Anti-diarrhoeal activity of methanol extract of Santalum album L. in mice and gastrointestinal effect on the contraction of isolated jejunum in rats

Ethnopharmacologically important highly subsidized Indian medicinal plants: Systematic review on their traditional uses, phytochemistry, pharmacology, quality control, conservation status and future prospective

ETHNOPHARMACOLOGICAL RELEVANCE

India has an extensive reservoir of traditional wisdom and a diverse range of medicinal plants that enrich its heritage. Plants have actively been used for healthcare practices globally since the time immemorial. Medicinal uses of plants have been well recognized in India, evident from plant species documented in different traditional medicinal systems such as Ayurveda (1400-1800 species), Siddha (500-900 species), Unani (400-700 species), Homeopathy (about 372 species), and Sowa-Rigpa (about 250 species), etc. AIM OF THE STUDY: The primary purpose of this review is to provide systematic updated information on thirteen medicinal plants prioritized by the Indian government (providing75 % subsidy on cultivation cost) based on the availability and market demand of these plants. Updated information regarding the traditional uses, phytochemistry, pharmacology, quality control, and conservation status of these plants will help in understanding their pharmacological and commercial importance. This will also help in developing new strategies for their conservation.

MATERIAL AND METHODS

Online databases such as SciFinder, Web of Science, Pubmed, and Google Scholar were used to collect the electronically available literature on targeted thirteen plants. Also, different Indian government official websites such as AYUSH (https://www.ayush.gov.in); NMPB (National Medicinal Plants Board) (https://nmpb.nic.in); e.charak (https://echarak.in) were used for collecting information related to the amount of subsidy, trade and price related information of these plants.

RESULTS

To promote medicinal plant cultivation, the Indian government provides subsidies for cultivating some traditionally important medicinal plants. These plants are divided into three categories according to the subsidy provided to farmers, i.e., 30%, 50%, and 75% of the cost of cultivation. Thirteen medicinal plants which are provided 75% subsidy are Aconitum ferox Wall., Aconitum heterophyllum Wall., Aquilaria agallocha Roxb., Berberis aristata DC., Commiphora wightii (Arn.) Bhandari, Nardostachys jatamansi (D.Don) DC., Oroxylum indicum (L.) Benth. ex Kurz, Picrorhiza kurroa Royle ex Benth., Podophyllum hexandrum Royle, Pterocarpus santalinus L.f., Santalum Album L., Saussurea costus (Falc.) Lipsch., and Swertia chirayita (Roxb.) H.Karst. The literature survey reveals the enormous traditional medicinal importance, wide geographical distribution, diverse range of natural products, and broad spectrum of pharmacological activities of these plants.

CONCLUSION

A comprehensive literature survey revealed that although remarkable progress has been made in isolation, bioactivity evaluation, quality assessment, and conservation, there is still a lot of scope for further scientific interventions. Scientific validation of traditionally claimed medicinal potential is lacking for various bioactivities. Some of the bioactivities are performed just on extracts/fractions, so there is a need for proper phytochemical studies to identify active constituents responsible for the specific bioactivity. Further, quality assessment methods using both targeted and non-targeted tools are required to evaluate the quality of these highly-priced medicinal plants and their adulterants. Ultimately, to encourage the cultivation of these endangered medicinal plant species, it is imperative to implement proper legislation and employ in-situ and ex-situ conservation tools.

A multimodality therapeutic application on Toxoplasma gondii encephalitis utilizing Spiramycin and 'de novo' Ferula asafetida in immunodeficient mice

This study investigated a 'de Novo' medicinal herb, Ferula asafetida (FA), against toxoplasma encephalitis either alone or combined with spiramycin (SP). Female Swiss-Webster mice (n = 72) were divided into three batches. Batch-I received no DMS to serve as an immunocompetent control, batch-II was immune-suppressed with the DMS (0.25 mg/g/day) for 14 days pre-infection, whilst batch-III was immune-suppressed with the DMS on the same day of infection. All experimental mice were inoculated with Toxoplasma gondii ME49 cysts (n = 75). Each batch was split into four subgroups: Mono-SP, mono-FA, combined drug (SP + FA), or neither. Therapies were administered on day zero of infection in batches (I and II) and 35 days post-infection in batch (III). Treatments lasted for 14 days, and mice were sacrificed 60 days post-infection. Histopathological changes, cysts load, and CD4 and CD8 T-cells were counted in brain tissues. The cyst-load count in mice receiving SP + FA was significantly (p < .0001) the least compared to the mono treatments in all protocols. Interestingly, the combined therapy demolished the T-cell subsets to zero in immunocompetent and immunocompromised infected mice. In conclusion, F. asafetida might be a powerfully natural, safe vehicle of SP in the digestive system and/or across the brain-blood barrier to control toxoplasmosis even through immunodeficient conditions.

Relationship among Chinese herb polysaccharide (CHP), gut microbiota, and chronic diarrhea and impact of CHP on chronic diarrhea

Chronic diarrhea, including diarrhea-predominant irritable bowel syndrome (IBS-D), osmotic diarrhea, bile acid diarrhea, and antibiotic-associated diarrhea, is a common problem which is highly associated with disorders of the gut microbiota composition such as small intestinal bacterial overgrowth (SIBO) and so on. A growing number of studies have supported the view that Chinese herbal formula alleviates the symptoms of diarrhea by modulating the fecal microbiota. Chinese herbal polysaccharides (CHPs) are natural polymers composed of monosaccharides that are widely found in Chinese herbs and function as important active ingredients. Commensal gut microbiota has an extensive capacity to utilize CHPs and play a vital role in degrading polysaccharides into short-chain fatty acids (SCFAs). Many CHPs, as prebiotics, have an antidiarrheal role to promote the growth of beneficial bacteria and inhibit the colonization of pathogenic bacteria. This review systematically summarizes the relationship among gut microbiota, chronic diarrhea, and CHPs as well as recent progress on the impacts of CHPs on the gut microbiota and recent advances on the possible role of CHPs in chronic diarrhea.

Ethanol Extract of Glycyrrhiza uralensis Fisch: Antidiarrheal Activity in Mice and Contraction Effect in Isolated Rabbit Jejunum

OBJECTIVE

To evaluate the antidiarrheal effect of ethanol extract of Glycyrrhiza uralensis Fisch root (GFR) in vivo and jejunal contraction in vitro.

METHODS

In vivo, 50 mice were divided into negative control, positive control (verapamil), low-, medium- and high-dose GFR (250, 500, 1,000 mg/kg) groups by a random number table, 10 mice in each group. The antidiarrheal activity was evaluated in castor oil-induced diarrhea mice model by evacuation index (EI). In vitro, the effects of GFR (0.01, 0.03, 0.1, 0.3, 1, 3, and 10 g/L) on the spontaneous contraction of isolated smooth muscle of rabbit jejunum and contraction of pretreated by Acetylcholine (ACh, 10 µmol/L) and KCl (60 mmol/L) were observed for 200 s. In addition, CaCl₂ was accumulated to further study its mechanism after pretreating jejunal smooth muscle with GFR (1 and 3 g/L) or verapamil (0.03 and 0.1 µmol/L) in a Ca²⁺-free-high-K⁺ solution containing ethylene diamine tetraacetic acid (EDTA).

RESULTS

GFR (500 and 1,000 mg/kg) significantly reduced EI in castor oil-induced diarrhea model mice (P<0.01). Meanwhile, GFR (0.01, 0.03, 0.1, 0.3, 1, 3, and 10 g/L) inhibited the spontaneous contraction of rabbit jejunum (P<0.05 or P<0.01). Contraction of jejunums samples pretreated by ACh and KCl with 50% effective concentration (EC₅₀) values was 1.05 (0.71-1.24), 0.34 (0.29-0.41) and 0.15 (0.11-0.20) g/L, respectively. In addition, GFR moved the concentration-effect curve of CaCl₂ down to the right, showing a similar effect to verapamil.

CONCLUSIONS

GFR can effectively against diarrhea and inhibit intestinal contraction, and these antidiarrheal effects may be based on blocking L-type Ca²⁺ channels and muscarinic receptors.

Oceanapia magna Sponge Presents Dual Effect on the Gastrointestinal Motility of Rodents: In Vitro and In Vivo Assays

Oceanapia magna Santos-Neto, Nascimento, Cavalcanti and Pinheiro sponges are distributed across tropical worldwide seas. Some studies of marine products have shown interesting activities in smooth muscle models. Hence, we assessed the effect of the ethanolic extract of Oceanapia magna. (OC-EtOH) on acute toxicity and gastrointestinal motility (in vitro and in vivo) in rodent models. On guinea pig ileum, OC-EtOH induced a concentration dependent contraction on basal tonus, which was not inhibited by atropine, but in the presence of pyrilamine or verapamil, the effect was antagonized. Contrastingly, on KCl- or histamine-induced contractions, OC-EtOH presented a transient contraction followed by a concentration-dependent relaxation. Moreover, OC-EtOH presented a relaxant profile on cumulative curves to CaCl₂ and tonic contraction induced by S-(-)-BayK8644, through Cav blockade. The acute toxicity assay showed that OC-EtOH (2,000 mg/kg, p.o.) did not present any sign of toxicity in female mice. Additionally, OC-EtOH presented antidiarrheal effect in mice, increased the intestinal normal transit and reduced the castor oil-induced intestinal transit. Thus, OC-EtOH presented a dual effect on guinea pig ileum promoting contraction through activation of H₁ and Ca_V, and relaxation through Ca_V blockade, besides the effect on upper gastrointestinal transit in mice, showing a potential medicinal use of this sponge in intestinal diseases such as diarrhea.

Aster tataricus alleviates constipation by antagonizing the binding of acetylcholine to muscarinic receptor and inhibiting Ca2+ influx

BACKGROUND

The dried root and rhizome of Aster tataricus (RA), is a traditional Chinese medicine has been used for more than 2000 years with the function of antitussive, expectorant and antiasthmatic. Ancient books and modern pharmacological researches demonstrated that RA may have the function of moistening intestines and relieving constipation, but there was a lack of systematic evidence. The aim of this study was to comprehensively evaluate the efficacy and possible mechanisms of ethanol extract of Aster tataricus (ATE) in treating constipation from in vivo to in vitro.

METHODS

In vivo, the ATE was studied in loperamide-induced constipation of mice. In vitro, different concentrations of ATE was tested separately or cumulatively on spontaneous and agonists-induced contractions of isolated rat duodenum strips.

RESULTS

In vivo, at doses of 0.16, 0.8 g/mL, ATE showed significantly promotion of the small intestinal charcoal transit, decrease of the amount of remnant fecal, and increase of the content of fecal water in colon. In addition, ATE could effectively relieve colonic pathological damage caused by loperamide as well. In vitro, with the cumulative concentration increase of ATE from 0.8 to 6.4 mg/mL, it could significantly decrease the contraction caused by KCl or Ach, and gradually restore to near base tension value.Meanwhile, it could also partially but significantly inhibit the contractions induced by Ach and CaCl2 on rat duodenum in a concentration related manner.

CONCLUSIONS

Taking all these findings together, it could be speculated that ATE may attenuate constipation mainly through antagonizing the binding of acetylcholine to muscarinic receptor, inhibiting Ca2+ influx and anti-inflammation.

Effect of the leaves aqueous extract of Jodina rhombifolia (Hook. & Arn.) Reissek (Santalaceae) on intestinal function and its acute toxicity

ETHNOPHARMACOLOGICAL RELEVANCE

In Argentine traditional medicine it is recorded the use of Jodina rhombifolia (Hook. & Arn.) Reissek (Santalaceae) leaves for treating various affections that compromise the intestinal normal functioning.

AIM OF THE STUDY

The aim of this study was to assess the effect of J. rhombifolia leaves lyophilized aqueous extract on the intestinal function by means of in vivo and ex vivo experimental assays for determinate the antidiarrheal and antispasmodic capacity. Furthermore, was to evaluate its acute toxicity potential by oral and intraperitoneal administration of extract.

MATERIALS AND METHODS

The in vivo assays were conducted by the experimental techniques of intestinal transit in mice, intestinal fluid accumulation in rats and Castor oil-induced diarrhea in mice. In the ex vivo assays, isolated rat duodenum and ileum segments were used for to evaluate the antispasmodic activity through contractile concentration-response curves induced by Carbachol and CaCl₂. The acute toxicity of the extract was also investigated by oral and intraperitoneal administration.

RESULTS

The extract intraperitoneal administration at the doses 125, 250 and 500 mg/kg, caused a marked reduction in the normal intestinal transit and in the number of diarrheal episodes in a dose-dependent manner. However, the extract did not produce significant changes in the intestinal fluid accumulation with any of the tested dose. The extract demonstrated a non-competitive inhibitory effect on the contractions of intestinal smooth muscle experimentally provoked by the spasmogenic agents Carbachol and CaCl2 in a dose-dependent manner (IC₅₀ = 10.57 ± 1.38 and 6.29 ± 1.54 mg extract/ml Tyrode solution in the isolated organ bath, respectively). ANOVA indicated a significative effect of treatment (p < 0.001).

CONCLUSIONS

The scientific evidence achieved based in the used experimental models allows us to indicate that J. rhombifolia leaves lyophilized aqueous extract manifest an antispasmodic activity on intestinal smooth muscle without observation of apparent toxicity symptoms.

Antibacterial, Mutagenic Properties and Chemical Characterisation of Sugar Bush (Protea caffra Meisn.): A South African Native Shrub Species

Protea caffra is used as a diarrhoeal remedy in South African herbal medicine, however, its pharmacological properties remain largely unknown. In the present study, extracts from different Protea caffra organs were screened against drug-sensitive and -resistant diarrhoeagenic pathogens using the microdilution assay (minimum inhibitory concentration, MIC). Twig extracts (70% methanol, MeOH) of the plant were purified and the resultant fractions screened for antibacterial properties (MIC). The chemical profiles of the fractions were determined by Gas Chromatography-Mass Spectrometry (GC-MS), while ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) was used to quantify the phenolic acids in the plant. The mutagenic properties of bioactive extracts were assessed using the Ames test. The extracts demonstrated weak-moderate antibacterial properties (MIC: 0.3–0.6 mg/mL). A cold ethyl acetate fraction of MeOH twig extract exhibited significant antibacterial properties (MIC = 0.078 mg/mL) against Enterococcus faecalis. The presence of antibacterial compounds (1-adamantane carboxylic acid, heptacosanol, levoglucosan, nonadecanol) in the plant was putatively confirmed based on GC-MS analysis. Furthermore, UHPLC-MS/MS analysis revealed varying concentrations of phenolic acids (0.08–374.55 µg/g DW). Based on the Ames test, the extracts were non-mutagenic thereby suggesting their safety. To a certain degree, the current study supports the traditional use of Protea caffra to manage diarrhoea among local communities in South Africa.

Antidiarrheal activity of methanol extract of Sophora tonkinensis in mice and spasmolytic effect on smooth muscle contraction of isolated jejunum in rabbits

Context: In China, the herb Sophora tonkinensis Gagnep. (Fabaceae, ST) (Committee of National Pharmacopeia. 2015) exhibits anti-inflammatory, antitumor, and antiviral effects. However, to date, there have been few studies on its gastrointestinal effect. Objective: The gastrointestinal effect of the methanol extract of ST rhizome (STR) was evaluated. Materials and methods: Study was conducted from February to December 2018. In vivo, antidiarrheal activity of STR (125, 250 and 500 mg/kg; orally) in castor oil-induced diarrheal mice was studied. In vitro, the effects of STR (0.01-10 mg/mL) on the isolated tissue preparations of rabbit jejunum were also investigated, the rabbit jejunum stripes were pre-contracted with Ach (10^-5M), K⁺ (60 mM) and tested in the presence of STR, the possible spasmolytic effect was analyzed in the pretreatment of the jejunum preparations with STR or verapamil in Ca²⁺-free high-K⁺ (60 mM) solution containing EDTA. Results: STR (125, 250 and 500 mg/kg) exhibited antidiarrheal activity. STR (0.01-10 mg/mL) completely relaxed spontaneously contracting, Ach (10^-5M) and high K⁺ (60 mM) induced contracted jejunum with an EC₅₀ value of 0.66 (0.49-0.96), 0.39 (0.28-0.44) and 0.17 (0.10-0.21), similar to verapamil. Concentration-response curves of CaCl₂ could be significantly moved to the right and down in the presence of STR (0.3, 1 mg/mL). Discussion and conclusions: Results suggest the presence of antidiarrheal activity and spasmolytic effects of STR, possibly mediated through Ca²⁺ channel blocking activity, providing the pharmacological basis for its traditional uses in gastrointestinal disorders.

Hydroxy-α-sanshool isolated from Zanthoxylum bungeanum attenuates learning and memory impairments in scopolamine-treated mice

Learning and memory impairments are common symptoms of dementia in neurodegenerative disorders.

Antidiarrheal activity of a novel sulfated polysaccharide from the red seaweed Gracilaria cervicornis

ETHNOPHARMACOLOGICAL RELEVANCE

The use of marine seaweeds as a source of natural compounds with medicinal purposes is increasing in Western countries in the last decades, becoming an important alternative in the traditional medicine of many developing countries, where diarrhea still remains a severe public health problem, with high rates of mortality and morbidity. Sulfated polysaccharides (PLS) extracted from red seaweeds can exhibit therapeutic effects for the treatment of gastrointestinal disorders. Thus, the pharmacological properties of the PLS from Gracilaria cervicornis, an endemic seaweed found in the Brazilian northeast coast, was evaluated as an alternative natural medication for diarrhea.

AIM OF THE STUDY

This study aimed to evaluate the antidiarrheal activity of sulfated polysaccharides (PLS) extracted from the red seaweed G. cervicornis in Swiss mice pre-treated with castor oil or cholera toxin.

MATERIALS AND METHODS

The seaweed Gracilaria cervicornis was collected at Flecheiras beach (city of Trairí, State of Ceará, Brazil) and the PLS was obtained through enzymatic extraction and administered in mice (25-30 g) before diarrhea induction with castor oil or cholera toxin. For the evaluation of the total number of fecal output and diarrheal feces, the animals were placed in cages lined with adsorbent material. The evaluation of intestinal fluid accumulation (enteropooling) on castor oil-induced diarrhea in mice occurred by dissecting the small intestine and measuring its volume. The determination of Na⁺/K⁺-ATPase activity was measured in the small intestine supernatants by colorimetry, using commercial biochemistry kits. The gastrointestinal motility was evaluated utilizing an activated charcoal as a food tracer. The intestinal fluid secretion and chloride ion concentration were evaluated in intestinal closed loops in mice with cholera toxin-induced secretory diarrhea. The binding ability of PLS with GM1 and/or cholera toxin was evaluated by an Enzyme-Linked Immunosorbent Assay (ELISA).

RESULTS

The G. cervicornis PLS showed antidiarrheal effects in both acute and secretory diarrhea, reducing the total number of fecal output, diarrheic stools, intestinal fluid accumulation, and increasing small intestine Na⁺/K⁺-ATPase activity on castor oil-induced diarrhea. However, the PLS did not affect gastrointestinal motility, indicating that this compound has a different action mechanism than loperamide. In secretory diarrhea, the PLS decreased intestinal fluid secretion and small intestine chloride excretion, binding with GM1 and/or cholera toxin and blocking their attachment to the enterocyte cell surface.

CONCLUSIONS

In conclusion, PLS has a significant antidiarrheal effect in acute and secretory diarrhea. Further investigation is needed towards its use as a natural medicine to treat diarrhea.

The Anti-diarrheal Activity of the Non-toxic Dihuang Powder in Mice

Dihuang powder (DHP) has been used in the traditional Chinese medicine for the treatment of diarrhea in some regions of China. But up to now, the anti-diarrheal activity of DHP haven't been performed with modern pharmacological technology. This study aims to investigate the quality control, the potential toxicity and anti-diarrheal activity of Dihuang powder in mice. High performance liquid chromatography (HPLC) and thin layer chromatography (TLC) were used to detect five active compounds in DHP for quality control, and the acute toxicity and sub-acute toxicity for 28-day oral administration of DHP were then evaluated. The anti-diarrheal activity was investigated using mouse model. Results showed that the levels of quercetin and berberine in DHP were 0.054 and 0.632 mg/g, respectively, and atractylodin, matrine, and patehouli aleohal were also detected in DHP. At the given doses, DHP was safe in terms of acute and sub-acute toxicity. Meanwhile, DHP exhibited strong anti-diarrheal effects as well as decreased gastrointestinal motility and the secretions induced by Sennae and castor oil in a dose-dependent manner. It could decrease the content of IL-1β, IL-6, and TNF-α in the small intestine, and improve the histopathological changes of small intestine and large intestine induced by Sennae. The antinociceptive and anti-inflammatory activities in vivo also were presented. Based on all of the results, we thought that DHP has anti-diarrheal activity, and could be used to treat diarrhea as well as alleviate the pain and inflammation induced by diarrhea. This study provides a theoretical basis for the clinical use of DHP and may assist in the development of new drugs for the treatment of diarrhea. The mechanism of the anti-diarrheal activity should be investigated in the future.

Using the "target constituent removal combined with bioactivity assay" strategy to investigate the optimum arecoline content in charred areca nut

Charred areca nut (CAN) is used to treat dyspepsia and abdominal distension in children. However, reports revealed that arecoline, the most important active constituent of CAN, possesses potential toxicities. This study was designed to investigate the optimum arecoline content in CAN, using the "target constituent removal combined with bioactivity assay" strategy. Based on PTLC method, we prepared CAN lacking all arecoline (WAC-100R) and a series of different ratios of arecoline-removed CAN samples (WAC-Rx). MTT and acute toxicity assays indicated that decreasing content by 50% decreased CAN toxicity significantly. Animal results revealed arecoline contents over 50% could guarantee the beneficial effects of CAN on gastrointestinal tract. Additionally, decreasing arecoline content in CAN by 50% decreased its pro-apoptotic effects significantly. Furthermore, decreasing 50% arecoline content in CAN down-regulated the expressions of Cleaved-Caspase-3, c-jun, c-fos, COX-2, PGE2, and IL-1α. Thus, our results revealed that CAN with 50% arecoline content (WAC-50R) has similar beneficial effects on the gastrointestinal tract to CAN, whereas its toxicity was decreased significantly. Collectively, our study suggested that the strategy of "target constituent removal combined with bioactivity assay" is a promising method to identify the optimum arecoline content in CAN, which is approximately 0.12%.

Role of gastrointestinal motility inhibition and antioxidant properties of myrtle berries (Myrtus communis L.) juice in diarrhea treatment

INTRODUCTION

The myrtle (Myrtus communis) belongs to the Myrtaceae family; it is one of the central plants as part of the list of medicinal plants in the Tunisian Pharmacopoeia. Myrtle berry was used for its astringent, tonic, and antiseptic properties, to treat diarrhea, hemorrhoids, and gastrointestinal injury.

METHODS

Adult male wistar rats were used to evaluate the normal gastro-intestinal transit and gastric emptying as well as castor oil-induced diarrhea, enteropooling tests, and small intestine oxidative stress. The effect of myrtle berries juice (MBJ) (5 and 10ml/kg, bw. p.o.) was after compared to the loperamide and clonidine effects.

RESULTS

MBJ significantly and dose-dependently inhibited the intestinal motility and gastric emptying. We also found that MBJ administration induced a significant dose-dependent protection against diarrhea and intestinal fluid accumulation. Castor oil-induced intestinal hypersecretion was accompanied by an oxidative stress status in the intestine, which was attenuated by MBJ administration.

CONCLUSION

We suggest that MBJ had a potent protective effects against castor oil-induced diarrhea in part due, to its antioxidant and antisecretory properties.

Therapeutic significance and pharmacological activities of antidiarrheal medicinal plants mention in Ayurveda: A review

Diarrhea is a serious problem affecting 3-5 billion people per year around the world, especially children of below 5 years. 70% of the world population uses traditional and indigenous medicine for their primary health care. The facts of these indigenous remedies are passed verbally and sometimes as documents. Since ancient time, Ayurveda is the main system of healing in South East Asian countries. Indian literature from ayurvedic texts and other books claim the potency of several plants in the treatment of diarrhea. As the global prospective of ayurvedic medicine is increasing, interest regarding the scientific basis of their action is parallely increasing. Researchers are doing experiments to establish the relation between the claimed action and observed pharmacological activities. In the present article, an attempt was made to compile the scientific basis of medicinal plants used to cure diarrhea in Ayurveda. Literature was collected via electronic search (PubMed, ScienceDirect, Medline, and Google Scholar) from published articles that reports antidiarrheal activity of plants that were mentioned in Ayurveda classics. A total of 109 plant species belonging to 58 families were reported for their antidiarrheal activity. Several Indian medicinal plants have demonstrated promising antidiarrheal effects, but the studies on the antidiarrheal potentials of these plants are not taken beyond proof of concept stage. It is hoped that the article would stimulate future clinical studies because of the paucity of knowledge in this area.