative abundance of Fusobacterium nucleatum, Bacteroides fragilis, Enterococcus faecalis, Campylobacter hominis, and Enterococcus faecalis species was significantly elevated in patients with colorectal cancer. Meanwhile, Faecalibacterium prausnitzii, Faecalibacterium duncaniae, and Prevotella copri were more commonly found in non-colorectal cancer.

CONCLUSION

Patients with colorectal cancer exhibit distinct differences in the composition and diversity of their colonic mucosal microbiota compared to those with non-colorectal cancer. This study was reviewed and approved by the Ethics Committee of Faculty of Medicine, Universitas Indonesia (No. KET-1517/UN2.F1/ETIK/PPM.00.02/2023).

HDAC inhibitors and IBD: Charting new approaches in disease management

Inflammatory bowel disease (IBD) represents a group of chronic inflammatory disorders of the gastrointestinal tract. Despite substantial advances in our understanding of IBD pathogenesis, the currently available therapeutic options remain limited in their efficacy and often come with significant side effects. Therefore, there is an urgent need to explore novel approaches for the management of IBD. One promising avenue of investigation revolves around the use of histone deacetylase (HDAC) inhibitors, which have garnered considerable attention for their potential in modulating gene expression and curbing inflammatory responses. This review emphasizes the pressing need for innovative drugs in the treatment of IBD, and drawing from a wealth of preclinical studies and clinical trials, we underscore the multifaceted roles and the therapeutic effects of HDAC inhibitors in IBD models and patients. This review aims to contribute significantly to the understanding of HDAC inhibitors' importance and prospects in the management of IBD, ultimately paving the way for improved therapeutic strategies in this challenging clinical landscape.

Probiotic Bacillus cereus regulates metabolic disorders and activates the cholic acid-FXR axis to alleviate DSS-induced colitis

Inflammatory bowel disease is characterized by severe imbalance of intestinal flora and metabolic disorders. Recent studies have demonstrated that probiotics can effectively alleviate inflammatory bowel disease by restoring the intestinal flora structure and modulating the immune response. However, the role of probiotics in regulating intestinal metabolism disorders is still unclear. This study explores the role of probiotic B. cereus in alleviating DSS-induced colitis. The findings indicated probiotic B. cereus treatment mitigated tissue damage and apoptosis during inflammation. Metabolome and transcriptome analysis revealed B. cereus activated the cholic acid-FXR axis by increasing cholic acid levels, which promoted the gene expression level of NF-κB inhibitor α, reduced the IL-1β, IL-6, IL-18 and TNF-α concentrations. Furthermore, it effectively mitigated the DSS-induced disruption of bile acid metabolism, arginine metabolism, and linoleic acid metabolism. This study explores the effect and mechanisms of probiotic B. cereus on alleviating DSS-induced colitis. It aims to provide a theoretical basis for microbial therapy in inflammatory bowel disease. SIGNIFICANCE: This study used metabolome and transcriptome to reveal the roles and mechanisms, which probiotic Bacillus cereus modulates metabolic disorders and alleviate DSS-induced colitis. We identified the cholic acid-FXR axis as an important target for alleviating DSS-induced colitis. These findings provide new insights into microbial treatment strategies for IBD.