Necrotizing enterocolitis, gut microbes, and sepsis

Human breast milk-derived phospholipid DOPE ameliorates intestinal injury associated with NEC by inhibiting ferroptosis

Neonatal necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease that commonly affects premature infants. Breastfeeding has been proven to be one of the most effective methods for preventing NEC. However, the specific role of lipids, the second major nutrient category in human breast milk (HBM), in intestinal development remains unclear. Our preliminary lipidomic analysis of the HBM lipidome revealed that dioleoyl phosphatidylethanolamine (DOPE) is not only abundant but also shows high solubility in lipids, endowing it with significant biological utility. Experimental results confirmed that DOPE significantly reduces the mortality of neonatal rats, ameliorates impairment of intestinal barrier function, and alleviates the expression of intestinal inflammatory factors IL-1β and IL-6. Furthermore, DOPE promotes the migration and proliferation of intestinal epithelial cells, thereby enhancing the integrity of the intestinal barrier function in vitro. The progression of NEC is linked with the onset of ferroptosis. Our cellular-level analysis of lipid peroxide and iron ion concentrations revealed that DOPE significantly reduces the indicators of ferroptosis, while also modulating the expression of pivotal ferroptosis-associated factors, including SLC7A11, GPX4, and ACSL4. Hence, this research on DOPE is expected to provide novel insights into the bioactive lipids present in HBM.

Severe anemia in preterm infants associated with increased bacterial virulence potential and metabolic disequilibrium

BACKGROUND

Anemia in preterm infants is associated with gut dysbiosis and necrotizing enterocolitis. Our study aimed to identify the bacterial functions and metabolites that can explain the underlying mechanisms of anemia associated disease conditions.

METHODS

We conducted a case control study in preterm infants with cases having a hematocrit ≤ 25%. The control infants were matched by birth gestational age and weight. Fecal samples were collected before, at the onset, and after the onset of anemia in cases and with matched postnatal age in controls for metagenomics and metabolomics analyzes.

RESULTS

18 anemic and 20 control infants with fecal samples collected at 17 days, 5 weeks, and 7 weeks postnatal age were included. Virulence factor potential, decrease in beta diversity evolution, and larger changes in metabolome were associated with severe anemia. Metabolite abundances of N-acetylneuraminate and butyrobetaine were associated with virulence factor potential. Anemic group had decreased prostaglandin and lactic acid levels.

CONCLUSION

Fecal omics data showed that severe anemia is associated with a pro-inflammatory gut microbiota with more virulent and less commensal anaerobic bacterial activities. Future studies can examine the link between anemia-associated dysbiosis and clinical outcomes and predict an infant-specific hematocrit threshold that negatively affects clinical outcomes.

IMPACT

Severe anemia in preterm infants contributes to a pro-inflammatory gut with greater bacterial virulence and less commensal bacterial activities. The multiomics approach using non-invasive fecal biospecimens identified functional and metabolic changes in the gut microbiota and these mechanistic changes are plausible explanations for anemia-associated disease conditions in preterm infants. Our findings identified biological changes of the gut environment in severely anemic preterm infants that can offer guidance for clinical management.

Does serum albumin at the onset of necrotisıng enterocolitis predict severe disease in preterm infants?

OBJECTIVE

To investigate whether laboratory markers obtained at the onset of necrotising enterocolitis (NEC) predict the severity of the disease in preterm infants.

METHODS

Prospective cohort study conducted in a tertiary referance hospital. A total of 88 preterm infants were included in the study. Of those, 60 infants had the diagnosis of severe NEC, while the remaining 28 infants constituted the non-severe NEC group. Severe NEC was defined as surgical NEC or NEC-related mortality. Infants with and without severe NEC were compared in terms of demographic, clinical and laboratory characteristics.

RESULTS

At the onset of disease, infants with severe NEC noted to have lower platelet count and serum ALB levels (p = 0.011, p = 0.004; respectively), whereas higher CRP, and serum lactate levels (p = 0.009, p = 0.008; respectively). Multiple binary logistic regression analyses showed that CRP (1.03(1.01-1.05), p = 0.024) and serum albumin level (0.16(0.04-0.64), p = 0.010) were statistically significant independent risk factors for severe NEC. The optimal cut-off value for the serum ALB level was found to be 23 g/L with 52% sensitivity (95%CI: 37-68%) and 84% specificity (95%CI: 60-97%) (AUC 0.727; p = 0.002).

CONCLUSION

Serum ALB level at NEC onset might be a reliable biomarker for severe disease in preterm infants.

Necrotizing Enterocolitis and Neurodevelopmental Impairments: Microbiome, Gut, and Brain Entanglements

There is significant communication and interdependence among the gut, the microbiome, and the brain during development. Diseases, such as necrotizing enterocolitis (NEC), highlight how injury to the immature gastrointestinal tract leads to long-term neurological consequences, due to vulnerabilities of the brain in the early stages of life. A better understanding of the developing gut-microbiota-brain axis is needed to both prevent and treat the devastating consequences of these disease processes. The gut-microbiota-brain axis is a bidirectional communication pathway that includes metabolic, nervous, endocrine, and immune components. In this review, we discuss gut development, microbiome colonization and maturation, and the interactions that influence neurodevelopment in the context of NEC. We describe the components of the gut-brain axis and how the microbiome is an integral member of this relationship. Finally, we explore how derangements within the microbiome and gut-microbiota-brain axis affect the normal development and function of the other systems and long-term neurodevelopmental consequences for patients.

Artificial Intelligence vs. Doctors: Diagnosing Necrotizing Enterocolitis on Abdominal Radiographs

BACKGROUND

Radiographic diagnosis of necrotizing enterocolitis (NEC) is challenging. Deep learning models may improve accuracy by recognizing subtle imaging patterns. We hypothesized it would perform with comparable accuracy to that of senior surgical residents.

METHODS

This cohort study compiled 494 anteroposterior neonatal abdominal radiographs (214 images NEC, 280 other) and randomly divided them into training, validation, and test sets. Transfer learning was utilized to fine-tune a ResNet-50 deep convolutional neural network (DCNN) pre-trained on ImageNet. Gradient-weighted Class Activation Mapping (Grad-CAM) heatmaps visualized image regions of greatest relevance to the pretrained neural network. Senior surgery residents at a single institution examined the test set. Resident and DCNN ability to identify pneumatosis on radiographic images were measured via area under the receiver operating curves (AUROC) and compared using DeLong's method.

RESULTS

The pretrained neural network achieved AUROC of 0.918 (95% CI, 0.837-0.978) with an accuracy of 87.8% with five false negative and one false positive prediction. Heatmaps confirmed appropriate image region emphasis by the pretrained neural network. Senior surgical residents had a median area under the receiver operating curve of 0.896, ranging from 0.778 (95% CI 0.615-0.941) to 0.991 (95% CI 0.971-0.999) with zero to five false negatives and one to eleven false positive predictions. The deep convolutional neural network performed comparably to each surgical resident's performance (p > 0.05 for all comparisons).

CONCLUSIONS

A deep convolutional neural network trained to recognize pneumatosis can quickly and accurately assist clinicians in promptly identifying NEC in clinical practice.

LEVEL OF EVIDENCE

III (study type: Study of Diagnostic Test, study of nonconsecutive patients without a universally applied "gold standard").

Evidences and perspectives on the association between gut microbiota and sepsis: A bibliometric analysis from 2003 to 2023

Background

In the last two decades, the role of the gut microbiome in the development, maintenance, and outcome of sepsis has received increased attention; however, few descriptive studies exist on its research focus, priorities, and future prospects. This study aimed to identify the current state, evolution, and emerging trends in the field of gut microbiota and sepsis using bibliometric analysis.

Methods

All publications on sepsis and gut microbiota were retrieved from the Web of Science Core Collection and included in this study. VOSviewer, CiteSpace, and the Web of Science online analysis platform were used to visualize trends based on publication country, institution, author, journal, and keywords.

Results

A total of 1,882 articles on sepsis-related gut microbiota were screened, mainly from 95 countries or regions and 2,581 institutions. The United States and China contributed the most to this research field, with 521 (27.683 %) and 376 (19.979 %) articles, respectively. Scientists from the University of California were the most prolific, publishing 63 (3.348 %) articles. Cani PD published papers with the highest H-index, establishing himself as a leader in the field. The most publications were published in the journals "Nutrients" and "PLOS One." The journals with the most co-citations were "PLOS One," "Nature," and "Gut." The most used keywords were prebiotics, gut microbiota, and sepsis. The keyword burst research analysis revealed that research on treatment strategies based on the intestinal microbiota, intestine-liver axis, and regulatory mechanisms of bacterial metabolites are currently hot directions.

Conclusion

This study presents a global overview of the current state and potential trends in the field of sepsis-related gut microbiota. This study identified hot research sub-directions and new trends through comparison and analysis, which will aid in the development of this field.

Deletion of CD38 mitigates the severity of NEC in experimental settings by modulating macrophage-mediated inflammation

Necrotizing enterocolitis (NEC) is a form of potentially lethal gastrointestinal inflammation that primarily affects preterm neonates. It is crucial to recognize that, while the disease carries significant risks, timely and effective medical intervention can greatly enhance the chances of survival. Additionally, NEC is closely linked to the activation of macrophages, highlighting the complex interplay between the immune response and disease progression. CD38, acting as an ectoenzyme, catalyzes the hydrolysis of NAD+ to produce cyclic ADP-ribose (cADPR), a reaction critical for modulating cellular redox balance and energy homeostasis. This enzymatic activity is particularly pertinent in the context of necrotizing enterocolitis (NEC). In this research, we investigated whether CD38 deletion can elevate NAD+ levels to reduce macrophage-mediated inflammation and improve NEC severity. We show that NEC patients was associated with the increased CD38 expression in intestine and blood. These results were also observed in NEC mice, and CD38 deletion ameliorated NEC intestinal injury. Mechanistically, CD38 deletion elevated NAD+ levels that reduced oxidative stress and intestinal inflammation. Furthermore, CD38 deletion promoted M2 macrophage polarization, inhibited macrophage activation and phagocytosis ability. Thus, our results reveal a critical role for CD38 as an intracellular immune regulator for regulating macrophage activation and intestinal inflammation in NEC. Targeting CD38 and NAD+ signal maybe a promising strategy for treatment of NEC.

Comparative efficacy of different single drugs to prevent necrotizing enterocolitis in preterm infants: an update systematic review and network meta-analysis

Objective

To investigate an optimal regimen of six drugs, including lactoferrin, probiotics, prebiotics, glutamine, arginine and erythropoietin (EPO), for the prevention of necrotizing enterocolitis (NEC) in preterm infants.

Methods

PubMed, Embase, Ovid, The Cochrane Library, and Web of Science databases were searched for randomized controlled trials (RCTs) investigating the efficacy of lactoferrin, probiotics, prebiotics, glutamine, arginine, and EPO in preventing NEC in preterm infants, with a cutoff date of June 20, 2024. Two authors independently screened studies and extracted all the data. Network meta-analysis (NMA) was conducted to compare the outcomes of different interventions, and group rankings were determined using the surface under the cumulative ranking curve (SUCRA).

Results

A total of 89 RCTs with 26,861 preterm infants were included. Arginine demonstrated the highest clinical efficacy in reducing the incidence of NEC, with probiotics being the next most effective and the placebo being the least effective. Lactoferrin was identified as the most effective intervention for reducing the incidence of NEC-associated sepsis. Prebiotics showed the highest effect on overall mortality, reducing the beginning of enteral feeding, and were associated with the shortest hospital stay. Glutamine significantly decreased the time to full enteral feeding.

Conclusion

Existing literature highlights arginine as the most efficacious pharmacological agent in preventing NEC in preterm infants. It has been shown to effectively lower the rates of NEC, septicemia, and mortality, warranting its recommendation as the first-line clinical intervention. Following this, probiotics are recommended as a second option.

Peripheral Lymphocyte Changes Associate With the Progression of Necrotizing Enterocolitis in Infants

INTRODUCTION

Immune factors are important antecedents in the pathophysiology of necrotizing enterocolitis (NEC). However, studies on the peripheral blood lymphocyte subsets changes in NEC patients among different Bell stages and in patients requiring surgery are scarce.

METHODS

34 infants with NEC and 33 age-matched controls were included. Peripheral blood was collected within 48 h after NEC diagnosis. Peripheral blood B and T lymphocytes subsets were detected by 12-color flow cytometry. Cell ratios were calculated, and their relationship to disease severity and their roles as indicators for surgery were assessed.

RESULTS

NEC patients showed elevated percentages of unSwB cells (CD27+IgD+ unswitched memory/activated B cells)/B cells, SwB cells (CD27+IgD-switched memory B cells)/B cells, CD8+ T (CD3+CD8+ T cells)/T cells, Tem (CD45RA-CCR7-effector memory T cells)/CD4+ T cells, Tem/CD8+ T cells and decreased Bn (CD27-IgD+ naïve B cells)/B cells, CD4+T (CD3+CD4+ T cells)/T cells, CD45RA+ CCR7+ naïve T cells (CD45RA+CCR7+ naïve T cells)/CD8+T cells. Compared to NEC patients at BELL stage I + II, patients at BELL stage III showed increased percentages of SwB cells/B cells, antibody secreting cell (ASC, CD3-CD20-CD27high CD38high ASCs)/B cells and Tem/CD4+ T cells, and decreased percentages of CD45RA+CCR7+ naïve T cells/CD4+ T cells. The Receiver Operating Characteristic Curve analysis showed that the sensitivity of ASC/B cells ratio (0.52%) is 86.67% and the specificity of Tem/CD4+T ratio (5.22%) is 100%, indicating that NEC patients required surgery.

CONCLUSIONS

The severity of NEC exhibits codirectional changes with the maturation of B and T lymphocytes, especially CD4+ T cells. The increased ASC/B and Tem/CD4+ T cells could serve as potential indicators for NEC patients requiring surgery.

Risk factors for necrotizing enterocolitis in small-for-gestational-age infants: a matched case-control study

Few studies have focused on the risk factors for necrotizing enterocolitis (NEC) in small for gestational age (SGA) infants. The aim of this study was to identify the risk factors for NEC in SGA newborns. This study included consecutive SGA neonates admitted to a tertiary hospital in Jiangxi Province, China from Jan 2008 to Dec 2022. Patients with NEC (Bell's stage ≥ II) were assigned to the NEC group. Gestational age- and birth weight-matched non-NEC infants born during the same period at the same hospital were assigned to the control group. The risk factors associated with NEC were analyzed with univariate and logistic regression models. During the study period, 2,912 SGA infants were enrolled, 150 (5.15%) of whom developed NEC. In total, 143 patients and 143 controls were included in the NEC and control groups, respectively. Logistic regression analysis revealed that sepsis (OR 2.399, 95% CI 1.271-4.527, P = 0.007) and anemia (OR 2.214, 95% CI 1.166-4.204, P = 0.015) might increase the incidence of NEC in SGA infants and that prophylactic administration of probiotics (OR 0.492, 95% CI 0.303-0.799, P = 0.004) was a protective factor against NEC. Therefore, sepsis, anemia and a lack of probiotic use are independent risk factors for NEC in SGA infants.

Macrophage α7nAChR alleviates the inflammation of neonatal necrotizing enterocolitis through mTOR/NLRP3/IL-1β pathway

BACKGROUND

Neonatal necrotizing enterocolitis (NEC) is one of the most prevalent and severe intestinal emergencies in newborns. The inflammatory activation of macrophages is associated with the intestinal injury of NEC. The neuroimmune regulation mediated by α7 nicotinic acetylcholine receptor (α7nAChR) plays an important role in regulating macrophage activation and inflammation progression, but in NEC remains unclear. This study aims to explore the effect of macrophage α7nAChR on NEC.

METHODS

Mice NEC model were conducted with high-osmolarity formula feeding, hypoxia, and cold stimulation. The α7nAChR agonist PNU-282987 and mTOR inhibitor rapamycin were treated by intraperitoneal injections in mice. The expression and distribution of macrophages, α7nAChR, and phospho-mammalian target of rapamycin (p-mTOR) in the intestines of NEC patients and mice was assessed using immunohistochemistry, immunofluorescence, and flow cytometry. The expression of NLRP3, activated caspase-1 and IL-1β in mice intestines was detected by flow cytometry, western blot or ELISA. In vitro, the mouse RAW264.7 macrophage cell line was also cultured followed by various treatments. Expression of p-mTOR, NLRP3, activated caspase-1, and IL-1β in macrophages was determined.

RESULTS

Macrophages accumulated in the intestines and the expression of α7nAChR in the mucosal and submucosal layers of the intestines was increased in both the NEC patients and mice. The p-mTOR and CD68 were increased and co-localized in intestines of NEC patients. In vitro, α7nAChR agonist PNU-282987 significantly reduced the increase of NLRP3, activated caspase-1, and IL-1β in macrophages. PNU-282987 also significantly reduced the increase of p-mTOR. The effect was blocked by AMPK inhibitor compound C. The expression of NLRP3, activated caspase-1, and IL-1β was inhibited after mTOR inhibitor rapamycin treatment. In NEC model mice, PNU-282987 reduced the expression of p-mTOR, NLRP3, activated caspase-1, and IL-1β in the intestine. Meanwhile, rapamycin significantly attenuated NLRP3 activation and the release of IL-1β. Moreover, the proportion of intestinal macrophages and intestinal injury decreased after PNU-282987 treatment.

CONCLUSION

Macrophage α7nAChR activation mitigates NLRP3 inflammasome activation by modulating mTOR phosphorylation, and subsequently alleviates intestinal inflammation and injury in NEC.

Epigenetic Insights Into Necrotizing Enterocolitis: Unraveling Methylation-Regulated Biomarkers

Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease with high morbidity and mortality among premature infants. This study aimed to identify novel methylation-regulated biomarkers in NEC intestinal tissue through multiomics analysis. We analyzed DNA methylation and transcriptome datasets from ileum and colon tissues of patients with NEC. We identify methylation-related differential genes (MrDEGs) based on the rule that the degree of methylation in the promoter region is inversely proportional to RNA transcription. These MrDEGs included ADAP1, GUCA2A, BCL2L14, FUT3, MISP, USH1C, ITGA3, UNC93A and IL22RA1. Single-cell data revealed that MrDEGs were mainly located in the intestinal epithelial part of intestinal tissue. These MrDEGs were verified through Target gene bisulfite sequencing and RT-qPCR. We successfully identified and verified the ADAP1, GUCA2A, IL22RA1 and MISP, primarily expressed in intestinal epithelial villus cells through single-cell data. Through single-gene gene set enrichment analysis, we found that these genes participate mainly in the pathological process of T-cell differentiation and the suppression of intestinal inflammation in NEC. This study enhances our understanding of the pathogenesis of NEC and may promote the development of new precision medicine methods for NEC prediction and diagnosis.

Nursing practice of routine gastric aspiration in preterm infants and its link to necrotizing enterocolitis: is the practice still clinically relevant?

The practice of routine gastric residual aspiration in preterm infants remains controversial, with conflicting evidence regarding its impact on necrotizing enterocolitis (NEC). As front-line caregivers, nurses play a vital role in gastric aspiration procedures and must be informed by evidence. This quasi-experimental nursing study aimed to assess whether gastric aspiration is clinically relevant in reducing the risk of NEC in preterm infants.A total of 250 preterm infants from two NICUs in Egypt were allocated to the gastric aspiration (n = 125) and non-aspiration (n = 125) groups. Feeding practices, gastric residuals, and incidence/severity of NEC were compared between groups according to modified Bell's criteria. Risk factors were analyzed using multivariate regression. There were no significant baseline differences between the groups. The gastric residual attributes and feeding outcomes did not differ substantially from aspiration. The overall incidence of NEC was 14-15%, with no significant differences in the odds of onset or progression of NEC by stage between the groups. Lower gestational age and birth weight emerged as stronger predictors of NEC. Routine gastric aspiration does not appear to directly prevent or reduce the severity of NEC in this population. Although gastric residuals retain clinical importance, study findings question assumptions that aspiration protects against NEC and informs nursing practice. Evidence-based feeding protocols must continually evolve through ongoing research on modifiable risk factors for this devastating intestinal disease in preterm infants.

[Application of near-infrared spectroscopy in the early identification of neonatal gastrointestinal diseases]

Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal diseases in neonatal intensive care units, characterized by rapid progression and a high mortality rate. Local intestinal ischemia and hypoxia are significant contributors to NEC. Feeding intolerance (FI), which refers to a range of gastrointestinal manifestations arising from the inability to tolerate enteral nutrition, is one of the most common clinical issues in neonates, and preventing and treating FI is crucial for improving neonatal survival rates. Near-infrared spectroscopy is a clinical tool that can be used at the bedside to monitor regional oxygen saturation. It is non-invasive, reliable, and sustainable, and its feasibility and safety in assessing intestinal blood circulation have been validated. Early identification of intestinal ischemia and differentiation of FI from precursor symptoms of NEC, as well as predicting the occurrence of NEC, are extremely important for reducing intestinal injury and adverse long-term outcomes. In recent years, there has been new research progress related to the monitoring of intestinal tissue oxygen saturation and cerebral oxygen saturation for the early identification of FI and precursor symptoms of NEC, and this article provides a review of these developments.

Parenteral nutrition emulsion inhibits CYP3A4 in an iPSC derived liver organoids testing platform

OBJECTIVES

Parenteral nutrition (PN) is used for patients of varying ages with intestinal failure to supplement calories. Premature newborns with low birth weight are at a high risk for developing PN associated liver disease (PNALD) including steatosis, cholestasis, and gallbladder sludge/stones. To optimize nutrition regimens, models are required to predict PNALD.

METHODS

We have exploited induced pluripotent stem cell derived liver organoids to provide a testing platform for PNALD. Liver organoids mimic the developing liver and contain the different hepatic cell types. The organoids have an early postnatal maturity making them a suitable model for premature newborns. To mimic PN treatment we used medium supplemented with either clinoleic (80% olive oil/20% soybean oil) or intralipid (100% soybean oil) for 7 days.

RESULTS

Homogenous HNF4a staining was found in all organoids and PN treatments caused accumulation of lipids in hepatocytes. Organoids exhibited a dose dependent decrease in CYP3A4 activity and expression of hepatocyte functional genes. The lipid emulsions did not affect overall organoid viability and glucose levels had no contributory effect to the observed results.

CONCLUSIONS

Liver organoids could be utilized as a potential screening platform for the development of new, less hepatotoxic PN solutions. Both lipid treatments caused hepatic lipid accumulation, a significant decrease in CYP3A4 activity and a decrease in the RNA levels of both CYP3A4 and CYP1A2 in a dose dependent manner. The presence of high glucose had no additive effect, while Clinoleic at high dose, caused significant upregulation of interleukin 6 and TLR4 expression.

Advances in Mass Spectrometry-Based Blood Metabolomics Profiling for Non-Cancer Diseases: A Comprehensive Review

Blood metabolomics profiling using mass spectrometry has emerged as a powerful approach for investigating non-cancer diseases and understanding their underlying metabolic alterations. Blood, as a readily accessible physiological fluid, contains a diverse repertoire of metabolites derived from various physiological systems. Mass spectrometry offers a universal and precise analytical platform for the comprehensive analysis of blood metabolites, encompassing proteins, lipids, peptides, glycans, and immunoglobulins. In this comprehensive review, we present an overview of the research landscape in mass spectrometry-based blood metabolomics profiling. While the field of metabolomics research is primarily focused on cancer, this review specifically highlights studies related to non-cancer diseases, aiming to bring attention to valuable research that often remains overshadowed. Employing natural language processing methods, we processed 507 articles to provide insights into the application of metabolomic studies for specific diseases and physiological systems. The review encompasses a wide range of non-cancer diseases, with emphasis on cardiovascular disease, reproductive disease, diabetes, inflammation, and immunodeficiency states. By analyzing blood samples, researchers gain valuable insights into the metabolic perturbations associated with these diseases, potentially leading to the identification of novel biomarkers and the development of personalized therapeutic approaches. Furthermore, we provide a comprehensive overview of various mass spectrometry approaches utilized in blood metabolomics research, including GC-MS, LC-MS, and others discussing their advantages and limitations. To enhance the scope, we propose including recent review articles supporting the applicability of GC×GC-MS for metabolomics-based studies. This addition will contribute to a more exhaustive understanding of the available analytical techniques. The Integration of mass spectrometry-based blood profiling into clinical practice holds promise for improving disease diagnosis, treatment monitoring, and patient outcomes. By unraveling the complex metabolic alterations associated with non-cancer diseases, researchers and healthcare professionals can pave the way for precision medicine and personalized therapeutic interventions. Continuous advancements in mass spectrometry technology and data analysis methods will further enhance the potential of blood metabolomics profiling in non-cancer diseases, facilitating its translation from the laboratory to routine clinical application.

Role of Probiotics and Prebiotics in Gut Symbiosis

The objective of this Special Issue entitled 'Role of Probiotics and Prebiotics in Gut Symbiosis' is to publish reviews, clinical trials and experimental studies that focus on probiotics and prebiotics that have a role in influencing disease and promoting gastrointestinal and overall health [...].