The Incidence of self-prescribed oral complementary and alternative medicine use by patients with gastrointestinal diseases

CT Appearance of Pulmonary Arteriovenous Malformations and Mimics

A pulmonary arteriovenous malformation (PAVM) is a fistulous connection between a pulmonary artery and a pulmonary vein that bypasses the normal pulmonary capillary bed resulting in a right-to-left shunt. Because of the potential for paradoxical emboli, PAVMs are treated when their feeding arteries exceed 3 mm or patients are symptomatic. PAVMs are often encountered in patients with suspected hereditary hemorrhagic telangiectasia (HHT). Sporadic cases are uncommon. The radiologist may be called on to diagnose a PAVM after positive transthoracic contrast-enhanced echocardiography in a patient with suspected HHT to direct patient management and avoid potential complications. The radiologist may also be required to evaluate a potential PAVM detected at CT performed for other reasons. Through the authors' experiences at an HHT Center of Excellence in an area endemic with histoplasmosis, the authors have gained a unique perspective on the diagnosis of PAVMs and differentiation of PAVMs from their mimics. Understanding the CT appearance of PAVMs limits misdiagnosis, directs appropriate treatment, and allows subsequent family screening for HHT (and avoidance of unnecessary screening when a PAVM mimic is encountered). Both vascular and nonvascular pulmonary lesions can mimic PAVMs. Vascular mimics include fibrosing mediastinitis, venovenous collaterals, arterial collaterals, pulmonary artery pseudoaneurysms, hepatopulmonary vessels, Sheehan vessels, meandering pulmonary veins, and pulmonary vein varices. Nonvascular mimics include granulomas, nodules, mucoceles, bronchoceles, ground-glass opacities, and atelectasis. The authors review the CT technique for evaluating PAVMs and the appearance of PAVMs and their mimics. ^©RSNA, 2022.

Hepatopulmonary syndrome delays postoperative recovery and increases pulmonary complications after hepatectomy

BACKGROUND

This study attempted to investigate the impact of hepatopulmonary syndrome (HPS) on postoperative outcomes in hepatitis B virus-induced hepatocellular carcinoma (HBV-HCC) patients.

METHODS

HBV-HCC patients undergoing primary curative hepatectomy for HCC in our hospital were diagnosed with HPS by contrast-enhanced echocardiography (CEE) and arterial blood gas analysis. Patients were divided into HPS, intrapulmonary vascular dilation (IPVD) (patients with positive CEE results and normal oxygenation) and control (patients with negative CEE results) groups. Baseline information, perioperative clinical data and postoperative pulmonary complications (PPCs) were compared among all groups. Cytokines in patient serums from each group (n = 8) were also assessed.

RESULTS

Eighty-seven patients undergoing hepatectomy from October 2019 to January 2020 were analyzed. The average time in the postanaesthesia care unit (112.10 ± 38.57 min) and oxygen absorption after extubation [34.0 (14.5-54.5) min] in the HPS group was longer than in IPVD [81.81 ± 26.18 min and 16.0 (12.3-24.0) min] and control [93.70 ± 34.06 min and 20.5 (13.8-37.0) min] groups. There were no significant differences in oxygen absorption time after extubation between HPS and control groups. The incidence of PPCs, especially bi-lateral pleural effusions in the HPS group (61.9%), was higher than in IPVD (12.5%) and control (30.0%) groups. Increased serum levels of the growth-regulated oncogene, monocyte chemoattractant protein, soluble CD40 ligand and interleukin 8 might be related to delayed recovery in HPS patients.

CONCLUSIONS

HPS patients with HBV-HCC suffer delayed postoperative recovery and are at higher risk for PPCs, especially bi-lateral pleural effusions, which might be associated with changes in certain cytokines.

Yoga as a Therapy for Irritable Bowel Syndrome

The aim of this state-of-the-art narrative review is to evaluate the current evidence about the effectiveness of yoga as therapy for IBS and explore its potential mechanisms of action. The current literature suggests yoga is effective and safe and may target multiple mechanisms involved in treatment of IBS. Evidence from randomized controlled trials identified yoga as more effective compared to pharmacological treatment and equally effective as dietary interventions or moderate-intensity walking. Improvements were seen in both physical health (IBS symptom severity, gastric motility, autonomic and somatic symptom scores, and physical functioning) and mental health outcomes (depression, anxiety, gastrointestinal-specific anxiety, and quality of life). Given favorable changes in IBS-related physical and mental health outcomes, preliminary data supports yoga as beneficial in this population. However, the relatively low-quality evidence resulting from heterogeneity of study designs, interventions, and outcome measures limit our ability to make specific recommendations about the use of yoga as therapy for patients with IBS.

Anti-irritable Bowel Syndrome Syrup Improves Constipation-Predominant Irritable Bowel Syndrome: A Randomized, Placebo-Controlled Trial

OBJECTIVE

To evaluate the efficacy and safety of administration of the formulated Persian herbal syrup on improving the symptoms of patients with constipation-predominant irritable bowel syndrome (IBS-C).

METHODS

This study was conducted in 70 patients with IBS-C, who were recruited from 3 medical centers in Mashhad, Iran, from November 2017 to August 2018. Seventy patients were randomly assigned to 2 groups including treatment and placebo groups by block randomization, 35 cases in each group. Patients in the treatment group received 15 mL of anti-IBS syrup, thrice daily for 6 weeks and followed up for 4 weeks. Placebo syrup was also prepared through similar instruction, BP syrup without plant extract was used. Primary outcome induding IBS Symptom Severity Scale (IBS-SSS) questionnaire and secondary outcomes in terms of Hospital Anxiety and Depression (HADS) questionnaires, the Bristol Stool Form Scale (BSFS) were completed and evaluated at weeks 6 and 10, respectively. Safety indices were collected at the end of the treatment and Common Terminology Criteria for Adverse Events v4.0 (CTCAE) was used to evaluate the adverse events.

RESULTS

The response to treatment was 84.4% (27/32) in the treatment group and 46.4% (13/28) in the placebo group, respectively (P= 0.002). Compared with pre-treatment, a significant decrease was found on the IBS-SSS and BSFS scores after 6-week intervention in both groups (P<0.001). Moreover, IBS-SSS and BSFS scores in the treatment group were lower than the placebo group after the intervention (P=0.041). There was no significant difference in the anxiety and depression scores after treatment in both groups (P>0.05). Side effects reported in the treatment group included 2 cases of headache during the first week of the onset of the treatment, 1 case of drowsiness, 1 case of increase in menstrual bleeding, which did not result in discontinuation of the treatment. In the placebo group, 1 case of exacerbation of the disease was reported.

CONCLUSIONS

Anti-IBS syrup significantly reduced the severity of IBS symptoms compared to placebo. However, there was a need for further investigation regarding the anxiety and depression scores. (Registration No. IRCT2017061034446N1).

Acupuncture and related therapies for treating irritable bowel syndrome: overview of systematic reviews and network meta-analysis

BACKGROUND

An overview of systematic reviews (SRs) and a network meta-analysis (NMA) were conducted to evaluate the comparative effectiveness of acupuncture and related therapies used either alone, or as an add-on to other irritable bowel syndrome (IBS) treatments.

METHODS

A total of eight international and Chinese databases were searched for SRs of randomized controlled trials (RCTs). The methodological quality of SRs was appraised using the AMSTAR instrument. From the included SRs, data from RCTs were extracted for the random-effect pairwise meta-analyses. An NMA was used to evaluate the comparative effectiveness of different treatment options. The risk of bias among included RCTs was assessed using the Cochrane risk of bias tool.

RESULTS

From 15 SRs of mediocre quality, 27 eligible RCTs (n = 2141) were included but none performed proper blinding. Results from pairwise meta-analysis showed that both needle acupuncture and electroacupuncture were superior in improving global IBS symptoms when compared with pinaverium bromide. NMA results showed needle acupuncture plus Geshanxiaoyao formula had the highest probability of being the best option for improving global IBS symptoms among 14 included treatment options, but a slight inconsistency exists.

CONCLUSION

The risk of bias and NMA inconsistency among included trials limited the trustworthiness of the conclusion. Patients who did not respond well to first-line conventional therapies or antidepressants may consider acupuncture as an alternative. Future trials should investigate the potential of (1) acupuncture as an add-on to antidepressants and (2) the combined effect of Chinese herbs and acupuncture, which is the norm of routine Chinese medicine practice.

Naturopathic Approaches to Irritable Bowel Syndrome-A Delphi Study

INTRODUCTION

Irritable bowel syndrome (IBS) affects 11% of the population, and up to 50% of patients report using complementary and alternative medicines (CAM) for it. To date, there is no research describing how providers of naturopathic medicine in North America, a well-defined CAM profession, approach IBS.

METHODS

A Delphi study was conducted over a 17-month period in 4 rounds with 15 North American naturopathic medicine experts in IBS. Consensus was defined as a median value of 75% or greater agreement with the relevant statement.

RESULTS

Consensus was met with 45 statements describing a "reasonable naturopathic approach" to IBS. These statements covered the domains of general, office visits, tracking progress, testing, interventions, and resources.

CONCLUSION

These results represent the beginning of an evidence base depicting naturopathic interventions for IBS and should inform future randomized controlled clinical trials in this area. Future research should look to reflect on and revise these guidance consensus statements particularly extending to other stakeholders as well as geographic and regulatory jurisdictions in the naturopathic profession.

Hepatopulmonary syndrome caused by hypothalamic obesity and nonalcoholic fatty liver disease after surgery for craniopharyngioma: a case report

Hypothalamic obesity is often complicated in patients with craniopharyngioma due to hypothalamic damage by the tumor itself, treatment modalities, and associated multiple pituitary hormone deficiency. Hypothalamic obesity causes secondary diseases such as nonalcoholic fatty liver disease (NAFLD) and diabetes mellitus (DM). We report a 19-year-old female who was diagnosed with craniopharyngioma, developed hypothalamic obesity after tumor resection, and progressed to hepatopulmonary syndrome. She manifested NAFLD 1 year after tumor resection. Two years later, the craniopharyngioma recurred, and she underwent a second resection. Three years after her second operation, she was diagnosed with type 2 DM, after which she did not visit the outpatient clinic for 2 years and then suddenly reappeared with a weight loss of 25.8 kg that had occurred over 21 months. One month later, she presented to the Emergency Department with dyspnea. Laboratory findings revealed liver dysfunction and hypoxia with increased alveolar artery oxygen gradient. Liver biopsy showed portal hypertension and micronodular cirrhosis. Echocardiography and a lung perfusion scan demonstrated a right to left shunt. She was finally diagnosed with hepatopulmonary syndrome and is currently awaiting a donor for liver transplantation. Patients surviving craniopharyngioma need to be followed up carefully to detect signs of hypothalamic obesity and monitored for the development of other comorbidities such as DM, NAFLD, and hepatopulmonary syndrome.

Brown rice and retrograded brown rice alleviate inflammatory response in dextran sulfate sodium (DSS)-induced colitis mice

We investigate the impact of brown rice and retrograded brown rice consumption on colonic health in dextran sulfate sodium induced colitis mice.

Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension

Objective

The aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni.

Location

The University of São Paulo Medical School, Brazil; Public Practice.

Methods

Hemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15).

Results

The cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05).

Conclusions

The late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.

Red wine polyphenol extract efficiently protects intestinal epithelial cells from inflammation via opposite modulation of JAK/STAT and Nrf2 pathways

The development of therapeutic approaches combining efficacy and safety represents an important goal in intestinal inflammation research. Recently, evidence has supported dietary polyphenols as useful tools in the treatment and prevention of chronic inflammatory diseases, but the mechanisms of action are still poorly understood. We here reveal molecular mechanisms underlying the anti-inflammatory action of a non-alcoholic polyphenol red wine extract (RWE), operating at complementary levels via the Janus kinase/signal transducer and activator of transcription (JAK/STAT) and Nuclear factor-erythroid 2-related factor-2 (Nrf2) pathways. RWE significantly reduced the nuclear levels of phosphorylated STAT1 and also the cellular levels of phosphorylated JAK1 induced by cytokines, suppressing the JAK/STAT inflammatory signalling cascade. In turn, RWE increased the Nrf2 nuclear level, activating the Nrf2 pathway, leading not only to an up-regulation of the heme oxygenase-1 (HO-1) expression but also to an increase of the glutamate-cysteine ligase subunit catalytic (GCLc) gene expression, enhancing the GSH synthesis, thereby counteracting GSH depletion that occurs under inflammatory conditions. Overall, data indicate that the anti-inflammatory action of RWE is exerted at complementary levels, via suppression of the JAK/STAT inflammatory pathway and positive modulation of the activity of Nrf2. These results point to the potential use of the RWE as an efficient, readily available and inexpensive therapeutic strategy in the context of gastrointestinal inflammation.

Hepatopulmonary Syndrome

Hepatopulmonary syndrome (HPS) is a pulmonary complication observed in patients with chronic liver disease and/or portal hypertension, attributable to an intrapulmonary vascular dilatation that may induce severe hypoxemia. Microvascular dilation and angiogenesis in the lung have been identified as pathologic features that drive gas exchange abnormalities in experimental HPS. Pulse oximetry is a useful screening test for HPS, which can guide subsequent use of arterial blood gases. Contrast-enhanced echocardiography, perfusion lung scanning, and pulmonary arteriography are three currently used diagnostic imaging modalities that identify the presence of intrapulmonary vascular abnormalities. The presence of HPS increases mortality and impairs quality of life, but is reversible with liver transplantation. No medical therapy is established as effective for HPS. At the present time, liver transplantation is the only available treatment for HPS.

Complementary and Alternative Medicine Use Is Prevalent Among Patients with Gastrointestinal Diseases

INTRODUCTION

Complementary and alternative medicine (CAM) use is reported to be higher among patients with irritable bowel syndrome and inflammatory bowel disease; however, demographic predictors and reasons for utilization for all GI conditions are less clear.

AIM

To determine prevalence, predictors, and reasons for CAM use among all patients attending a gastrointestinal (GI) clinic in a single academic center.

METHODS

Adults attending outpatient GI clinics at Beth Israel Deaconess Medical Center completed a questionnaire to assess CAM utilization as well as perceived benefits, harms, and costs of CAM therapy. Fisher's exact test was used to compare statistical differences between CAM and non-CAM users.

RESULTS

Survey questionnaires were completed by 269 patients. Prevalence of CAM use was 44 % (95 % CI 38-50). Users were more likely to be female (81 vs. 56 %, p < 0.01) and dissatisfied with conventional treatment (22 vs. 8 %, p < 0.01). There was no significant difference in age, race, education, income, GI diagnosis, and duration of symptoms between the two groups. Users reported "wish to feel generally better" as main reason for utilization, and a majority of patients (62 %) experienced improved GI symptoms. Among patients who did not discuss CAM with their physicians (30 %), they cited physician failure to ask about CAM as the major reason (82 %).

CONCLUSION

CAM is prevalent among patients attending a GI clinic, particularly among women and those who are dissatisfied with conventional therapies and "wish to feel better." Greater awareness and understanding of CAM among GI physicians is necessary.

The hepatopulmonary syndrome

Introduction

The hepatopulmonary syndrome has been acknowledged as an important vascular complication in lungs developing systemic hypoxemia in patients with cirrhosis and portal hypertension. Is formed by arterial oxygenation abnormalities induced from intrapulmonary vascular dilatations with liver disease. It is present in 4-32% of patients with cirrhosis. It increases mortality in the setting of cirrhosis and may influence the frequency and severity. Initially the hypoxemia responds to low-flow supplemental oxygen, but over time, the need for oxygen supplementation is necessary. The liver transplantation is the only effective therapeutic option for its resolution.

Aim

To update clinical manifestation, diagnosis and treatment of this entity.

Method

A literature review was performed on management of hepatopulmonary syndrome. The electronic search was held of the Medline-PubMed, in English crossing the headings "hepatopulmonary syndrome", "liver transplantation" and "surgery". The search was completed in September 2013.

Results

Hepatopulmonary syndrome is classically defined by a widened alveolar-arterial oxygen gradient (AaPO2) on room air (>15 mmHg, or >20 mmHg in patients >64 years of age) with or without hypoxemia resulting from intrapulmonary vasodilatation in the presence of hepatic dysfunction or portal hypertension. Clinical manifestation, diagnosis, classification, treatments and outcomes are varied.

Conclusion

The severity of hepatopulmonary syndrome is an important survival predictor and determine the improvement, the time and risks for liver transplantation. The liver transplantation still remains the only effective therapeutic.

Calea zacatechichi dichloromethane extract exhibits antidiarrheal and antinociceptive effects in mouse models mimicking irritable bowel syndrome

Calea zacatechichi Schltdl. (Asteraceae alt. Compositae) is a Mexican plant commonly used in folk medicine to treat respiratory and gastrointestinal (GI) disorders. The objective of this study is to characterize the effect of C. zacatechichi extracts in mouse models mimicking the symptoms of irritable bowel syndrome (IBS). Powdered C. zacatechichi herb (leaves, stems, and flowers) was extracted with methanol. Methanolic extract was filtered and evaporated giving methanolic fraction. The residue was extracted with dichloromethane (DCM). Methanolic and DCM (200 mg/kg, per os) extracts were screened for their effect on GI motility in several in vitro tests, and the antidiarrheal and antinociceptive effects were assessed using mouse models. The influence of the DCM extract on motoric parameters and exploratory behaviors was also assessed. Finally, the composition of C. zacatechichi DCM extract was qualitatively analyzed using liquid chromatography-mass spectrometry (LC-MS) method. C. zacatechichi DCM extract significantly inhibited the contractility of mouse colon in vitro (IC₅₀ = 17 ± 2 μg/ml). Administration of the DCM extract in vivo (200 mg/kg, per os) significantly prolonged the time of whole GI transit (46 ± 1 vs. 117 ± 27 min for control and DCM-treated animals, respectively; P = 0.0023), inhibited hypermotility, and reduced pain in mouse models mimicking functional GI disorders. Our findings suggest that constituents of the C. zacatechichi DCM extract exhibit antidiarrheal and analgesic activity. The extract may thus become an attractive material for isolation of compounds that may be used as a supplementary treatment for pain and diarrhea associated with IBS in the future.

Bone morphogenic protein-2 regulates the myogenic differentiation of PMVECs in CBDL rat serum-induced pulmonary microvascular remodeling

Hepatopulmonary syndrome (HPS) is characterized by an arterial oxygenation defect induced by intrapulmonary vasodilation (IPVD) that increases morbidity and mortality. In our previous study, it was determined that both the proliferation and the myogenic differentiation of pulmonary microvascular endothelial cells (PMVECs) play a key role in the development of IPVD. However, the molecular mechanism underlying the relationship between IPVD and the myogenic differentiation of PMVECs remains unknown. Additionally, it has been shown that bone morphogenic protein-2 (BMP2), via the control of protein expression, may regulate cell differentiation including cardiomyocyte differentiation, neuronal differentiation and odontoblastic differentiation. In this study, we observed that common bile duct ligation (CBDL)-rat serum induced the upregulation of the expression of several myogenic proteins (SM-α-actin, calponin, SM-MHC) and enhanced the expression levels of BMP2 mRNA and protein in PMVECs. We also observed that both the expression levels of Smad1/5 and the activation of phosphorylated Smad1/5 were significantly elevated in PMVECs following exposure to CBDL-rat serum, which was accompanied by the down-regulation of Smurf1. The blockage of the BMP2/Smad signaling pathway with Noggin inhibited the myogenic differentiation of PMVECs, a process that was associated with relatively low expression levels of both SM-α-actin and calponin in the setting of CBDL-rat serum exposure, although SM-MHC expression was not affected. These findings suggested that the BMP2/Smad signaling pathway is involved in the myogenic differentiation of the PMVECs. In conclusion, our data highlight the pivotal role of BMP2 in the CBDL-rat serum-induced myogenic differentiation of PMVECs via the activation of both Smad1 and Smad5 and the down-regulation of Smurf1, which may represent a potential therapy for HPS-induced pulmonary vascular remodeling.

Surfactant protein A is decreased in the lung of rats with hepatopulmonary syndrome

PURPOSE

To evaluate surfactant protein A levels in an hepatopulmonary syndrome rat model. To date, there have been no studies aimed at evaluating surfactant levels in the setting of cirrhosis or hepatopulmonary syndrome.

METHODS

A total of 35 rats were divided into control, sham, and experimental HPS groups. We evaluated surfactant protein A levels in rats and the experimental model designed to induce hepatopulmonary syndrome was common bile duct ligation. Statistical analysis was performed using GraphPad Prism Software(r). Differences were considered statistically significant when p<0.05.

RESULTS

Lung homogenate of surfactant protein A levels were lower in the experimental hepatopulmonary syndrome and sham groups in comparison to the control group (p<0.05). Serum SP-A levels were the same in experimental hepatopulmonary syndrome and control groups but decreased in the sham group compared with the experimental groups (p<0.05). Myeloperoxidase activity was higher in the experimental hepatopulmonary syndrome group than the other two groups (p<0.05).

CONCLUSION

Surfactant protein A is present in experimental hepatopulmonary syndrome and leads to an imbalance between serum and pulmonary levels due to systemic inflammatory response.

Aggravation of hepatopulmonary syndrome after sildenafil treatment in a patient with coexisting portopulmonary hypertension

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PPHTN) are complications of portal hypertension and cirrhosis. Their pathophysiological mechanisms clearly differ. HPS is characterized by a defect in arterial oxygenation induced by pulmonary vascular dilatation. In contrast, PPHTN is predominantly due to excessive pulmonary vasoconstriction and vascular remodeling, but is rarely associated with hypoxia. We report a case of a patient who had both HPS and PPHTN at the time of presentation. HPS was aggravated after sildenafil administration for the treatment of PPHTN. We demonstrated increased amount of intrapulmonay shunt after sildenafil challenge by using agitated saline contrast transthoracic echocardiography.

Hypoxia among patients on the liver-transplant waiting list

Background

Hepatopulmonary syndrome is formed by a triad of liver disease, intrapulmonary vascular dilatation and changes in blood gases. This condition is present in 4-32% of patients with cirrhosis.

Aim

To analyze the blood gas changes data of patients in liver-transplant waiting list.

Method

Clinical data of 279 patients in liver transplantation waiting list in May 2013 were studied. Overall patient was analyzed by the demographic aspects, laboratorial and image findings on exams that determine lung disease (hypoxemia) in these cirrhotic patients. The mean values and standard deviations were used to examine normally distributed variables.

Results

There was a high prevalence of male patients (68%); the mean age was 51(±5,89) years, and the predominant reason for listing was hepatitis C cirrhosis. The MELD score mean was 16±5,89, without prioritization or special situation. The most common blood type was O in 129 cases (46%) and the mean of body max index was 25,94±4,58. Regarding arterial blood gas tests was observed 214 patients with PaO2 <90 mmHg, 80 with PaO2 <80 mmHg and 39 with PaO2 <50 mmHg. In relation to O₂ saturation, 50 patients had <90%, 33 <80% and 10 <50%.

Conclusion

Was observed a high rate of hypoxemia in patients on waiting list liver transplant. Due to the high severity and morbidity, is suggested better monitoring and therapeutic support to hypoxemic patients on liver transplant waiting list.

Myeloperoxidase activity is increased in hepatopulmonary syndrome in rats

BACKGROUND

Hepatopulmonary syndrome is formed by a triad of liver disease, intrapulmonary vascular dilatation and changes in blood gases. Its pathogenesis is not well defined, but it is speculated that a combination of factors, such as the imbalance of endothelin receptor responses, pulmonary microvascular remodeling, and genetic predisposition, leads to bacterial translocation and intrapulmonary vascular dilatation.

AIM

To evaluate the myeloperoxidase activity in hepatopulmonary syndrome in rat model.

METHOD

Twenty-nine rats were divided into control, sham and experimental hepatopulmonary syndrome groups. Was evaluated the myeloperoxidase activity and the experimental model used to induce hepatopulmonary syndrome was common bile duct ligation.

RESULTS

The myeloperoxidase activity levels were significantly increased in the common bile duct ligation group as compared with the other groups. Myeloperoxidase activity was higher in the common bile duct ligation group than control group (p<0.05) and than sham group (p<0.05).

CONCLUSION

The myeloperoxidase activity is increased in experimental hepatopulmonary syndrome in rats.

Antagonizing arachidonic acid-derived eicosanoids reduces inflammatory Th17 and Th1 cell-mediated inflammation and colitis severity

During colitis, activation of two inflammatory T cell subsets, Th17 and Th1 cells, promotes ongoing intestinal inflammatory responses. n-6 polyunsaturated fatty acid- (PUFA-) derived eicosanoids, such as prostaglandin E2 (PGE2), promote Th17 cell-mediated inflammation, while n-3 PUFA antagonize both Th17 and Th1 cells and suppress PGE2 levels. We utilized two genetic mouse models, which differentially antagonize PGE2 levels, to examine the effect on Th17 cells and disease outcomes in trinitrobenzene sulfonic acid- (TNBS-) induced colitis. Fat-1 mice contain the ω3 desaturase gene from C. elegans and synthesize n-3 PUFA de novo, thereby reducing the biosynthesis of n-6 PUFA-derived eicosanoids. In contrast, Fads1 Null mice contain a disrupted Δ5 desaturase gene and produce lower levels of n-6 PUFA-derived eicosanoids. Compared to Wt littermates, Fat-1 and Fads1 Null mice exhibited a similar colitic phenotype characterized by reduced colonic mucosal inflammatory eicosanoid levels and mRNA expression of Th17 cell markers (IL-17A, RORγτ, and IL-23), decreased percentages of Th17 cells and, improved colon injury scores (P ≤ 0.05). Thus, during colitis, similar outcomes were obtained in two genetically distinct models, both of which antagonize PGE2 levels via different mechanisms. Our data highlight the critical impact of n-6 PUFA-derived eicosanoids in the promotion of Th17 cell-mediated colonic inflammation.

Lung and liver changes due to the induction of cirrhosis in two experimental models

CONTEXT

To evaluate lung and liver changes in two experimental models using intraperitoneal carbon tetrachloride (CCl4) and bile duct ligation (BDL). methods: Twenty-four male Wistar rats were divided into a control group (CO) and an experimental group (EX). We evaluated the liver transaminases (AST, ALT, AP), arterial blood gases (PaO2, PCO2 and SpO2) and lipid peroxidation by TBARS (substances that react to thiobarbituric acid) and chemiluminescence. We also evaluated the antioxidant enzyme superoxide dismutase (SOD) and histology of lung tissue and liver.

RESULTS

There were significant differences in AST, ALT, ALP and PaO2 between CO group and EX group (P<0.05). The levels of TBARS, chemiluminescence and activity of enzyme superoxide dismutase were increased to different degrees in the CCl4 groups: CO and in the BDL -EX (P<0.05, respectively). In the lung histology, an increase in the wall thickness of the pulmonary artery and a diameter reduction in the CCl4 animal model were observed: comparing CO group with EX group, we observed a reduction in thickness and an increase in the diameter of the artery wall lung.

CONCLUSION

Both experimental models have caused liver damage and alterations in the artery wall that are associated with major changes in pulmonary gas exchange.

Irritable bowel syndrome: The evolution of multi-dimensional looking and multidisciplinary treatments

Irritable bowel syndrome (IBS) is common in the society. Among the putative pathogeneses, gut dysmotility results in pain and disturbed defecation. The latter is probably caused by the effect of abnormal gut water secretion. The interaction between abnormal gas accumulation, abdominal pain and bloating remains controversial. Visceral hypersensitivity and its modification along with the central transmission are the characteristics of IBS patients. The identification of biologic markers based on genetic polymorphisms is undetermined. Imbalanced gut microbiota may alter epithelial permeability to activate nociceptive sensory pathways which in turn lead to IBS. Certain food constituents may exacerbate bowel symptoms. The impact of adult and childhood abuses on IBS is underestimated. Using the concept of biopsychosocial dysfunction can integrate multidimensional pathogeneses. Antispasmodics plus stool consistency modifiers to treat the major symptoms and defecation are the first-line drug treatment. New drugs targeting receptors governing bowel motility, sensation and secretion can be considered, but clinicians must be aware of their potential serious side effects. Psychiatric drugs and modalities may be the final options for treating intractable subjects. Probiotics of multi-species preparations are safe and worth to be considered for the treatment. Antibiotics are promising but their long-term safety and effectiveness are unknown. Diet therapy including exclusion of certain food constituents is an economic measure. Using relatively safe complementary and alternative medicines (CAMs) may be optional to those patients who failed classical treatment. In conclusion, IBS is a heterogeneous disorder with multidimensional pathogeneses. Personalized medicines with multidisciplinary approaches using different classes of drugs, psychiatric measures, probiotics and antibiotics, dietary therapy, and finally CAMs, can be considered.

The effects of flavanoid on the treatment of hepatopulmonary syndrome

Purpose

Hepatopulmonary syndrome is an arterial oxygenation disorder brought about by advanced liver failure and pulmonary vascular dilatations. The reason why hypoxia develops in hepatopulmonary syndrome depends on the broadening of perialveolar capillary veins. Our study aims to investigate the effects of Flavanoid on hepatopulmonary syndrome through its inhibition of nitric oxide.

Methods

Three groups, each having 8 rats, were formed within the scope of our study. Group I (the control group) only received laparatomy, group II received choledoch ligation, and group III was administered Flavanoid (90% flavonoid diosmin, 10% flavonoid hesperidin) following choledoch ligation. The rats were administered Flavanoid at week two following choledoch ligation. The rats' livers and lungs were examined histopathologically following a five-week follow-up and the perialveolar vein diameters were measured. Arterial blood gases and biochemical parameters were evaluated.

Results

It was seen that fibrosis and oxidative damage in the liver with obstructive jaundice as well as hypoxia with pulmonary perialveolar vein sizes were significantly lower than the other group with cirrhosis formed through the administration of Flavanoid.

Conclusion

We have concluded that Flavanoid administration might be useful in the treatment of hypoxia in hepatopulmonary syndrome and the delay of cirrhosis contraction.

Annexin A1 protein regulates the expression of PMVEC cytoskeletal proteins in CBDL rat serum-induced pulmonary microvascular remodeling

Background

Hepatopulmonary syndrome (HPS) is characterized by advanced liver disease, hypoxemia and intrapulmonary vascular dilatation (IPVD). The pathogenesis of HPS is not completely understood. Recent findings have established the role of proliferation and phenotype differentiation of pulmonary microvascular endothelial cells (PMVECs) in IPVD of HPS; the change in cytoskeletal proteins and their molecular mechanism play an essential role in the proliferation, phenotype modulation and differentiation of PMVECs. However, little is known about the relevance of cytoskeletal protein expression and its molecular mechanism in IPVD of HPS. In addition, ANX A1 protein has been identified as a key regulator in some important signaling pathways, which influences cytoskeletal remodeling in many diseases, such as lung cancer, liver cancer, etc.

Methods

PMVECs were cultured from the normal rats and then divided into three groups(Ad-ANXA1-transfected group, a non-transfected group, and an adenovirus empty vector group) and incubated by nomal rat serum or hepatopulmonary syndrome rat serum respectively. mRNA level was evaluated by real time reverse transcription polymerase chain reaction, and protein expression was detected by western blot. Cell proliferation was determined by the MTT and thymidine incorporation assay.

Results

In this study, we found that the serum from a common bile duct ligation(CBDL) Rat model decreased the expression levels of the ANX A1 mRNA and protein by at least two-fold in human PMVECs. We also found the expression of cytoskeletal proteins (Destrin, a1-actin, and a1-tubulin) in PMVECs significantly increased. After stimulating ANX A1 over-expression in PMVECs by adenovirus-mediated ANX A1 (Ad-ANXA1) transfection, we found the expression levels of cytoskeletal proteins were significantly suppressed in PMVECs at all time points. Additionally, we report here that serum from a CBDL Rat model increases the proliferation of PMVECs by nearly two-fold and that over-expression of Ad-ANXA1 significantly inhibits HPS-rat-serum-induced PMVEC proliferation (p <0.05). These findings suggest that the ANX A1 down-regulation of PMVEC proliferation in the presence of HPS-rat-serum may be the major cause of aberrant dysregulation of cytoskeletal proteins (Destrin, a1-actin, and a1-tubulin) and may, therefore, play a fundamental role in the proliferation and phenotype differentiation of PMVECs in the PVD of HPS.

Conclusion

Finally, the fact that transfection with Ad-ANXA1 results in inhibition of the aberrant dysregulation of cytoskeletal proteins and proliferation of PMVECs suggests a potential therapeutic effect on PVD of HPS.

Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys

This systematic review aimed to estimate the prevalence of use of complementary and alternative medicine (CAM) in the UK. Five databases were searched for English language, peer-reviewed surveys published between 1 January 2000 and 7 October 2011. In addition, relevant book chapters and files from our own departmental records were searched by hand. Eighty-nine surveys were included, with a total of 97,222 participants. Most studies were of poor methodological quality. Across surveys on CAM in general, the average one-year prevalence of use of CAM was 41.1% and the average lifetime prevalence was 51.8%. In methodologically sound surveys, the equivalent rates were 26.3% and 44%, respectively. In surveys with response rates >70%, average one-year prevalence was nearly threefold lower than in surveys with response rates between 21% and 50%. Herbal medicine was the most popular CAM, followed by homeopathy, aromatherapy, massage and reflexology. Many patients and consumers in the UK use CAM; healthcare professionals should therefore responsibly advise their patients about the use of CAM.

Use and predictors of oral complementary and alternative medicine by patients with inflammatory bowel disease: a population-based, case-control study

BACKGROUND

The use of complementary and alternative medicine (CAM) in the general population and in patients with chronic diseases has increased markedly in recent decades. We aimed to determine the prevalence, type, and predictors of oral CAM use among patients with inflammatory bowel disease (IBD) compared with the general population in a large, population-based, case-control study.

METHODS

Overall, 1370 patients with IBD and 598 control subjects in Canterbury, New Zealand, were recruited. Environmental and phenotypic data were obtained through a questionnaire and case note review. Predictors of oral CAM use were identified using binary logistic regression.

RESULTS

In the previous year, 44.1% of patients with IBD and 42.3% of control subjects used oral CAM (odds ratio [OR], 1.078; 95% confidence interval [CI], 0.885-1.312). The types of oral CAM used most frequently were vitamins (Crohn's disease [CD], 25.2%; ulcerative colitis, 23.7%; control subjects, 24.9%), followed by herbs (CD 15.1%, ulcerative colitis 15.2%, control subjects 12.8%), and dietary supplements (CD, 8.5%; ulcerative colitis 12.6%, control subjects 12.1%). Female gender (OR, 1.61; 95% CI, 1.25-2.08), younger age (P = 0.005), higher education (P = 0.002), higher income (P = 0.04), being a vegetarian (OR, 3.58; 95% CI, 1.97-6.48) and a middle social class at birth (P = 0.024) were independent predictors of oral CAM use in patients with IBD. Disease phenotype was not associated with oral CAM use. In control subjects, female gender (OR, 2.67; 95% CI, 1.85-3.86), higher education (P = 0.003) and a diagnosis of asthma (P = 0.017) predicted oral CAM use.

CONCLUSIONS

Oral CAM use is common in, and does not differ between, patients with IBD and the general population in Canterbury, New Zealand. Socio-demographic factors, and not disease phenotype, predict oral CAM use in patients with IBD.

Oxidative stress and pulmonary changes in experimental liver cirrhosis

The use of carbon tetrachloride (CCl₄) in rats is an experimental model of hepatic tissue damage; which leads to fibrosis, and at the long term, cirrhosis. Cirrhosis is the consequence of progressive continued liver damage, it may be reversible when the damaging noxae have been withdrawn. The aim of this study is to evaluate the changes caused by cirrhosis in lung and liver, through the experimental model of intraperitoneal CCI₄ administration. We used 18 male Wistar rats divided into three groups: control (CO) and two groups divided by the time of cirrhosis induction by CCI₄: G1 (11 weeks), G2 (16 weeks). We found significant increase of transaminase levels and lipid peroxidation (TBARS) in liver and lung tissue and also increased antioxidant enzymes SOD and CAT, as well as the expression of TNF-α and IL-1β in the lung of cirrhotic animals. We observed changes in gas exchange in both cirrhotic groups. We can conclude that our model reproduces a model of liver cirrhosis, which causes alterations in the pulmonary system that leads to changes in gas exchange and size of pulmonary vessels.

Use of complementary and alternative medicine in patients with inflammatory bowel disease: results of a cross-sectional study in Norway

OBJECTIVE

To determine the proportion of complementary and alternative medicine (CAM) use in patients with inflammatory bowel disease (IBD) and to identify demographic and clinical factors that are associated with CAM use.

MATERIAL AND METHODS

In this cross-sectional study design, patients with confirmed diagnosis of ulcerative colitis (UC) or Crohn's disease (CD), and ≥18 years old, attending outpatient clinics at 14 hospitals in Norway were eligible to complete questionnaires including demographics, clinical variables, and the International CAM Questionnaire (I-CAM-Q).

RESULTS

Of 460 patients included in the study, 430 had evaluable questionnaires (response rate 93%). Forty-nine percent (95% CI: 44-54) had used some type of CAM within the past 12 months. CAM services were utilized by 27% (95% CI: 23-31) of the patients, 21% (95% CI: 16-23) reported use of CAM products, and 28% (95% CI: 23-31) used CAM self-help practices. The most common pattern of CAM use was to combine CAM services and CAM products. Significantly, more UC patients (56%) than CD patients (44%) reported CAM use, p = 0.03. In UC, only the presence of at least one comorbid condition was directly related to CAM use. In CD, being a woman, being aged 31-50 years, having a higher education level, and experiencing adverse drug reactions from IBD medication were factors independently associated with the use of CAM.

CONCLUSION

Use of CAM was common among IBD patients attending outpatient clinics. Both demographic and clinical factors were associated to CAM use, but the factors differed in their significance for UC and CD.

Meditation over medication for irritable bowel syndrome? On exercise and alternative treatments for irritable bowel syndrome

Complimentary alternative treatment regimens are widely used in irritable bowel syndrome (IBS), but the evidence supporting their use varies. For psychological treatment options, such as cognitive behavioral therapy, mindfulness, gut-directed hypnotherapy, and psychodynamic therapy, the evidence supporting their use in IBS patients is strong, but the availability limits their use in clinical practice. Dietary interventions are commonly included in the management of IBS patients, but these are primarily based on studies assessing physiological function in relation to dietary components, and to a lesser degree upon research examining the role of dietary components in the therapeutic management of IBS. Several probiotic products improve a range of symptoms in IBS patients. Physical activity is of benefit for health in general and recent data implicates its usefulness also for IBS patients. Acupuncture does not seem to have an effect beyond placebo in IBS. A beneficial effect of some herbal treatments has been reported.

Effects of caffeic acid phenethyl ester (CAPE) on hepatopulmonary syndrome

The aim of this study was to investigate the effects of caffeic acid phenethyl ester (CAPE) on inflammatory and related histopathological changes in the lung and liver in experimental hepatopulmonary syndrome (HPS) model. Forty Sprague Dawley rats were used in this study. The animals were divided into four groups of ten rats each. Group 1 and 2 was subjected the common bile duct (CBD) but not ligated, Group 3; (cirrhosis + saline): the CBD was ligated and was given intraperitoneal saline infusion treatment during 5 weeks. Group 4; (cirrhosis + CAPE): the CBD was ligated and was given intraperitoneal CAPE infusion treatment during 5 weeks. A 5-week waiting period was observed for the development of cirrhosis and the rats' lungs and liver were taken for histopathological examination. The induction of HPS resulted in a significant increase in serum bilurubin, AST, ALT, and NO levels, and decrease PO2 and O2 saturation. The use of CAPE significant decrease these parameters. Histopathological examination revealed less congestion, portal inflammation, and nodular formations of the liver, and less congestion, emphysematous and inflammatory changes and smallest perialviolar vascular diameters, in the lung in the cirrhosis + CAPE groups than in the other groups. CAPE treatment may be a potential approach for the treatment of hepatopulmonary syndrome in the future.

Dietary intervention with narrow-leaved cattail rhizome flour (Typha angustifolia L.) prevents intestinal inflammation in the trinitrobenzenesulphonic acid model of rat colitis

Background

Inflammatory bowel disease (IBD) is a chronic inflammation of the intestinal epithelium that is driven by the intestinal immune system, oxidative stress and the loss of tolerance to the luminal microbiota. The use of dietary products containing ingredients such as fibres and carbohydrates and/or antioxidant compounds have been used as a therapeutic strategy for intestinal diseases because these products are considered effective in the modulation of the immune system and colonic microbiota. We investigated the beneficial effects of cattail rhizome flour (Typha angustifolia L.) in the trinitrobenzenesulphonic acid (TNBS) model of rat colitis. In addition, we investigated the effects of cattail rhizome flour on the intestinal anti-inflammatory activity of prednisolone, which is a reference drug that is used for treatment of human IBD.

Methods

The present study included the preparation of flour from rhizomes of cattail (Typha angustifolia L.); an evaluation of the qualitative phytochemical profile of cattail rhizomes; an evaluation of the efficacy of cattail rhizome flour in TNBS-induced rat colitis; an evaluation of the synergistic effects of cattail rhizome flour on the intestinal anti-inflammatory activity of prednisolone; and macroscopic, clinical, biochemical, histopathological and microbiological studies to assess the healing effects of cattail rhizome flour and its synergistic effects in TNBS-induced rat colitis. The data were analysed by ANOVA, Kruskal-Wallis and χ² tests.

Results

We tested several concentrations of cattail rhizome flour and found that dietary supplementation with 10% cattail rhizome flour showed the best effects at reducing the extension of the lesion, the colon weight ratio, adherences to adjacent organs and diarrhoea. These effects were related to inhibition of myeloperoxidase (MPO) and alkaline phosphatase (AP) activities and an attenuation of glutathione (GSH) depletion. The 10% cattail rhizome flour was as effective as prednisolone, and no synergistic effects were observed. Saponins, flavonoids and coumarins were detected in the rhizome flour. No changes were observed in the total number of lactic bacteria after dietary supplementation with cattail rhizome flour.

Conclusions

Dietary supplementation with 10% cattail rhizome flour and its combination with prednisolone prevent TNBS-induced colonic damage in rats, but no synergistic effects were observed. The prevention of TNBS-induced colon damage was associated with an improvement in intestinal oxidative stress, which likely resulted from the antioxidant properties of the active compounds detected in the cattail rhizome. This protective effect was not related to an improvement in lactic bacteria counts.

Irritable bowel syndrome and other gastrointestinal disorders: evaluating self-medication in an Asian community setting

BACKGROUND

Gastrointestinal disorders frequently present symptoms which are often self-treated.

OBJECTIVE

To record demographic profile of patients visiting community pharmacies for self-treatment with medications for gastrointestinal disorders, the number of these patients who fulfilled irritable bowel syndrome diagnostic criteria, and to judge the appropriateness of their treatment requests.

SETTING

Singapore community pharmacies.

METHOD

The multicentre study was conducted using ROME III adapted criteria on adults above 18 years who have self-selected medicinal products for treatment of irritable bowel syndrome or gastrointestinal symptoms in the community pharmacy.

RESULTS

Among those seeking self-medication, 36.8 % fulfilled criteria for irritable bowel syndrome, with irritable bowel syndrome-mixed (16.3 %) being the most prevalent subtype. For patients not fulfilling criteria for irritable bowel syndrome diagnosis, rates for other functional gastrointestinal disorders were constipation (20.5 %), dyspepsia (16.3 %), gastroesophageal reflux disease (12.1 %), diarrhoea (8.9 %), bloating (4.2 %), and heartburn (3.2 %). There were more females with gastrointestinal complaints. Overall, 21.6 % of the total participants had recently sought medical attention for their gastrointestinal complaint. 20 % of patients selected inappropriate medication for their gastrointestinal complaints, and the antacids class had the highest incidence of inappropriate medication use. Possible co-existing relationships were seen between gastroesophageal reflux disease with dyspepsia, irritable bowel syndrome with gastroesophageal reflux disease, irritable bowel syndrome with dyspepsia, and diarrhoea with constipation.

CONCLUSION

Patients who fulfilled criteria for irritable bowel syndrome had a high tendency to self-treat their gastrointestinal symptoms. Constipation complaints were also common. Around one in five patients self-medicated gastrointestinal symptoms inappropriately, with antacids being the most common.

Detection of hepatopulmonary syndrome in patients with liver cirrhosis using 3D contrast echocardiography

BACKGROUND AND STUDY AIMS

Hepatopulmonary syndrome (HPS) is characterised by the triad of advanced liver disease, arterial hypoxaemia and intrapulmonary vascular dilatation (IPVD). The present study aimed to evaluate HPS in patients with liver cirrhosis and the role of three-dimensional (3D) contrast echocardiography in the detection of this syndrome.

PATIENTS AND METHODS

A total of 78 chronic liver disease patients aged 42 ± 11 years fulfilled the criteria for this study and were subjected to clinical examination, laboratory investigations, arterial blood gases measurement, pulmonary function tests, upper gastrointestinal endoscopy, 3D contrast echocardiography and computed tomography (CT) pulmonary angiography.

RESULTS

According to 3D contrast echocardiography results, we divided the patients into a positive group (n=26) in which patients showed a delayed appearance of contrast in left heart chambers and a negative group (n=52). Among 26 patients of the positive group, nine had hypoxaemia (partial pressure of oxygen (PaO(2)) <70 mm Hg) and were diagnosed as having hepatopulmonary syndrome (HPS), the other 17 who had shown echocardiographic evidence of IPVDs but without hypoxaemia were diagnosed as having sub-clinical HPS. This study showed significant correlation between positive contrast echocardiography findings and duration of liver disease, Child score, cyanosis, clubbing, orthodeoxia, portal vein diameter, spleen size and oesophageal varices grades. No significant correlation was found between 3D contrast echocardiography findings and age, sex, spider naevi and pulmonary function tests. Multivariate logistic regression showed that cyanosis, clubbing, orthodeoxia, Child score and portal vein diameter are independent predictors of HPS.

CONCLUSION

Cyanosis, clubbing and platypnoea-orthodeoxia are suggestive indicators of HPS, which can be easily detected by 3D contrast echocardiography which can replace the trans-oesophageal echocardiogram (TEE) in cirrhotic patients.

Pulmonary complications of gastrointestinal disorders

The pulmonary involvement concurrent with gastrointestinal (GI) diseases is often clinically subtle. Radiological manifestations might lag behind the respiratory compromise, and only such specialized testing as high resolution computed tomography (HRCT), permeability studies with labelled proteins, or comprehensive pulmonary function tests (PFTs) may be sensitive enough to detect the evolving pathophysiology. Increasing recognition of specific entities, such as immune-mediated alveolitis, will allow implementation of therapies that can significantly improve a patient's prognosis.

Immunomodulatory action of dietary fish oil and targeted deletion of intestinal epithelial cell PPARδ in inflammation-induced colon carcinogenesis

The ligand-activated transcription factor peroxisome proliferator-activated receptor (PPAR)-δ is highly expressed in colonic epithelial cells; however, the role of PPARδ ligands, such as fatty acids, in mucosal inflammation and malignant transformation has not been clarified. Recent evidence suggests that the anti-inflammatory/chemoprotective properties of fish oil (FO)-derived n-3 polyunsaturated fatty acids (PUFAs) may be partly mediated by PPARδ. Therefore, we assessed the role of PPARδ in modulating the effects of dietary n-3 PUFAs by targeted deletion of intestinal epithelial cell PPARδ (PPARδ(ΔIEpC)). Subsequently, we documented changes in colon tumorigenesis and the inflammatory microenvironment, i.e., local [mesenteric lymph node (MLN)] and systemic (spleen) T cell activation. Animals were fed chemopromotive [corn oil (CO)] or chemoprotective (FO) diets during the induction of chronic inflammation/carcinogenesis. Tumor incidence was similar in control and PPARδ(ΔIEpC) mice. FO reduced mucosal injury, tumor incidence, colonic STAT3 activation, and inflammatory cytokine gene expression, independent of PPARδ genotype. CD8(+) T cell recruitment into MLNs was suppressed in PPARδ(ΔIEpC) mice. Similarly, FO reduced CD8(+) T cell numbers in the MLN. Dietary FO independently modulated MLN CD4(+) T cell activation status by decreasing CD44 expression. CD11a expression by MLN CD4(+) T cells was downregulated in PPARδ(ΔIEpC) mice. Lastly, splenic CD62L expression was downregulated in PPARδ(ΔIEpC) CD4(+) and CD8(+) T cells. These data demonstrate that expression of intestinal epithelial cell PPARδ does not influence azoxymethane/dextran sodium sulfate-induced colon tumor incidence. Moreover, we provide new evidence that dietary n-3 PUFAs attenuate intestinal inflammation in an intestinal epithelial cell PPARδ-independent manner.

Cannabis use amongst patients with inflammatory bowel disease

BACKGROUND

Experimental evidence suggests the endogenous cannabinoid system may protect against colonic inflammation, leading to the possibility that activation of this system may have a therapeutic role in inflammatory bowel disease (IBD). Medicinal use of cannabis for chronic pain and other symptoms has been reported in a number of medical conditions. We aimed to evaluate cannabis use in patients with IBD.

METHODS

One hundred patients with ulcerative colitis (UC) and 191 patients with Crohn's disease (CD) attending a tertiary-care outpatient clinic completed a questionnaire regarding current and previous cannabis use, socioeconomic factors, disease history and medication use, including complimentary alternative medicines. Quality of life was assessed using the short-inflammatory bowel disease questionnaire.

RESULTS

A comparable proportion of UC and CD patients reported lifetime [48/95 (51%) UC vs. 91/189 (48%) CD] or current [11/95 (12%) UC vs. 30/189 (16%) CD] cannabis use. Of lifetime users, 14/43 (33%) UC and 40/80 (50%) CD patients have used it to relieve IBD-related symptoms, including abdominal pain, diarrhoea and reduced appetite. Patients were more likely to use cannabis for symptom relief if they had a history of abdominal surgery [29/48 (60%) vs. 24/74 (32%); P=0.002], chronic analgesic use [29/41 (71%) vs. 25/81 (31%); P<0.001], complimentary alternative medicine use [36/66 (55%) vs. 18/56 (32%); P=0.01] and a lower short inflammatory bowel disease questionnaire score (45.1±2.1 vs. 50.3±1.5; P=0.03). Patients who had used cannabis [60/139 (43%)] were more likely than nonusers [13/133 (10%); P<0.001 vs. users] to express an interest in participating in a hypothetical therapeutic trial of cannabis for IBD.

CONCLUSION

Cannabis use is common amongst patients with IBD for symptom relief, particularly amongst those with a history of abdominal surgery, chronic abdominal pain and/or a low quality of life index. The therapeutic benefits of cannabinoid derivatives in IBD may warrant further exploration.

Pharmacologic and complementary and alternative medicine therapies for irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by episodic abdominal pain or discomfort in association with altered bowel habits (diarrhea and/or constipation). Other gastrointestinal symptoms, such as bloating and flatulence, are also common. A variety of factors are believed to play a role in the development of IBS symptoms, including altered bowel motility, visceral hypersensitivity, psychosocial stressors, altered brain-gut interactions, immune activation/low grade inflammation, alterations in the gut microbiome, and genetic factors. In the absence of biomarkers that can distinguish between IBS subgroups on the basis of pathophysiology, treatment of this condition is predicated upon a patient's most bothersome symptoms. In clinical trials, effective therapies have only offered a therapeutic gain over placebos of 7-15%. Evidence based therapies for the global symptoms of constipation predominant IBS (IBS-C) include lubiprostone and tegaserod; evidence based therapies for the global symptoms of diarrhea predominant IBS (IBS-D) include the probiotic Bifidobacter infantis, the nonabsorbable antibiotic rifaximin, and alosetron. Additionally, there is persuasive evidence to suggest that selected antispasmodics and antidepressants are of benefit for the treatment of abdominal pain in IBS patients. Finally, several emerging therapies with novel mechanisms of action are in development. Complementary and alternative medicine therapies including probiotics, herbal therapies and acupuncture are gaining popularity among IBS sufferers, although concerns regarding manufacturing standards and the paucity of high quality efficacy and safety data remain.

Integrated medicine in the management of chronic illness: a qualitative study

BACKGROUND

Complementary and alternative medicine (CAM) is popular with patients, yet how patients use CAM in relation to orthodox medicine (OM) is poorly understood.

AIM

To explore how patients integrate CAM and OM when self-managing chronic illness.

DESIGN OF STUDY

Qualitative analysis of interviews.

METHOD

Semi-structured interviews were conducted with individuals attending private CAM practices in the UK, who had had a chronic benign condition for 12 months and were using CAM alongside OM for more than 3 months. Patients were selected to create a maximum variation sample. The interviews were analysed using framework analysis.

RESULTS

Thirty five patient interviews were conducted and seven categories of use were identified: using CAM to facilitate OM use; using OM to support long-term CAM use; using CAM to reduce OM; using CAM to avoid OM; using CAM to replace OM; maximising relief using both CAM and OM; and returning to OM. Participants described initiating CAM use following a perceived lack of suitable orthodox treatment. Participants rejecting OM for a specific condition never totally rejected OM in favour of CAM.

CONCLUSION

Patients utilise CAM and OM in identifiably different ways, individualising and integrating both approaches to manage their chronic conditions. To support patients and prevent potential adverse interactions, open dialogue between patients, OM practitioners, and CAM practitioners must be improved.

Use of complementary and alternative medicine by patients with inflammatory bowel disease

In this review article we provide a broad overview of complementary and alternative medicine (CAM) use in inflammatory bowel diseases (IBDs), including prevalence of use, common therapies used, and reasons for and factors associated with CAM use. CAM is commonly used by those suffering from IBD. Multiple forms of CAM are used to treat IBD, and often patients use multiple CAM therapies and continue to use conventional medical therapies. Patients using CAM report benefits that extend beyond simply improved disease control. Using CAM allows patients to exert a greater degree of control over their disease and its management than they are afforded by conventional medicine. There is limited evidence on the efficacy of CAM therapies in IBD. It is important for physicians caring for those with IBD to be familiar with common forms of CAM and to be able to provide general counseling to their patients about CAM use.

Alterations in plasma carbon monoxide levels and alveolar permeability in cirrhotic rats

AIM: To examine possible alterations in plasma carbon monoxide (CO) levels and alveolar permeability in rats with carbon tetrachloride-induced cirrhosis.

METHODS: Liver cirrhosis was induced in rats by subcutaneous administration of carbon tetrachloride. Mean arterial pressure (MAP, kPa), heart rate (HR, b/min), and portal pressure (PP, cm/H₂O) were monitored by using an indwelling catheter. Plasma CO levels were determined by Chalmers method, and alveolar permeability was measured using the Evens blue extravasation technique.

RESULTS: Typical features of cirrhosis were histologically observed in carbon tetrachloride-treated rats. Compared with normal control rats, cirrhotic rats presented a significant increase in portal pressure (16.67 cmH₂O ± 0.63 cmH₂O vs 8.82 cmH₂O ± 0.29 cmH₂O; P < 0.01), plasma CO levels (18.69 μmol/L ± 1.86 μmol/L vs 10.27 μmol/L ± 1.21 μmol/L; P < 0.01), and Evens blue extravasation (36.57 μg/g ± 1.69 μg/g vs 29.83 μg/g ± 2.34 μg/g; P < 0.01), but a significant decrease in mean arterial pressure (15.92 kPa ± 0.74 kPa vs 18.93 kPa ± 0.71 kPa; P < 0.01).

CONCLUSION: Activation of the HO-CO system and increased alveolar permeability may be important causes of development of hepatopulmonary syndrome in patients with cirrhosis.

Probiotic and prebiotic use in patients with inflammatory bowel disease: a case-control study

BACKGROUND

The use of complementary and alternative medicine in inflammatory bowel disease (IBD) has been extensively studied. However, the use of probiotics and prebiotics is poorly documented, despite evidence of efficacy of particular probiotic strains in specific forms of IBD.

METHODS

A case-control study comprising interviewer-administered questionnaires was conducted in IBD patients and healthy controls. Data regarding use and knowledge of probiotics and prebiotics, demographic, and clinical information were collected.

RESULTS

In total, 334 participants (234 IBD, 100 controls) were interviewed. Significantly more IBD patients than controls had ever used probiotics to manage their health (Crohn's disease [CD] 43%, ulcerative colitis [UC] 51%, controls 21%, P < 0.001). Prebiotic use was negligible. On logistic regression analysis, having UC (odds ratio [OR] 4.30, 95% confidence interval [CI] 2.27-8.12) or CD (OR 3.05, 95% CI 1.66-5.60) were the strongest predictors of probiotic use. Within IBD patients the strongest predictor of probiotic use was current steroid use (OR 2.4, 95% CI 1.11-5.18). IBD patients had greater probiotic knowledge scores than controls (P = 0.003), although 20% of IBD probiotic users could not provide a definition of a probiotic. Less than half of IBD probiotic users discussed probiotic use with healthcare professionals, with commercial advertising being the primary source of information.

CONCLUSIONS

Patients with IBD use probiotics to manage their health but frequently choose strains without evidence of efficacy in IBD. Patients rely on nonclinical sources of information and often do not disclose probiotic use to healthcare professionals. Conventional healthcare providers should inquire about probiotic use among their patients and offer evidence-based advice.

Dietary conjugated linoleic acid and n-3 polyunsaturated fatty acids in inflammatory bowel disease

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) is a debilitating and widespread immune-mediated illness of unknown etiology. Current treatments are modestly successful and with significant side-effects. The purpose of this review is to summarize the current understanding of mechanisms of action underlying the anti-inflammatory actions of conjugated linoleic acid (CLA) and n-3 polyunsaturated fatty acids (PUFAs) in IBD.

RECENT FINDINGS

Nutrition-based interventions that target peroxisome proliferator-activated receptors (PPARs) such as dietary CLA and n-3 PUFA have demonstrated anti-inflammatory efficacy in animal models of IBD. Clinical data on n-3 PUFA in IBD remains generally unimpressive, although results of a recent human study demonstrate that IBD remission can be maintained by maintaining the n-3: n-6 ratio more than 0.65 via n-3 PUFA intervention. In mice, CLA prevented inflammation-driven colorectal cancer by activating PPAR gamma and modulating regulatory T cells and macrophages. CLA is the subject of an ongoing clinical study in Crohn's disease patients.

SUMMARY

Compelling evidence demonstrates that n-3 PUFA and CLA prevent or ameliorate IBD in animal models. However, this basic knowledge has not been translated into novel nutrition-based clinical interventions. For both compounds there is an urgent need for placebo-controlled, large-scale, multicenter clinical trials.

Reduced baroreflex sensitivity and pulmonary dysfunction in alcoholic cirrhosis: effect of hyperoxia

Patients with cirrhosis exhibit impaired regulation of the arterial blood pressure, reduced baroreflex sensitivity (BRS), and prolonged QT interval. In addition, a considerable number of patients have a pulmonary dysfunction with hypoxemia, impaired lung diffusing capacity (Dl(CO)), and presence of hepatopulmonary syndrome (HPS). BRS is reduced at exposure to chronic hypoxia such as during sojourn in high altitudes. In this study, we assessed the relation of BRS to pulmonary dysfunction and cardiovascular characteristics and the effects of hyperoxia. Forty-three patients with cirrhosis and 12 healthy matched controls underwent hemodynamic and pulmonary investigations. BRS was assessed by cross-spectral analysis of variabilities between blood pressure and heart rate time series. A 100% oxygen test was performed with the assessment of arterial oxygen tensions (Pa(O(2))) and alveolar-arterial oxygen gradient. Baseline BRS was significantly reduced in the cirrhotic patients compared with the controls (4.7 +/- 0.8 vs. 10.3 +/- 2.0 ms/mmHg; P < 0.001). The frequency-corrected QT interval was significantly prolonged in the cirrhotic patients (P < 0.05). There was no significant difference in BRS according to presence of HPS, Pa(O(2)), Dl(CO), or Child-Turcotte score, but BRS correlated with metabolic and hemodynamic characteristics. After 100% oxygen inhalation, BRS and the QT interval remained unchanged in the cirrhotic patients. In conclusion, BRS is significantly reduced in patients with cirrhosis compared with controls, but it is unrelated to the degree of pulmonary dysfunction and portal hypertension. Acute hyperoxia does not significantly revert the low BRS or the prolonged QT interval in cirrhosis.

Coexisting hepatopulmonary syndrome and portopulmonary hypertension: implications for liver transplantation

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) represent pulmonary complications of liver disease and portal hypertension. The underlying pathophysiology behind these entities is complex and involves different effects of vasoactive substances on the pulmonary vasculature, among them endothelin-1 and nitric oxide (NO). Hepatopulmonary syndrome results from vasodilation, intrapulmonary shunting, and hypoxia. In contrast, portopulmonary hypertension is predominantly owing to generalized vasoconstriction that leads to remodeling and an increase in pulmonary vascular resistance, but is rarely associated with hypoxia. We present a case report in which these 2 processes with opposing pathologic mechanisms coexist in the same patient. We also conducted a literature search to identify other documented cases of coexisting hepatopulmonary syndrome and portopulmonary hypertension, common clinical features of these patients, and outcomes with or without treatment. Our case highlights the importance of recognizing the coexistence of these 2 disease processes, as they may occur simultaneously and affect the approach to treatment, including liver transplantation.

Herbal remedies are the main etiologic factor in melanosis coli, a case series study

Melanosis coli is a brown to black discoloration of the colon mucosa usually associated with long-term ingestion of laxatives. However, melanosis coli can be found in patients with no history of laxative use. Regular use of herbal remedies could be the major source of anthranoid laxatives in such patients. We designed a prospective case series study to identify the clinical characteristics and etiology of melanosis coli in affected patients. This study took place in Ankara, Turkey, between 08/2005 and 11/2006. Patients with endoscopic diagnosis of melanosis coli were interviewed for demographical data and use of herbal remedies. A total of 380 colonoscopies were performed during this period. Melanosis coli was diagnosed endoscopically in 12 patients (3.17%), 11 of whom were found to have characteristic pigment-laden macrophages in histopathological examination. Herbal remedies were the main etiological factor in the development of melanosis coli in 10 out of 11 patients. Diffuse involvement was found in 2 patients who had a history of long-term use. In 8 patients, melanosis coli was located in the left side of the colon. Although melanosis coli is a harmless discoloration of colonic mucosa resulting from complementary or alternative medicine, we believe that this association with herbals was overlooked or not inquired in patients. Therefore, it should be emphasized that “natural” or “alternative” is not equal to “safe”.