Nutritional supplements and alternative medicine

Epigallocatechin Gallate (EGCG) for Parkinson's Disease

In the last couple of decades, we have experienced increased use of nutraceuticals worldwide with a demand for organic foods, which has been elevated to an extent probably unmatched with other periods of our civilization. One of the nutraceuticals that gained attention is epigallocatechin gallate (EGCG), a polyphenol in green tea. It has been suggested that diseases of the central nervous system (CNS) can benefit from consuming some antioxidants, despite current results showing little evidence for their use in preventing and treating these diseases. ECGC may be beneficial in delaying the neurodegeneration of the substantia nigra (SN) regardless of the origin of Parkinson's disease (PD). This review covers the effect of EGCG on vitro and animal models of PD, the potential mechanisms of neuroprotection involved and summaries recent clinical trials in human PD. This review also aims to provide an investigative analysis of the current knowledge in this field and identify putative crucial issues. Environmental factors such as dietary habits, drug use, and social interaction are all factors that influence the evolution of neurodegenerative diseases. Therefore, the use of nutraceuticals requires further investigation. This article is protected by copyright. All rights reserved.

Probiotics for patients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a disorder of brain function as a result of liver failure and/or portosystemic shunt. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning and represent a significant burden on health care resources. Probiotics are live microorganisms, which when administered in adequate amounts may confer a health benefit on the host.

OBJECTIVES

To quantify the beneficial and harmful effects of any probiotic in any dosage, compared with placebo or no intervention, or with any other treatment for patients with any grade of acute or chronic hepatic encephalopathy as assessed from randomised trials.

SEARCH METHODS

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, conference proceedings, reference lists of included trials and the WHO international clinical trials registry until April 2011 registry platform to identify new and ongoing trials.

SELECTION CRITERIA

We included randomised trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in patients with hepatic encephalopathy.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the risk of bias of the included trials and extracted data on relevant outcomes, with differences resolved by consensus. We conducted random-effects model meta-analysis due to obvious heterogeneity of patients and interventions. A P value of 0.05 or less was defined as significant. Dichotomous outcomes are expressed as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included seven trials of which 550 participants were randomised. Four of the seven trials compared a probiotic with placebo or no treatment in 245 participants, another trial compared a probiotic with lactulose in 40 participants , and the remaining two trials compared a probiotic with both placebo and lactulose in 265 participants. Each trial used different types of probiotics. Duration of administration of the experimental intervention varied from 10 days to 180 days. Two trials were industry funded, and five were unclear about origin of funding. All trials had high risk of bias. When probiotics were compared with no treatment, there was no significant difference in all-cause mortality (2 trials, 105 participants; 1/57 (2%) versus 1/48 (2%): RR 0.72; 95% CI 0.08 to 6.60), lack of recovery (4 trials, 206 participants; 54/107 (50%) versus 68/99 (69%): RR 0.72; 95% CI 0.49 to 1.05), adverse events (3 trials, 145 participants; 2/77 (3%) versus 6/68 (9%): RR 0.34; 95% CI 0.08 to 1.42), quality of life (1 trial, 20 participants contributed to the physical quality of life measurement, 20 participants contributed to the mental quality of life: MD Physical 0.00; 95% CI -5.47 to 5.47; MD Mental 4.00; 95% CI -1.82 to 9.82), or change of/or withdrawal from treatment (3 trials, 175 participants; 11/92 (12%) versus 7/83 (8%): RR 1.28; 95% CI 0.52 to 3.19). No trial reported sepsis or duration of hospital stay as an outcome. Plasma ammonia concentration was significantly lower for participants treated with probiotic at one month (3 trials, 226 participants: MD -2.99 μmol/L; 95% CI -5.70 to -0.29) but not at two months (3 trials, 181 participants: MD -1.82 μmol/L; 95% CI -14.04 to 10.41). Plasma ammonia decreased the most in the participants treated with probiotic at three months (1 trial, 73 participants: MD -6.79 μmol/L; 95% CI -10.39 to -3.19). When probiotics were compared with lactulose no trial reported all-cause mortality, quality of life, duration of hospital stay, or septicaemia. There were no significant differences in lack of recovery (3 trials, 173 participants; 47/87 (54%) versus 44/86 (51%): RR 1.05; 95% CI 0.75 to 1.47), adverse events (2 trials, 111 participants; 3/56 (5%) versus 6/55 (11%): RR 0.57; 95% CI 0.06 to 5.74), change of/or withdrawal from treatment at one month (3 trials, 190 participants; 8/95 (8%) versus 7/95 (7%): RR 1.10; 95% CI 0.40 to 3.03), plasma ammonia concentration (2 trials, 93 participants: MD -6.61 μmol/L; 95% CI -30.05 to 16.84), or change in plasma ammonia concentration (1 trial, 77 participants: MD 1.16 μmol/L; 95% CI -1.96 to 4.28).

AUTHORS' CONCLUSIONS

The trials we located suffered from a high risk of systematic errors ('bias') and high risk of random errors ('play of chance'). While probiotics appear to reduce plasma ammonia concentration when compared with placebo or no intervention, we are unable to conclude that probiotics are efficacious in altering clinically relevant outcomes. Demonstration of unequivocal efficacy is needed before probiotics can be endorsed as effective therapy for hepatic encephalopathy. Further randomised clinical trials are needed.

Betaine inhibits Toll-like receptor 4 expression in rats with ethanol-induced liver injury

AIM: To test whether ethanol feeding could induce Toll-like receptor 4 (TLR4) responses, assess the hepatoprotective effect of betaine and its inhibitive effect on TLR4 in animal models of alcoholic liver injury.

METHODS: Forty-eight female Sprague-Dawley rats were randomly divided into four groups as control, model, low and high dose betaine groups. Except control group, all rats were fed with high fat-containing diet plus ethanol and fish oil gavages for 8 wk. Betaine was administered intragastrically after exposure of ethanol for 4 wk. The changes of liver histology were examined. The expression of TLR4 mRNA and protein was detected by RT-PCR and Western blotting, respectively. The serum aminotransferase activity [alanine transarninase (ALT), aspartate aminotransferase (AST)], serum endotoxin, and liver inflammatory factors [tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin-18 (IL-18)] were also assayed.

RESULTS: Compared with control group, rats of model group developed marked liver injury, accompanied by an increase of ALT (159.41 ± 7.74 U/L vs 59.47 ± 2.34 U/L, P < 0.0001), AST (248.25 ± 1.40 U/L vs 116.89 ± 3.48 U/L, P < 0.0001), endotoxin (135.37 ± 30.17 ng/L vs 44.15 ± 7.54 ng/L, P < 0.0001), TNF-α (20.81 ± 8.58 pg/mL vs 9.34 ± 2.57 pg/mL, P = 0.0003), IFN-γ (30.18 ± 7.60 pg/mL vs 16.86 ± 9.49 pg/mL, P = 0.0039) and IL-18 (40.99 ± 8.25 pg/mL vs 19.73 ± 9.31 pg/mL, P = 0.0001). At the same time, the expression of TLR4 mRNA and protein was markedly induced in the liver after chronic ethanol consumption (1.45 ± 0.07 vs 0.44 ± 0.04, P < 0.0001; 1.83 ± 0.13 vs 0.56 ± 0.08, P < 0.0001). Compared with model group, betaine feeding resulted in significant decreases of ALT (64.93 ± 6.06 U/L vs 159.41 ± 7.74 U/L, P < 0.0001), AST (188.73 ± 1.11 U/L vs 248.25 ± 1.40 U/L, P < 0.0001), endotoxin (61.80 ± 12.56 ng/L vs 135.37 ± 30.17 ng/L, P < 0.0001), TNF-α (9.79 ± 1.32 pg/mL vs 20.81 ± 8.58 pg/mL, P = 0.0003), IFN-γ (18.02 ± 5.96 pg/mL vs 30.18 ± 7.60 pg/mL, P = 0.0008) and IL-18 (18.23 ± 7.01 pg/mL vs 40.99 ± 8.25 pg/mL, P < 0.0001). Betaine also improved liver steatosis. The expression levels of TLR4 mRNA or protein in liver tissues were significantly lowered (0.62 ± 0.04 vs 1.45 ± 0.07, P < 0.0001; and 0.65 ± 0.06 vs 1.83 ± 0.13, P < 0.0001). There was a statistical difference of TLR4 mRNA and protein expression between high- and low-dose betaine groups (0.62 ± 0.04 vs 0.73 ± 0.05, P < 0.0001, and 0.65 ± 0.06 vs 0.81 ± 0.09, P < 0.0001).

CONCLUSION: Betaine can prevent the alcohol-induced liver injury effectively and improve the liver function. The expression of TLR4 increases significantly in ethanol-fed rats and betaine administration can inhibit TLR4 expression.

Effect of Qingchang Supporsitory on expression of MAdCAM-1 in the colonic mucosa of rats with TNBS-induced colitis

AIM: To investigate the role of mucosal addressin cell adhesion molecule-1 (MAdCAM-1) in the pathogenesis of trinitrobenzene sulfonic acid (TNBS) induced rat colitis and to investigate the mechanisms underlying the anti-inflammatory action of Qingchang Supporistory (QCS).

METHODS: The TNBS induced rat colitis model was established. Rats were randomly divided into QCS high-dose group, QCS low-dose group, salicylazosulfapyridine (SASP) group, model Ⅰgroup, model Ⅱ group and normal group. Rats in model Ⅰ group were killed at day 3 while other rats were killed after 7 days' treatment. Histopathological assessment of the colonic mucosa was performed. LTB₄ and TNF-α in the colonic mucosa were determined using sandwich enzyme-linked immunosorbent assay (ELISA). Expression of MAdCAM-1 was determined using immunohistochemistry staining and Western blot.

RESULTS: Three days after TNBS administration, colonic mucosal injury occurred in model Ⅰ group while colonic mucosal injury was attenuated in QCS group after 7 days' treatment of QCS. Compared with normal group, the levels of LTB4 and TNF-α in colonic mucosal were raised in the model group (436.38 ± 66.56, 396.81 ± 69.43 vs 203.76 ± 42.84; 394.78 ± 61.53, 413.43 ± 47.39 vs 233.84 ± 55.24, P < 0.01). Compared with model II group, the colonic mucosa levels of LTB4 and TNF-α of all treatment groups were markedly decreased, especially in QCS high-dose group (275.74 ± 36.35, 282.72 ± 47.94, both P < 0.01). MAdCAM-1 was constitutively expressed on the lamina propria of normal colonic mucosa and the amount of positive staining cells dramatically were enhanced in model Ⅰ group. Compared with model Ⅱ group, the expression of MAdCAM-1 was significantly down-regulated in QCS high-dose group, QCS low-dose group and SASP group.

CONCLUSION: QCS performs significant anti-inflammatory action likely through inhibiting colonic mucosal LTB₄ and TNF-α production as well as down-regulating MAdCAM-1 expression.

Prevention of hepatic oxidative injury by Xiao-Chen-Chi-Tang in mice

The three purgative Cheng-Chi-Tang decoctions (CCTDs) including Ta-Cheng-Chi-Tang (TCCT), Xiao-Chen-Chi-Tang (XCCT), and Tiao-Wei-Chen-Chi-Tang (TWCCT) are used for treating gastrointestinal disorders, including liver diseases in traditional Chinese medicine. However, the underlying mechanisms as liver disease remedies are far from fully clarified. The objective of the study is to investigate and compare the antioxidant activity of the three purgative CCTDs in order to delineate their hepatic protective potential and mechanism. Antioxidant activity measured with the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging test indicated XCCT as the most potent preparation (IC(50) 8.94 microg/ml). In tert-butylhydroperoxide (TBH, 50mM)-induced lipid peroxidation in ICR mice liver homogenates, XCCT also showed stronger and dose-dependent inhibitory activity against TBH-induced malondialdehyde (MDA, a marker of lipid peroxidation) production (IC(50) 53.66 microg/ml). In addition, XCCT showed dose-dependent protective effect against TBH-induced cytotoxicity in normal human Chung liver cells Furthermore, in carbon tetrachloride (CCl(4))-induced acute liver injury model, mice pretreated with 0.2g/kg and 0.4 g/kg of XCCT extracts showed a decrease of 59.8 and 43.1% in serum glutamic oxaloactetic transaminase (GOT) level, 51.4 and 52% in glutamic pyruvate transaminase (GPT) level, along with a reduction of 31 and 15% in MDA level, respectively, similar to the effects exerted by silymarin. XCCT pretreated mice also showed milder necrotic changes in the microscopic picture of the liver. The results suggest that XCCT has significant antioxidant activity and hepatic protection potential.

Cultural adaptation and application of the IBS-QOL in China: a disease-specific quality-of-life questionnaire

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and episodic illness characterized by altered bowel habits and associated abdominal pain. At present, IBS is one of the most common functional gastrointestinal and motility disorders affecting countries around the world. Surveys have found that patients with IBS have a significantly lower health-related quality of life.

OBJECTIVES

The aim of this study was to translate and examine the validity of the Irritable Bowel Syndrome-Quality of Life questionnaire (IBS-QOL) in patients suffering from IBS in China.

METHODS

A structured procedure was used for the translation and cultural adaptation of the original English IBS-QOL into Chinese. The questionnaire was administered to 73 clinical patients with IBS and 70 healthy individuals. Psychometric testing for reliability, validity and responsiveness followed standardized procedures. Test-retest reliability (10-20 hours) was assessed using the clinical patients. Follow-up (4 weeks) was collected for 61 clinical patients. All enrolled patients also completed the Short Form-36 Health Survey (SF-36) at the baseline visit. Responsiveness to treatment (Venlafaxine and traditional Chinese herbal medicine) was assessed by one-way ANOVA methods.

RESULTS

The average length of time required to complete the questionnaire was short (5.63 min for IBS patients and 5.54 min for healthy subjects by self-administration). Internal consistency (Cronbach's alpha) values ranged from 0.722 to 0.914 for the Chinese IBS-QOL subscales and test-retest reliability coefficients were higher than 0.920 on all subscales. The convergent and discriminate validity results comparing the Chinese translation of the IBS-QOL overall score and the SF-36 subscales confirmed our predicted hypotheses. The Chinese IBS-QOL scores are more highly correlated with social functioning, vitality and general health (SF-36) and show weaker associations with physical functioning, role physical, mental health, and bodily pain (SF-36). The Chinese translation of the IBS-QOL was responsive to treatment.

CONCLUSION

In general, the Chinese translation of the IBS-QOL, after cultural adaptation and revision, possesses good reliability, validity and responsiveness. It is a reliable and valid instrument to assess the quality of life in Chinese patients suffering from IBS and is an appropriate measure to use in further clinical trials or for related research projects in China.

Idiosyncratic toxicity: a convergence of risk factors

The therapeutic margin for any drug is based on both toxicity and efficacy. Generally, toxicity is dose-dependent and is driven either by the therapeutic target or by an untoward target. However, idiosyncratic toxicities are usually not observed until a drug has been on the market and has gained broad exposure. Except in the case of pharmacokinetic interactions, these toxicities are not driven solely by drug exposure but rather depend on several drug- and patient-related risk factors. Drug-related risk factors include metabolism, bioactivation and covalent binding, and the inhibition of key cell functions. Patient-related risk factors include underlying disease, age, gender, comedications, nutritional status, activation of the innate immune system, physical activity, and genetic predispositions. Idiosyncratic toxicity can occur when a convergence of risk factors, including drug exposure, tips the risk-benefit balance away from benefit and toward risk.

The use of selected nutrition supplements and complementary and alternative medicine in liver disease

Almost all patients with liver disease, especially advanced liver disease, have some evidence of malnutrition, including mineral/vitamin deficiency. A major health trend in the United States has been the significant growth in the use of complementary and alternative medicine (CAM), including nutrition supplements and herbal agents. In the 1990s, the United States government created the National Center for Complementary and Alternative Medicine (NCCAM), as well as the Office on Dietary Supplements, to extend our knowledge in these areas. CAM users are often highly educated and frequently use CAM therapy for chronic diseases, including chronic liver disease. Indeed, most studies suggest that patients with chronic liver disease frequently use nutrition supplements and CAM agents in addition to their traditional medicines. The purpose of this review is to provide an update on the role of nutrition supplements and herbals in liver disease. This article will focus mainly on 7 selected agents (vitamin E, zinc, magnesium, S-adenosylmethionine, betaine, silymarin, and glycyrrhizin), for which there have been not only in vitro and animal studies but also human clinical trials, and we will review both potential efficacy and safety issues.

Polyphenols and gastrointestinal diseases

PURPOSE OF REVIEW

This article will review the role of polyphenols in gastrointestinal diseases. Ingested polyphenols are concentrated in the gastrointestinal tract and are not well absorbed into the rest of the body. Thus, the high luminal concentrations achieved support a potential for therapeutic uses in the gastrointestinal tract. Additionally, there is great interest from the general public in complementary and alternative medicine.

RECENT FINDINGS

Dietary polyphenols are a major source of antioxidants consumed by humans. Polyphenols possess not only antioxidant properties but also antiviral, antibacterial, antiinflammatory and anticarcinogenic effects, as well as the ability to modulate certain signaling pathways such as nuclear factor-kappaB activation. Green tea polyphenols have been shown to have efficacy in various models of inflammatory bowel disease. Silymarin, or milk thistle, is hepatoprotective against many forms of experimental liver injury and is widely used in human liver diseases, such as hepatitis C and alcoholic cirrhosis, with an excellent safety profile (but with unclear efficacy).

SUMMARY

Substantial in-vitro and animal studies support the beneficial effects of polyphenols in many gastrointestinal diseases. Well designed multicenter trials in humans, such as those called for in the 2005 National Institutes of Health Requests for Applications for Silymarin Centers, will be critical for defining the safety, appropriate dosing and therapeutic efficacy of such agents.

Effects of betaine on expression of caspase-12 in ethanol-induced liver injury in rats

AIM: To investigate the effects of betaine on the expression of caspase-12 in the liver of rats with ethanol-induced liver injury.

METHODS: Forty-eight female SD rats were randomly divided into 4 groups: control, model, and low and high dose betaine group. Except the rats in control group, all the rats were fed fat-rich diet plus ethanol plus fish oil gavage for 8 wk. Betaine was administered intragastrically in the rats of betaine groups after 4-wk exposure of ethanol. The expression of caspase-12 was detected in the liver tissues by immunohistomistry and semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS: Compared with that in control group, the expression of caspase-12 was markedly induced in the liver after chronic ethanol consumption (mRNA: 1.00 vs 0.18, P <0.01; protein: 0.296 9±0.045 1 vs 0.052 6±0.023 4, P < 0.01). However, the level of caspa-se-12 expression was significantly lower in high- and low-dose betaine group than that in model group (mRNA: 0.10, 0.12 vs 1.00, P < 0.01; protein: 0.121 5±0.013 0, 0.185 0±0.008 5 vs 0.296 9±0.045 1, P < 0.01). Significant difference of caspase-12 expression also existed between high- and low-dose betaine group (mRNA: 0.10 vs 0.12, P < 0.05; protein: 0.121 5±0.013 0 vs 0.185 0±0.008 5, P < 0.05).

CONCLUSION: Betaine suppresses the expression of caspase-12 both in mRNA and protein level in the rats with ethanol-induced liver injury, which may be related to its anti-apoptotic mechanism.