Inflammatory bowel disease: long-term therapeutic challenges

The preventive effects of native probiotic and postbiotic on inflammation and oxidative stress in DSS-induced colitis with normal diet: Which of these agents may offer greater advantages?

Background

Maintaining a well-rounded and healthy diet is essential to promote the well-being and optimal performance of the body, especially for those suffering from Inflammatory Bowel Disease (IBD). The objective of this study is to examine whether probiotics and postbiotics can modulate oxidative stress and inflammation, and to evaluate the properties of these compounds.

Methods

A total of eighty eight strains of Lactobacillus and Bifidobacterium were assessed for their antioxidant activities. C57BL/6 mice were allocated into four groups: normal diet (ND) + PBS, ND + DSS, ND + DSS + 10⁹ cfu/ml of probiotics, and ND + DSS + 10⁹ cfu/ml of postbiotics. Biochemical antioxidant assays, along with colitis indices, were evaluated. The ELISA assay was conducted to measure oxidant/antioxidant properties and cytokines. Additionally, the genes enrolled in NF-kB and Nrf2 signaling pathways was analyzed.

Results

In comparison to the groups exposed to DSS alone, mice that received our native agents in addition to DSS demonstrated an improvement in the negative effects induced by DSS on DAI and pathological scores, as well as on colon length and body weight. The levels of cytokines and antioxidant markers have also been normalized following the administration of our native agents, along with molecular markers. It should also be noted that our native postbiotic was able to develop more pronounced and significant anti-inflammatory and antioxidant effects in comparison to the probiotic strains.

Conclusion

In this study, our native postbiotic has demonstrated a more pronounced ability to exhibit antioxidant and anti-inflammatory effects. This finding is particularly important for individuals with impaired immune function, for whom the use of live bacteria could be risky. Therefore, the utilization of agents like probiotics and postbiotics, which come with minimal side effects in compared to chemical drugs, could be essential in managing symptoms in IBD patients.

Noninvasive Stool RNA Test Approximates Disease Activity in Patients With Crohn's Disease

Background and Aims

Management of Crohn's disease (CD) requires frequent monitoring for disease activity and response to therapy. In this study, we examined the clinical utility of a novel stool-derived eukaryotic RNA (seRNA)-based diagnostic in patients with CD.

Methods

Stool samples were collected from 68 individuals for up to 3 time points prior to, and after initiation of an advanced therapy. Stool samples underwent RNA extraction and sequencing using a custom capture panel (n = 1507 transcripts). seRNA signatures were compared to Crohn's Disease Activity Index scores and endoscopies, when available. Random forest models classified disease severity when compared to Crohn's Disease Activity Index scores. seRNA signatures were also used to assess expression of the therapy target and cell type abundance at various time points.

Results

Across all 102 samples collected from 68 individuals, the classifier successfully parsed individuals with active disease (n = 37) relative to those in remission (n = 65) with 87% sensitivity and 77% specificity, respectively. A second classifier, which was employed on subjects with active disease (n = 37), successfully parsed individuals with mild disease (n = 15) from those with moderate disease (n = 22) with 93% and 86% sensitivity, respectively. For the 16 subjects with longitudinal data, seRNA expression of the therapeutic target (eg, ITGA4/ITGB7 for vedolizumab or IL12/IL23 for ustekinumab) as well as lymphocyte burden was correlated with response.

Conclusion

A novel seRNA and informatic-based method reliably discriminates active disease from remission and stratifies mild from moderate CD activity. This demonstrates preliminary feasibility to predict therapeutic response and assess disease activity for patients with CD.

Exploration of Therapeutic Strategies of Herbal Prescriptions for Carbuncle Treatment to Suggest Modern Approaches to Inflammatory Bowel Disease: Cluster and Network Analyses of the Book «Liu Juan Zi Gui Yi Fang»

Inflammatory bowel disease (IBD) treatments in East Asian traditional medicine (EATM) originate from principles for treating abscesses and carbuncles. Understanding the therapeutic principles of Liu Juan Zi Gui Yi Fang (GYF) is essential for optimizing EATM treatment strategies for IBD, but quantitative analysis is lacking. This study aims to extract quantitative information on therapeutic strategies from GYF and present the EATM conceptual framework for IBD treatment. Oral prescriptions for carbuncles were selected, and their constituent herbs and indications were standardized and tokenized for analysis. An EATM expert group classified prescriptions based on the similarity of herbs and indications. Hierarchical and k-means cluster analyses were performed based on herb similarity. The herb-indication (H-I) network for all prescriptions was constructed. Additionally, H-I subnetworks based on the expert group's classifications and the k-means clustering results were constructed and compared to identify treatment goals and the herbs used for each goal. The results showed that the treatment focused on abscess status, wound healing, and patient's recovery capacity, with 'fever' and 'deficiency' as the main indications addressed by tonifying and anti-inflammatory herbs. The therapeutic principles identified in this study can serve as a foundation for developing future herbal intervention units. Further preclinical and clinical research is needed to validate these findings.

Phyllanthus emblica L. polysaccharides ameliorate colitis via microbiota modulation and dual inhibition of the RAGE/NF-κB and MAPKs signaling pathways in rats

Pharmacological treatments for colitis have limited efficacy and side effects. Plant polysaccharides improve colitis by modulating the gut microbiota. However, the specific benefits of Phyllanthus emblica L. polysaccharides (PEPs) in colitis remain unclear. Therefore, this study aimed to assess the physical characteristics and health advantages of PEP in rats subjected to 2,4,6-trinitrobenzene sulfonic acid (TNBS) treatment. The results showed that PEP (1.226 × 103 kDa) was an α-acidic pyran heteropolysaccharide rich in galactose and galacturonic acid. Prefeeding rats with PEP significantly decreased the levels of NO, MDA, proinflammatory cytokines (IL-6, IL-1β, TNF-α), apoptosis, and the activities of mucinase and β-glucuronidase. These changes were accompanied by increases in the levels of anti-inflammatory cytokines (IL-4, IL-10) and antioxidant enzymes (SOD, catalase, GPx) in colitis rats. Mechanistically, PEP suppressed the abundance of inflammatory-related bacteria (Bacteroides, Intestinimonas, and Parabacteroides) while promoting the growth of short-chain fatty acid (SCFA)-producing bacteria (Romboutsia, Clostridium_sensu_stricto_1, and Lactobacillus), along with an increase in SCFA secretion. SCFAs may engage with the GPR43 receptor and inhibit downstream HDAC3, consequently downregulating the activation of the RAGE/NF-κB and MAPK pathways. In conclusion, PEP demonstrated preventive effects through its antioxidant, anti-inflammatory, and microbiota modulation properties, thereby ameliorating TNBS-induced colitis in rats.

The Pediatric Crohn Disease Morbidity Index (PCD-MI): Development of a Tool to Assess Long-Term Disease Burden Using a Data-Driven Approach

BACKGROUND/OBJECTIVE

Heterogeneity and chronicity of Crohn disease (CD) make prediction of outcomes difficult. To date, no longitudinal measure can quantify burden over a patient's disease course, preventing assessment and integration into predictive modeling. Here, we aimed to demonstrate the feasibility of constructing a data driven, longitudinal disease burden score.

METHODS

Literature was reviewed for tools used in assessment of CD activity. Themes were identified to construct a pediatric CD morbidity index (PCD-MI). Scores were assigned to variables. Data were extracted automatically from the electronic patient records at Southampton Children's Hospital, diagnosed from 2012 to 2019 (inclusive). PCD-MI scores were calculated, adjusted for duration of follow up and assessed for variation (ANOVA) and distribution (Kolmogorov-Smirnov).

RESULTS

Nineteen clinical/biological features across five themes were included in the PCD-MI including blood/fecal/radiological/endoscopic results, medication usage, surgery, growth parameters, and extraintestinal manifestations. Maximal score was 100 after accounting for follow-up duration. PCD-MI was assessed in 66 patients, mean age 12.5 years. Following quality filtering, 9528 blood/fecal test results and 1309 growth measures were included. Mean PCD-MI score was 14.95 (range 2.2-32.5); data were normally distributed ( P = 0.2) with 25% of patients having a PCD-MI < 10. There was no difference in the mean PCD-MI when split by year of diagnosis, F -statistic 1.625, P = 0.147.

CONCLUSIONS

PCD-MI is a calculatable measure for a cohort of patients diagnosed over an 8-year period, integrating a wide-range of data with potential to determine high or low disease burden. Future iterations of the PCD-MI require refinement of included features, optimized scores, and validation on external cohorts.

Surface-anchored microbial enzyme-responsive solid lipid nanoparticles enabling colonic budesonide release for ulcerative colitis treatment

Colon-targeted oral drug delivery systems (CDDSs) are desirable for the treatment of ulcerative colitis (UC), which is a disease with high relapse and remission rates associated with immune system inflammation and dysregulation localized within the lining of the large bowel. However, the success of current available approaches used for colon-targeted therapy is limited. Budesonide (BUD) is a corticosteroid drug, and its rectal and oral formulations are used to treat UC, but the inconvenience of rectal administration and the systemic toxicity of oral administration restrict its long-term use. In this study, we designed and prepared colon-targeted solid lipid nanoparticles (SLNs) encapsulating BUD to treat UC by oral administration. A negatively charged surfactant (NaCS-C12) was synthesized to anchor cellulase-responsive layers consisting of polyelectrolyte complexes (PECs) formed by negatively charged NaCS and cationic chitosan onto the SLNs. The release rate and colon-specific release behavior of BUD could be easily modified by regulating the number of coated layers. We found that the two-layer BUD-loaded SLNs (SLN-BUD-2L) with a nanoscale particle size and negative zeta potential showed the designed colon-specific drug release profile in response to localized high cellulase activity. In addition, SLN-BUD-2L exhibited excellent anti-inflammatory activity in a dextran sulfate sodium (DSS)-induced colitis mouse model, suggesting its potential anti-UC applications.

IBD disease-modifying therapies: insights from emerging therapeutics

Inflammatory bowel disease (IBD) pathogenesis is associated with gut mucosal inflammation, epithelial damage, and dysbiosis leading to a dysregulated gut mucosal barrier. However, the extent and underlying mechanisms remain largely unknown. Current treatment regimens have focused mainly on treating IBD symptoms; however, such treatment strategies do not address mucosal epithelial repair, barrier homeostasis, or intestinal dysbiosis. Although attempts have been made to identify new therapeutic modalities to enhance gut barrier functions, these are at an early developmental stage and have not been wholly successful. We review conventional therapies, the possible relevant role of gut barrier-protecting agents, and biomaterial strategies relating to combination therapies that may pave the way towards developing new therapeutic approaches for IBD.

Using machine learning to impact on long-term clinical care: principles, challenges, and practicalities

The rise of machine learning in healthcare has significant implications for paediatrics. Long-term conditions with significant disease heterogeneity comprise large portions of the routine work performed by paediatricians. Improving outcomes through discovery of disease and treatment prediction models, alongside novel subgroup clustering of patients, are some of the areas in which machine learning holds significant promise. While artificial intelligence has percolated into routine use in our day to day lives through advertising algorithms, song or movie selections and sifting of spam emails, the ability of machine learning to utilise highly complex and dimensional data has not yet reached its full potential in healthcare. In this review article, we discuss some of the foundations of machine learning, including some of the basic algorithms. We emphasise the importance of correct utilisation of machine learning, including adequate data preparation and external validation. Using nutrition in preterm infants and paediatric inflammatory bowel disease as examples, we discuss the evidence and potential utility of machine learning in paediatrics. Finally, we review some of the future applications, alongside challenges and ethical considerations related to application of artificial intelligence. IMPACT: Machine learning is a widely used term; however, understanding of the process and application to healthcare is lacking. This article uses clinical examples to explore complex machine learning terms and algorithms. We discuss limitations and potential future applications within paediatrics and neonatal medicine.

Rapid and Sustained Symptom Relief in Patients With Ulcerative Colitis Treated With Filgotinib: Data From the Phase 2b/3 SELECTION Trial

INTRODUCTION

Patients with ulcerative colitis (UC) regard rapid onset of action among the most important aspects of their treatment. We used the partial Mayo Clinic Score (pMCS) and component patient-reported subscores to assess the rapidity and sustainability of response to filgotinib, a once-daily, oral Janus kinase 1 preferential inhibitor, in adults with moderately to severely active UC in the phase 2b/3 SELECTION trial. The association between early symptomatic improvements and health-related quality of life (HRQoL) outcomes was also assessed.

METHODS

In these post hoc analyses of the double-blinded, randomized, placebo-controlled 58-week SELECTION trial (NCT02914522), rectal bleeding and stool frequency diary data on days 1-15 and pMCS remission and response at multiple time points including weeks 10 and 58 were evaluated. HRQoL was assessed using the Inflammatory Bowel Disease Questionnaire at weeks 10 and 58.

RESULTS

Filgotinib 200 mg relative to placebo improved rectal bleeding and stool frequency within 7 days ( P < 0.05). By week 2, greater proportions of filgotinib 200 mg-treated patients than placebo-treated patients achieved pMCS remission (biologic-naive, 15.1% vs 8.0%, P = 0.0410; biologic-experienced, 10.3% vs 4.2%, P = 0.0274). A similar treatment effect was observed at week 58 ( P < 0.0001). Day 7 rectal bleeding and stool frequency subscores were associated with the Mayo Clinic Score response at weeks 10 and 58. Patients in pMCS remission at weeks 10 and 58 had greater improvements in the Inflammatory Bowel Disease Questionnaire score than those not in pMCS remission.

DISCUSSION

Filgotinib 200 mg daily resulted in rapid and sustained improvements in both UC symptoms and HRQoL.

Efficacy and safety of filgotinib as induction and maintenance therapy for Japanese patients with moderately to severely active ulcerative colitis: a post-hoc analysis of the phase 2b/3 SELECTION trial

BACKGROUND/AIMS

The safety and efficacy of filgotinib, a once-daily oral Janus kinase 1 preferential inhibitor, were evaluated in Japanese patients with ulcerative colitis (UC) in the phase 2b/3 SELECTION trial.

METHODS

SELECTION (NCT02914522) was a randomized, placebo-controlled trial comprising 2 induction studies and a maintenance study. Adults with moderately to severely active UC were randomized in induction study A (biologic-naïve) or B (biologic-experienced) to receive filgotinib 200 mg, 100 mg, or placebo once daily for 11 weeks. Patients in clinical remission or Mayo Clinic score response at week 10 entered the 47-week maintenance study. Efficacy and safety outcomes were assessed in Japanese patients enrolled in Japan.

RESULTS

Overall, 37 and 72 Japanese patients were enrolled in Japan in induction studies A and B, respectively, and 54 entered the maintenance study. Numerically higher proportions of filgotinib 200 mg-treated than placebo-treated patients achieved clinical remission in induction study A (4/15 [26.7%] vs. 0/6 [0%]) and the maintenance study (5/20 [25.0%] vs. 0/9 [0%]), but not induction study B (1/29 [3.4%] vs. 1/14 [7.1%]). Both doses were well tolerated, and no new safety signals were noted. Herpes zoster was reported in 1 filgotinib 200 mg-treated patient in each of induction study A (2.3%, 1/44) and the maintenance study (5.0%, 1/20).

CONCLUSIONS

These data, alongside those of the overall SELECTION population, suggest the potential of filgotinib 200 mg as a viable treatment option for Japanese patients with UC. Owing to small patient numbers, data should be interpreted cautiously.

Prevalence of Sarcopenia and Its Effect on Postoperative Complications in Patients with Crohn's Disease

Background and Aims

Sarcopenia is a prognostic factor of outcomes for various diseases, but reports on sarcopenia in patients with Crohn's disease (CD) are few. We aim to determine the prevalence of sarcopenia and assess the role of sarcopenia in postoperative complications in patients with CD at a tertiary referral center.

Methods

Patients who underwent intestinal surgery for CD from January 2013 to October 2019 were retrospectively enrolled. The L3 skeletal muscle mass index (SMI) was used to identify sarcopenia. Demographic data, preoperative laboratory data, surgical details, and hospital outcomes were recorded. The factors associated with postoperative complications were evaluated through univariate and multivariate analyses.

Results

One hundred and twenty-four patients were enrolled. Thirty-four of them (27.4%), including 11 males, were diagnosed with sarcopenia. Compared with patients without sarcopenia, sarcopenic patients had a significantly lower BMI (P < 0.001); lower preoperative serum albumin (P = 0.006), prealbumin (P = 0.030), and hemoglobin levels (P < 0.001); longer hospital stay (34.4 ± 26.8 days vs. 22.8 ± 15.6 days, P = 0.003); and more occurrences of complications (41.2% vs. 23.3%, P = 0.049). The overall incidence of postoperative complications was 28.2%. Infection (51.4%) and intestinal fistula (22.9%) were the most common among such complications. Through the multivariate analysis, sarcopenia was identified as an independent risk factor for major postoperative complications (odds ratio = 3.974, 95%CI = 1.171-13.489, P = 0.027).

Conclusion

Sarcopenia is common in patients with CD requiring bowel resection, and it significantly increases the risk of major postoperative complications.