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Ziaka M, Exadaktylos A. Exploring the lung-gut direction of the gut-lung axis in patients with ARDS. Crit Care 2024; 28:179. [PMID: 38802959 PMCID: PMC11131229 DOI: 10.1186/s13054-024-04966-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) represents a life-threatening inflammatory reaction marked by refractory hypoxaemia and pulmonary oedema. Despite advancements in treatment perspectives, ARDS still carries a high mortality rate, often due to systemic inflammatory responses leading to multiple organ dysfunction syndrome (MODS). Indeed, the deterioration and associated mortality in patients with acute lung injury (LI)/ARDS is believed to originate alongside respiratory failure mainly from the involvement of extrapulmonary organs, a consequence of the complex interaction between initial inflammatory cascades related to the primary event and ongoing mechanical ventilation-induced injury resulting in multiple organ failure (MOF) and potentially death. Even though recent research has increasingly highlighted the role of the gastrointestinal tract in this process, the pathophysiology of gut dysfunction in patients with ARDS remains mainly underexplored. This review aims to elucidate the complex interplay between lung and gut in patients with LI/ARDS. We will examine various factors, including systemic inflammation, epithelial barrier dysfunction, the effects of mechanical ventilation (MV), hypercapnia, and gut dysbiosis. Understanding these factors and their interaction may provide valuable insights into the pathophysiology of ARDS and potential therapeutic strategies to improve patient outcomes.
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Affiliation(s)
- Mairi Ziaka
- Clinic of Geriatric Medicine, Center of Geriatric Medicine and Rehabilitation, Kantonsspital Baselland, Bruderholz, Switzerland.
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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2
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DeSana AJ, Estus S, Barrett TA, Saatman KE. Acute gastrointestinal permeability after traumatic brain injury in mice precedes a bloom in Akkermansia muciniphila supported by intestinal hypoxia. Sci Rep 2024; 14:2990. [PMID: 38316862 PMCID: PMC10844296 DOI: 10.1038/s41598-024-53430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
Traumatic brain injury (TBI) increases gastrointestinal morbidity and associated mortality. Clinical and preclinical studies implicate gut dysbiosis as a consequence of TBI and an amplifier of brain damage. However, little is known about the association of gut dysbiosis with structural and functional changes of the gastrointestinal tract after an isolated TBI. To assess gastrointestinal dysfunction, mice received a controlled cortical impact or sham brain injury and intestinal permeability was assessed at 4 h, 8 h, 1 d, and 3 d after injury by oral administration of 4 kDa FITC Dextran prior to euthanasia. Quantification of serum fluorescence revealed an acute, short-lived increase in permeability 4 h after TBI. Despite transient intestinal dysfunction, no overt morphological changes were evident in the ileum or colon across timepoints from 4 h to 4 wks post-injury. To elucidate the timeline of microbiome changes after TBI, 16 s gene sequencing was performed on DNA extracted from fecal samples collected prior to and over the first month after TBI. Differential abundance analysis revealed that the phylum Verrucomicrobiota was increased at 1, 2, and 3 d after TBI. The Verrucomicrobiota species was identified by qPCR as Akkermansia muciniphila, an obligate anaerobe that resides in the intestinal mucus bilayer and produces short chain fatty acids (e.g. butyrate) utilized by intestinal epithelial cells. We postulated that TBI promotes intestinal changes favorable for the bloom of A. muciniphila. Consistent with this premise, the relative area of mucus-producing goblet cells in the medial colon was significantly increased at 1 d after injury, while colon hypoxia was significantly increased at 3 d. Our findings reveal acute gastrointestinal functional changes coupled with an increase of beneficial bacteria suggesting a potential compensatory response to systemic stress after TBI.
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Affiliation(s)
- Anthony J DeSana
- Department of Physiology, University of Kentucky, Biomedical and Biological Sciences Research Building (BBSRB), B473, 741 South Limestone St., Lexington, KY, 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Biomedical and Biological Sciences Research Building (BBSRB), B473, 741 South Limestone St., Lexington, KY, 40536, USA
| | - Steven Estus
- Department of Physiology, University of Kentucky, Biomedical and Biological Sciences Research Building (BBSRB), B473, 741 South Limestone St., Lexington, KY, 40536, USA
- Sanders Brown Center on Aging, University of Kentucky, Lee T. Todd, Jr. Building, Rm: 537, 789 South Limestone St., Lexington, KY, 40536, USA
| | - Terrence A Barrett
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine - Digestive Health, University of Kentucky, Lexington, KY, 40536, USA
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Medical Science Building, MN649, 780 Rose St., Lexington, KY, 40536, USA
| | - Kathryn E Saatman
- Department of Physiology, University of Kentucky, Biomedical and Biological Sciences Research Building (BBSRB), B473, 741 South Limestone St., Lexington, KY, 40536, USA.
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Biomedical and Biological Sciences Research Building (BBSRB), B473, 741 South Limestone St., Lexington, KY, 40536, USA.
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3
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Chiu LS, Anderton RS. The role of the microbiota-gut-brain axis in long-term neurodegenerative processes following traumatic brain injury. Eur J Neurosci 2023; 57:400-418. [PMID: 36494087 PMCID: PMC10107147 DOI: 10.1111/ejn.15892] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Traumatic brain injury (TBI) can be a devastating and debilitating disease to endure. Due to improvements in clinical practice, declining mortality rates have led to research into the long-term consequences of TBI. For example, the incidence and severity of TBI have been associated with an increased susceptibility of developing neurodegenerative disorders, such as Parkinson's or Alzheimer's disease. However, the mechanisms linking this alarming association are yet to be fully understood. Recently, there has been a groundswell of evidence implicating the microbiota-gut-brain axis in the pathogenesis of these diseases. Interestingly, survivors of TBI often report gastrointestinal complaints and animal studies have demonstrated gastrointestinal dysfunction and dysbiosis following injury. Autonomic dysregulation and chronic inflammation appear to be the main driver of these pathologies. Consequently, this review will explore the potential role of the microbiota-gut-brain axis in the development of neurodegenerative diseases following TBI.
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Affiliation(s)
- Li Shan Chiu
- School of Medicine, The University Notre Dame Australia, Fremantle, Western Australia, Australia
- Ear Science Institute Australia, Nedlands, Western Australia, Australia
| | - Ryan S Anderton
- Institute for Health Research, The University Notre Dame Australia, Fremantle, Western Australia, Australia
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4
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Yuan B, Lu XJ, Wu Q. Gut Microbiota and Acute Central Nervous System Injury: A New Target for Therapeutic Intervention. Front Immunol 2022; 12:800796. [PMID: 35003127 PMCID: PMC8740048 DOI: 10.3389/fimmu.2021.800796] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
Acute central nervous system (CNS) injuries, including stroke, traumatic brain injury (TBI), and spinal cord injury (SCI), are the common causes of death or lifelong disabilities. Research into the role of the gut microbiota in modulating CNS function has been rapidly increasing in the past few decades, particularly in animal models. Growing preclinical and clinical evidence suggests that gut microbiota is involved in the modulation of multiple cellular and molecular mechanisms fundamental to the progression of acute CNS injury-induced pathophysiological processes. The altered composition of gut microbiota after acute CNS injury damages the equilibrium of the bidirectional gut-brain axis, aggravating secondary brain injury, cognitive impairments, and motor dysfunctions, which leads to poor prognosis by triggering pro-inflammatory responses in both peripheral circulation and CNS. This review summarizes the studies concerning gut microbiota and acute CNS injuries. Experimental models identify a bidirectional communication between the gut and CNS in post-injury gut dysbiosis, intestinal lymphatic tissue-mediated neuroinflammation, and bacterial-metabolite-associated neurotransmission. Additionally, fecal microbiota transplantation, probiotics, and prebiotics manipulating the gut microbiota can be used as effective therapeutic agents to alleviate secondary brain injury and facilitate functional outcomes. The role of gut microbiota in acute CNS injury would be an exciting frontier in clinical and experimental medicine.
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Affiliation(s)
- Bin Yuan
- Department of Neurosurgery, The Affiliated Wuxi No. 2 Hospital of Nanjing Medical University, Wuxi, China
| | - Xiao-Jie Lu
- Department of Neurosurgery, The Affiliated Wuxi No. 2 Hospital of Nanjing Medical University, Wuxi, China.,Department of Neurosurgery, The Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University, School of Medicine, Nanjing, China
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5
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Buchmann Godinho D, da Silva Fiorin F, Schneider Oliveira M, Furian AF, Rechia Fighera M, Freire Royes LF. The immunological influence of physical exercise on TBI-induced pathophysiology: Crosstalk between the spleen, gut, and brain. Neurosci Biobehav Rev 2021; 130:15-30. [PMID: 34400178 DOI: 10.1016/j.neubiorev.2021.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is a non-degenerative and non-congenital insult to the brain and is recognized as a global public health problem, with a high incidence of neurological disorders. Despite the causal relationship not being entirely known, it has been suggested that multiorgan inflammatory response involving the autonomic nervous system and the spleen-gut brain axis dysfunction exacerbate the TBI pathogenesis in the brain. Thus, applying new therapeutic tools, such as physical exercise, have been described in the literature to act on the immune modulation induced by brain injuries. However, there are caveats to consider when interpreting the effects of physical exercise on this neurological injury. Given the above, this review will highlight the main findings of the literature involving peripheral immune responses in TBI-induced neurological damage and how changes in the cellular metabolism of the spleen-gut brain axis elicited by different protocols of physical exercise alter the pathophysiology induced by this neurological injury.
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Affiliation(s)
- Douglas Buchmann Godinho
- Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil; Programa de Pós-Graduação em Bioquímica Toxicológica, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Fernando da Silva Fiorin
- Programa de Pós-Graduação em Neuroengenharia, Instituto Internacional de Neurociências Edmond e Lily Safra, Instituto Santos Dumont, Macaíba, RN, Brazil
| | - Mauro Schneider Oliveira
- Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Ana Flavia Furian
- Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Michele Rechia Fighera
- Laboratório de Bioquímica do Exercício, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil; Centro de Ciências da Saúde, Departamento de Clínica Médica e Pediatria, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
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Agustí A, Campillo I, Balzano T, Benítez-Páez A, López-Almela I, Romaní-Pérez M, Forteza J, Felipo V, Avena NM, Sanz Y. Bacteroides uniformis CECT 7771 Modulates the Brain Reward Response to Reduce Binge Eating and Anxiety-Like Behavior in Rat. Mol Neurobiol 2021; 58:4959-4979. [PMID: 34228269 PMCID: PMC8497301 DOI: 10.1007/s12035-021-02462-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/17/2021] [Indexed: 12/18/2022]
Abstract
Food addiction (FA) is characterized by behavioral and neurochemical changes linked to loss of food intake control. Gut microbiota may influence appetite and food intake via endocrine and neural routes. The gut microbiota is known to impact homeostatic energy mechanisms, but its role in regulating the reward system is less certain. We show that the administration of Bacteroides uniformis CECT 7771 (B. uniformis) in a rat FA model impacts on the brain reward response, ameliorating binge eating and decreasing anxiety-like behavior. These effects are mediated, at least in part, by changes in the levels of dopamine, serotonin, and noradrenaline in the nucleus accumbens and in the expression of dopamine D1 and D2 receptors in the prefrontal cortex and intestine. B. uniformis reverses the fasting-induced microbiota changes and increases the abundance of species linked to healthy metabolotypes. Our data indicate that microbiota-based interventions might help to control compulsive overeating by modulating the reward response.
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Affiliation(s)
- Ana Agustí
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain.
| | - Isabel Campillo
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain
| | - Tiziano Balzano
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Alfonso Benítez-Páez
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain
| | - Inmaculada López-Almela
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain
| | - Marina Romaní-Pérez
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain
| | - Jerónimo Forteza
- Instituto Valenciano de Patología Unidad Mixta de Patología Molecular, Centro Investigación Príncipe Felipe/Universidad Católica de Valencia, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Nicole M Avena
- Department of Neuroscience, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Yolanda Sanz
- Microbial Ecology, Nutrition and Health. Research Unit, Institute of Agrochemistry and Food Technology, Spanish Council for Scientific Research(IATA-CSIC), Valencia, Spain.
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Hanscom M, Loane DJ, Shea-Donohue T. Brain-gut axis dysfunction in the pathogenesis of traumatic brain injury. J Clin Invest 2021; 131:143777. [PMID: 34128471 PMCID: PMC8203445 DOI: 10.1172/jci143777] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a chronic and progressive disease, and management requires an understanding of both the primary neurological injury and the secondary sequelae that affect peripheral organs, including the gastrointestinal (GI) tract. The brain-gut axis is composed of bidirectional pathways through which TBI-induced neuroinflammation and neurodegeneration impact gut function. The resulting TBI-induced dysautonomia and systemic inflammation contribute to the secondary GI events, including dysmotility and increased mucosal permeability. These effects shape, and are shaped by, changes in microbiota composition and activation of resident and recruited immune cells. Microbial products and immune cell mediators in turn modulate brain-gut activity. Importantly, secondary enteric inflammatory challenges prolong systemic inflammation and worsen TBI-induced neuropathology and neurobehavioral deficits. The importance of brain-gut communication in maintaining GI homeostasis highlights it as a viable therapeutic target for TBI. Currently, treatments directed toward dysautonomia, dysbiosis, and/or systemic inflammation offer the most promise.
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Affiliation(s)
- Marie Hanscom
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David J. Loane
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Terez Shea-Donohue
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
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8
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Weaver JL. The brain-gut axis: A prime therapeutic target in traumatic brain injury. Brain Res 2020; 1753:147225. [PMID: 33359374 DOI: 10.1016/j.brainres.2020.147225] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 01/10/2023]
Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in trauma patients. The primary focus of treating TBI is to prevent additional injury to the damaged brain tissue, known as secondary brain injury. This treatment can include treating the body's inflammatory response. Despite promise in animal models, anti-inflammatory therapy has failed to improve outcomes in human patients, suggesting a more targeted and precise approach may be needed. There is a bidirectional axis between the intestine and the brain that contributes to this inflammation in acute and chronic injury. The mechanisms for this interaction are not completely understood, but there is evidence that neural, inflammatory, endocrine, and microbiome signals all participate in this process. Therapies that target the intestine as a source of inflammation have potential to lessen secondary brain injury and improve outcomes in TBI patients, but to develop these treatments we need to better understand the mechanisms behind this intestinal inflammatory response.
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Affiliation(s)
- Jessica L Weaver
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego School of Medicine, 200 W Arbor Drive #8896, San Diego, CA 92103-8896, United States.
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9
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Weaver JL. The Kinetics of Intestinal Permeability in a Mouse Model of Traumatic Brain Injury. CURRENT PROTOCOLS IN MOUSE BIOLOGY 2020; 10:e86. [PMID: 33264493 DOI: 10.1002/cpmo.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality among trauma patients. Increased intestinal permeability plays an important role in the inflammatory process that accompanies TBI, and therapies that prevent this permeability change may improve outcomes in TBI patients. Different animal models have been developed to test permeability changes, but there has been no agreement on when permeability should be tested after TBI. Here, we describe a method for creating the TBI mouse model and for measuring intestinal permeability. We also detail our permeability measurements at different time points after TBI to help guide future experimental design. The TBI is made using a controlled cortical impact model with the cortical impactor set to speed 6 m/s, depth 3 mm, dwell time 0.2 s, and tip size 3 mm to produce a severe TBI. Permeability is measured at 2, 4, 6, and 24 hr after TBI by removing a piece of terminal ileum, tying the ends, filling the lumen with FITC-labeled dextran, and then measuring how much of the dextran moves into the surrounding solution bath over time using a fluorescent plate reader. Our results show that peak permeability occurs between 4 and 6 hr after TBI. We recommend that future experiments incorporate permeability measurements 4 to 6 hr after TBI in order to take advantage of this peak permeability. © 2020 Wiley Periodicals LLC. Basic Protocol: Mouse CCI traumatic brain injury model and intestinal permeability measurement.
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Affiliation(s)
- Jessica L Weaver
- Department of Surgery, University of California San Diego, San Diego, California
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Yu C, Zhang J, Qin Q, Liu J, Xu J, Xu W. Berberine improved intestinal barrier function by modulating the intestinal microbiota in blunt snout bream (Megalobrama amblycephala) under dietary high-fat and high-carbohydrate stress. FISH & SHELLFISH IMMUNOLOGY 2020; 102:336-349. [PMID: 32360278 DOI: 10.1016/j.fsi.2020.04.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 06/11/2023]
Abstract
The study investigated whether dietary berberine supplementation could improve intestinal barrier against inflammation induced by high-fat and high-carbohydrate diets in blunt snout bream. Fish (average initial weight 44.83 ± 0.06 g) were fed with six kinds of diets (control, high-fat diet (10% lipid) and high-carbohydrate (43% nitrogen-free extract) diet, control/berberine, high-fat/berberine or high-carbohydrate/berberine) for 8 weeks, respectively. Feeding mode of berberine (50 mg/kg diet) was adopted to two-week interval. After feeding trial, fish growth performance and intestinal barrier function were estimated. The result showed that no significant interactions between diet and berberine in growth performance, whole body composition or protein utilization were observed (P > 0.05). Specific growth rate (SGR) and feed conversion ratio (FCR) were significantly affected by berberine (P < 0.05). Protein efficiency ratio (PER), nitrogen retention (NRE), fish whole-body lipid contents increased greatly in high-fat or high-carbohydrate diets (P < 0.05). Significant interactions between diet and berberine were observed in fish intestinal barrier (physical, chemical, immunological and microbiological barriers) (P < 0.05). High-fat and high-carbohydrate diets could increase significantly intestinal permeability and inflammatory response, decrease intestinal mucins gene expression levels, and make the intestinal microbiota out of balance (P < 0.05). Berberine significantly inhibited inflammation response and modulated intestinal microflora profile (P < 0.05). Taken together, berberine could alleviate intestinal barrier damage injured by high-fat or high-carbohydrate diet and improve the growth performance of blunt snout bream.
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Affiliation(s)
- Chengbing Yu
- Shanghai Key Laboratory for Veterinary and Biotechnology, School of Agriculture and Biology, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, PR China
| | - Jing Zhang
- Shanghai Key Laboratory for Veterinary and Biotechnology, School of Agriculture and Biology, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, PR China
| | - Qin Qin
- Institute of Chinese Traditional Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No.725 Wanping South Road, Shanghai, 200032, PR China
| | - Jin Liu
- Shanghai Key Laboratory for Veterinary and Biotechnology, School of Agriculture and Biology, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, PR China
| | - Jianxiong Xu
- Shanghai Key Laboratory for Veterinary and Biotechnology, School of Agriculture and Biology, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, PR China
| | - Weina Xu
- Shanghai Key Laboratory for Veterinary and Biotechnology, School of Agriculture and Biology, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, PR China.
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Cassol G, Godinho DB, de Zorzi VN, Farinha JB, Della-Pace ID, de Carvalho Gonçalves M, Oliveira MS, Furian AF, Fighera MR, Royes LFF. Potential therapeutic implications of ergogenic compounds on pathophysiology induced by traumatic brain injury: A narrative review. Life Sci 2019; 233:116684. [DOI: 10.1016/j.lfs.2019.116684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022]
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12
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Ko IG, Kim CJ, Kim H. Treadmill exercise improves memory by up-regulating dopamine and down-regulating D 2 dopamine receptor in traumatic brain injury rats. J Exerc Rehabil 2019; 15:504-511. [PMID: 31523669 PMCID: PMC6732546 DOI: 10.12965/jer.1938316.158] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/16/2019] [Indexed: 12/22/2022] Open
Abstract
Traumatic brain injury (TBI) causes a variety of neuropathological manifestations including cognitive, emotional, physiological and psychological deficits. Physical exercise is known to ameliorate neurological impairments induced by various brain injuries. We investigated the effects of treadmill exercise on memory impairments due to TBI in relation to dopamine and D2 dopamine receptor. TBI was induced with an electromagnetic-controlled cortical impact device. The rats in the exercise groups were scheduled to run on a treadmill for 30 min once a day for 28 days after TBI induction. Then, step-down avoidance task, radial 8-arm maze test, immunohistochemistry for tyrosine hydroxylase (TH), and western blot for D2 dopamine receptor were performed. TBI impaired short-term and spatial learning memories. TBI decreased TH expressions in the prefrontal cortex (PFC), striatum, hippocampus dentate gyrus, and substantia nigra (SN). By contrast, the expressions of D2 dopamine receptor in the PFC, striatum, hippocampus, and SN were increased by TBI. Treadmill exercise alleviated the impairments of short-term and spatial learning memories observed in TBI rats. TH expression was decreased and D2 dopamine receptor expression was increased in TBI rats. Treadmill exercise enhanced TH expression and suppressed D2 dopamine receptor expression in TBI rats. TBI deteriorated short-term and spatial learning memories, in contrast, treadmill exercise alleviated the TBI-induced memory impairments by up-regulating dopamine level and down-regulating D2 dopamine receptor expression.
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Affiliation(s)
- Il-Gyu Ko
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Chang-Ju Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hong Kim
- Department of Oriental Sports Medicine, College of Biomedical Science, Daegu Haany University, Gyeongsan, Korea
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Royes LFF, Gomez-Pinilla F. Making sense of gut feelings in the traumatic brain injury pathogenesis. Neurosci Biobehav Rev 2019; 102:345-361. [PMID: 31102601 DOI: 10.1016/j.neubiorev.2019.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is a devastating condition which often initiates a sequel of neurological disorders that can last throughout lifespan. From metabolic perspective, TBI also compromises systemic physiology including the function of body organs with subsequent malfunctions in metabolism. The emerging panorama is that the effects of TBI on the periphery strike back on the brain and exacerbate the overall TBI pathogenesis. An increasing number of clinical reports are alarming to show that metabolic dysfunction is associated with incidence of long-term neurological and psychiatric disorders. The autonomic nervous system, associated hypothalamic-pituitary axis, and the immune system are at the center of the interface between brain and body and are central to the regulation of overall homeostasis and disease. We review the strong association between mechanisms that regulate cell metabolism and inflammation which has important clinical implications for the communication between body and brain. We also discuss the integrative actions of lifestyle interventions such as diet and exercise on promoting brain and body health and cognition after TBI.
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Affiliation(s)
- Luiz Fernando Freire Royes
- Exercise Biochemistry Laboratory, Center of Physical Education and Sports, Federal University of Santa Maria - UFSM, Santa Maria, RS, Brazil
| | - Fernando Gomez-Pinilla
- Departments of Neurosurgery, and Integrative and Biology and Physiology, UCLA Brain Injury Research Center, University of California, Los Angeles, USA.
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14
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Intestinal barrier dysfunction following traumatic brain injury. Neurol Sci 2019; 40:1105-1110. [PMID: 30771023 DOI: 10.1007/s10072-019-03739-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Abstract
Traumatic brain injury (TBI) can cause non-neurological injuries to other organs such as the intestine. Newer studies have shown that paracellular hyperpermeability is the basis of intestinal barrier dysfunction following TBI. Ischemia-reperfusion injury, inflammatory response, abnormal release of neurotransmitters and hormones, and malnutrition contribute to TBI-induced intestinal barrier dysfunction. Several interventions that may protect intestinal barrier function and promote the recovery of TBI have been proposed, but relevant studies are still limited. This review is to clarify the established mechanisms of intestinal barrier dysfunction following TBI and to describe the possible strategies to reduce or prevent intestinal barrier dysfunction.
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González-González M, Díaz-Zepeda C, Eyzaguirre-Velásquez J, González-Arancibia C, Bravo JA, Julio-Pieper M. Investigating Gut Permeability in Animal Models of Disease. Front Physiol 2019; 9:1962. [PMID: 30697168 PMCID: PMC6341294 DOI: 10.3389/fphys.2018.01962] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022] Open
Abstract
A growing number of investigations report the association between gut permeability and intestinal or extra-intestinal disorders under the basis that translocation of gut luminal contents could affect tissue function, either directly or indirectly. Still, in many cases it is unknown whether disruption of the gut barrier is a causative agent or a consequence of these conditions. Adequate experimental models are therefore required to further understand the pathophysiology of health disorders associated to gut barrier disruption and to develop and test pharmacological treatments. Here, we review the current animal models that display enhanced intestinal permeability, and discuss (1) their suitability to address mechanistic questions, such as the association between gut barrier alterations and disease and (2) their validity to test potential treatments for pathologies that are characterized by enhanced intestinal permeability.
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Affiliation(s)
- Marianela González-González
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Camilo Díaz-Zepeda
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Johana Eyzaguirre-Velásquez
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Camila González-Arancibia
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Javier A Bravo
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Marcela Julio-Pieper
- Grupo de NeuroGastroBioquímica, Instituto de Química, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
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Zhao L, Xiong Q, Stary CM, Mahgoub OK, Ye Y, Gu L, Xiong X, Zhu S. Bidirectional gut-brain-microbiota axis as a potential link between inflammatory bowel disease and ischemic stroke. J Neuroinflammation 2018; 15:339. [PMID: 30537997 PMCID: PMC6290529 DOI: 10.1186/s12974-018-1382-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022] Open
Abstract
Emerging evidence suggests that gut-brain-microbiota axis (GBMAx) may play a pivotal role linking gastrointestinal and neuronal disease. In this review, we summarize the latest advances in studies of GBMAx in inflammatory bowel disease (IBD) and ischemic stroke. A more thorough understanding of the GBMAx could advance our knowledge about the pathophysiology of IBD and ischemic stroke and help to identify novel therapeutic targets via modulation of the GBMAx.
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Affiliation(s)
- Liang Zhao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiutang Xiong
- Diabetes Research Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Creed M. Stary
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305 USA
| | | | - Yingze Ye
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lijuan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoxing Xiong
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, Renmin Hospital of Wuhan University, 99 Zhang Zhidong Rd, Wuhan, 430060 Hubei China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000 Zhejiang China
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Paydar S, Moein-Vaziri N, Dehghankhalili M, Abdolrahimzaeh H, Bolandparvaz S, Abbasi HR. Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique. Cureus 2018; 10:e3431. [PMID: 30546978 PMCID: PMC6289558 DOI: 10.7759/cureus.3431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.
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Affiliation(s)
- Shahram Paydar
- General Surgery, Shiraz University of Medical Sciences, Shiraz, IRN
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18
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe established and emerging mechanisms of gut injury and dysfunction in trauma, describe emerging strategies to improve gut dysfunction, detail the effect of trauma on the gut microbiome, and describe the gut-brain connection in traumatic brain injury. RECENT FINDINGS Newer data suggest intraluminal contents, pancreatic enzymes, and hepatobiliary factors disrupt the intestinal mucosal layer. These mechanisms serve to perpetuate the inflammatory response leading to multiple organ dysfunction syndrome (MODS). To date, therapies to mitigate acute gut dysfunction have included enteral nutrition and immunonutrition; emerging therapies aimed to intestinal mucosal layer disruption, however, include protease inhibitors such as tranexamic acid, parenteral nutrition-supplemented bombesin, and hypothermia. Clinical trials to demonstrate benefit in humans are needed before widespread applications can be recommended. SUMMARY Despite resuscitation, gut dysfunction promotes distant organ injury. In addition, postresuscitation nosocomial and iatrogenic 'hits' exaggerate the immune response, contributing to MODS. This was a provocative concept, suggesting infectious and noninfectious causes of inflammation may trigger, heighten, and perpetuate an inflammatory response culminating in MODS and death. Emerging evidence suggests posttraumatic injury mechanisms, such as intestinal mucosal disruption and shifting of the gut microbiome to a pathobiome. In addition, traumatic brain injury activates the gut-brain axis and increases intestinal permeability.
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Charles EJ, Mehaffey JH, Hawkins RB, Safavian D, Schirmer BD, Hallowell PT. Benefit of feeding tube placement for refractory malnutrition after bariatric surgery. Surg Obes Relat Dis 2018; 14:162-167. [PMID: 28169202 PMCID: PMC5484748 DOI: 10.1016/j.soard.2016.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/18/2016] [Accepted: 12/19/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bariatric surgery provides durable weight loss and decreases the incidence of co-morbid conditions for people with obesity. Most patients benefit from resultant weight loss, but some are at risk for postoperative refractory malnutrition, a serious but poorly understood complication. OBJECTIVE To evaluate differences in bariatric surgery patients who received a feeding tube postoperatively for malnutrition compared with other indications. SETTING Retrospective cohort study at an academic bariatric surgery center (1985-2015). METHODS All bariatric surgery patients that received a feeding tube postoperatively over a 30-year period were identified. Data abstraction from the medical record was performed to assess demographic characteristics, operative details, tube indication, and resultant body mass index (BMI) changes. RESULTS From a total of 3487 patients who underwent bariatric surgery during the study period, 139 (3.9%) required placement of a feeding tube postoperatively. Refractory malnutrition was the indication in 24 patients, all after Roux-en-Y gastric bypass. There were no significant differences between these patients and other bariatric surgery patients in terms of mean age (40.6±9.9 versus 43.1±13.4 years, P = .4) and preoperative BMI (47.5±10.5 versus 51.0±9.6 kg/m2, P = .1). The median time from surgery to tube placement for malnutrition patients was 4 years. Compared with other feeding tube indications, malnutrition patients had higher percent excess BMI lost after surgery (126.2±31.9 versus 52.5±44.3%, P<.0001). After tube placement, malnutrition patients had a significant increase in mean BMI compared with other indications (14.5±20.9 versus-13.0±14.0%, P< .001). CONCLUSION Patients with refractory malnutrition benefit from feeding tube placement, which results in a significant increase in BMI.
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Affiliation(s)
- Eric J Charles
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dana Safavian
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bruce D Schirmer
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Peter T Hallowell
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
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Jia K, Tong X, Liang F. Effects of sequential nutritional support on nutritional status and expression of regulatory T lymphocyte in patients with early severe traumatic brain injury. Neuropsychiatr Dis Treat 2018; 14:1561-1567. [PMID: 29950840 PMCID: PMC6011880 DOI: 10.2147/ndt.s149802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To investigate the effects of sequential nutritional support on nutritional status and immune regulation in patients with early severe traumatic brain injury (STBI). PATIENTS AND METHODS A total of 62 patients diagnosed with STBI enrolled from Chaoyang Hospital (Beijing, China) from February 2015 to October 2016 were divided into two groups. The observational group (n=34) was given sequential nutritional support and the control group (n=28) was given the standard formula of whole protein enteral preparations. The energy supply for the two groups was 30 kcal/kg/d and protein 1.6 g/kg/d, respectively. The albumin (ALB), total protein (TP), high-sensitivity C-reactive protein (Hs-CRP), neuron-specific enolase (NSE), Glasgow Coma Score (GCS), and regulatory T cells before and after nutritional treatment were measured in both groups. RESULTS At the 14th day, the levels of ALB (41.7±4.2 g/L) and TP (70.6±4.9 g/L) were significantly higher than those in the control group (33.5±2.3 g/L and 62.3±3.9 g/L) (P<0.05). The levels of Hs-CRP and NSE were significantly lower in the observational group (0.96±0.82 mg/L and 11.96±7.82 ng/L) than in the control group (1.17±0.74 mg/L and 19.17±6.74 ng/L) (P<0.05). The GCS score in the observational group (11.5±2.9) was significantly higher than that in the control group (8.1±1.7) (P<0.05). The percentage of Tregs in the peripheral CD4+ lymphocytes was significantly lower in the observational group than in the control group (P<0.05). CONCLUSION The effect of sequential nutritional support is better than conventional nutritional support in patients with STBI. The findings call for early identification of malnutrition and individual nutritional support.
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Affiliation(s)
- Kai Jia
- Department of Nutrition, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Xin Tong
- Department of Nutrition, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Fang Liang
- Department of Hyperbaric Oxygen, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Evaluation of gut-blood barrier dysfunction in various models of trauma, hemorrhagic shock, and burn injury. J Trauma Acute Care Surg 2017; 83:944-953. [DOI: 10.1097/ta.0000000000001654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sundman MH, Chen NK, Subbian V, Chou YH. The bidirectional gut-brain-microbiota axis as a potential nexus between traumatic brain injury, inflammation, and disease. Brain Behav Immun 2017; 66:31-44. [PMID: 28526435 DOI: 10.1016/j.bbi.2017.05.009] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/25/2017] [Accepted: 05/10/2017] [Indexed: 02/06/2023] Open
Abstract
As head injuries and their sequelae have become an increasingly salient matter of public health, experts in the field have made great progress elucidating the biological processes occurring within the brain at the moment of injury and throughout the recovery thereafter. Given the extraordinary rate at which our collective knowledge of neurotrauma has grown, new insights may be revealed by examining the existing literature across disciplines with a new perspective. This article will aim to expand the scope of this rapidly evolving field of research beyond the confines of the central nervous system (CNS). Specifically, we will examine the extent to which the bidirectional influence of the gut-brain axis modulates the complex biological processes occurring at the time of traumatic brain injury (TBI) and over the days, months, and years that follow. In addition to local enteric signals originating in the gut, it is well accepted that gastrointestinal (GI) physiology is highly regulated by innervation from the CNS. Conversely, emerging data suggests that the function and health of the CNS is modulated by the interaction between 1) neurotransmitters, immune signaling, hormones, and neuropeptides produced in the gut, 2) the composition of the gut microbiota, and 3) integrity of the intestinal wall serving as a barrier to the external environment. Specific to TBI, existing pre-clinical data indicates that head injuries can cause structural and functional damage to the GI tract, but research directly investigating the neuronal consequences of this intestinal damage is lacking. Despite this void, the proposed mechanisms emanating from a damaged gut are closely implicated in the inflammatory processes known to promote neuropathology in the brain following TBI, which suggests the gut-brain axis may be a therapeutic target to reduce the risk of Chronic Traumatic Encephalopathy and other neurodegenerative diseases following TBI. To better appreciate how various peripheral influences are implicated in the health of the CNS following TBI, this paper will also review the secondary biological injury mechanisms and the dynamic pathophysiological response to neurotrauma. Together, this review article will attempt to connect the dots to reveal novel insights into the bidirectional influence of the gut-brain axis and propose a conceptual model relevant to the recovery from TBI and subsequent risk for future neurological conditions.
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Affiliation(s)
- Mark H Sundman
- Department of Psychology, University of Arizona, Tucson, AZ, USA.
| | - Nan-Kuei Chen
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA
| | - Vignesh Subbian
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, USA; Department of Systems and Industrial Engineering, University of Arizona, Tucson, AZ, USA
| | - Ying-Hui Chou
- Department of Psychology, University of Arizona, Tucson, AZ, USA; Cognitive Science Program, University of Arizona, Tucson, AZ, USA; Arizona Center on Aging, University of Arizona, Tucson, AZ, USA
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Feng XY, Zhang DN, Wang YA, Fan RF, Hong F, Zhang Y, Li Y, Zhu JX. Dopamine enhances duodenal epithelial permeability via the dopamine D 5 receptor in rodent. Acta Physiol (Oxf) 2017; 220:113-123. [PMID: 27652590 DOI: 10.1111/apha.12806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/05/2016] [Accepted: 09/16/2016] [Indexed: 12/24/2022]
Abstract
AIM The intestinal barrier is made up of epithelial cells and intercellular junctional complexes to regulate epithelial ion transport and permeability. Dopamine (DA) is able to promote duodenal epithelial ion transport through D1-like receptors, which includes subtypes of D1 (D1 R) and D5 (D5 R), but whether D1-like receptors influence the duodenal permeability is unclear. METHODS FITC-dextran permeability, short-circuit current (ISC ), Western blot, immunohistochemistry and ELISA were used in human D5 R transgenic mice and hyperendogenous enteric DA (HEnD) rats in this study. RESULTS Dopamine induced a downward deflection in ISC and an increase in FITC-dextran permeability of control rat duodenum, which were inhibited by the D1-like receptor antagonist, SCH-23390. However, DA decreased duodenal transepithelial resistance (TER), an effect also reversed by SCH-23390. A strong immunofluorescence signal for D5 R, but not D1 R, was observed in the duodenum of control rat. In human D5 R knock-in transgenic mice, duodenal mucosa displayed an increased basal ISC with high FITC-dextran permeability and decreased TER with a lowered expression of tight junction proteins, suggesting attenuated duodenal barrier function in these transgenic mice. D5 R knock-down transgenic mice manifested a decreased basal ISC with lowered FITC-dextran permeability. Moreover, an increased FITC-dextran permeability combined with decreased TER and tight junction protein expression in duodenal mucosa were also observed in HEnD rats. CONCLUSION This study demonstrates, for the first time, that DA enhances duodenal permeability of control rat via D5 R, which provides new experimental and theoretical evidence for the influence of DA on duodenal epithelial barrier function.
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Affiliation(s)
- X.-Y. Feng
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - D.-N. Zhang
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - Y.-A. Wang
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - R.-F. Fan
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - F. Hong
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - Y. Zhang
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - Y. Li
- Department of Immunology; School of Basic Medical Science; Capital Medical University; Beijing China
| | - J.-X. Zhu
- Department of Physiology and Pathophysiology; School of Basic Medical Science; Capital Medical University; Beijing China
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Barrenschee M, Zorenkov D, Böttner M, Lange C, Cossais F, Scharf AB, Deuschl G, Schneider SA, Ellrichmann M, Fritscher-Ravens A, Wedel T. Distinct pattern of enteric phospho-alpha-synuclein aggregates and gene expression profiles in patients with Parkinson's disease. Acta Neuropathol Commun 2017; 5:1. [PMID: 28057070 PMCID: PMC5217296 DOI: 10.1186/s40478-016-0408-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 12/18/2016] [Indexed: 01/16/2023] Open
Abstract
Phosphorylated alpha-synuclein (p-α-syn) containing Lewy bodies (LBs) and Lewy neurites (LNs) are neuropathological hallmarks of Parkinson’s disease (PD) in the central nervous system (CNS). Since they have been also demonstrated in the enteric nervous system (ENS) of PD patients, the aim of the study was to analyze enteric p-α-syn positive aggregates and intestinal gene expression. Submucosal rectal biopsies were obtained from patients with PD and controls and processed for dual-label-immunohistochemistry for p-α-syn and PGP 9.5. p-α-syn positive aggregates in nerve fibers and neuronal somata were subjected to a morphometric analysis. mRNA expression of α-syn and dopaminergic, serotonergic, VIP (vaso intestinal peptide) ergic, cholinergic, muscarinergic neurotransmitter systems were investigated using qPCR. Frequency of p-α-syn positive nerve fibers was comparable between PD and controls. Although neuronal p-α-syn positive aggregates were detectable in both groups, total number and area of p-α-syn positive aggregates were increased in PD patients as was the number of small and large sized aggregates. Increased expression of dopamine receptor D1, VIP and serotonin receptor 3A was observed in PD patients, while serotonin receptor 4 and muscarinic receptor 3 (M3R) were downregulated. M3R expression correlated negative with the number of small sized p-α-syn positive aggregates. The findings strengthen the hypothesis that the CNS pathology of increased p-α-syn in PD also applies to the ENS, if elaborated morphometry is applied and give further insights in altered intestinal gene expression in PD. Although the mere presence of p-α-syn positive aggregates in the ENS should not be regarded as a criterion for PD diagnosis, elaborated morphometric analysis of p-α-syn positive aggregates in gastrointestinal biopsies could serve as a suitable tool for in-vivo diagnosis of PD.
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Achamrah N, Déchelotte P, Coëffier M. Glutamine and the regulation of intestinal permeability: from bench to bedside. Curr Opin Clin Nutr Metab Care 2017; 20:86-91. [PMID: 27749689 DOI: 10.1097/mco.0000000000000339] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Glutamine is the most abundant amino acid in plasma and plays a key role in maintaining the integrity of intestinal barrier. RECENT FINDINGS Experimental studies showed that glutamine is able to modulate intestinal permeability and tight junction protein expression in several conditions. Recent articles underlined its putative beneficial role in gastrointestinal disorders such as irritable bowel syndrome. SUMMARY Glutamine is a major nutrient to maintain intestinal barrier function in animals and humans. Depletion of glutamine results in villus atrophy, decreased expression of tight junction proteins and increased intestinal permeability. Moreover, glutamine supplementation can improve gut barrier function in several experimental conditions of injury and in some clinical situations. Furthermore, preventive effects of glutamine in experimental models of intestinal injuries have been recently reported. Despite promising data in experimental models, further studies are needed to evaluate glutamine supplementation in clinical practice.
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Affiliation(s)
- Najate Achamrah
- aNormandie Univ bINSERM UMR 1073 'Nutrition, Inflammation and Dysfunction of Gut-brain Axis', University of Rouen cNutrition Department, Rouen University Hospital, Rouen, France
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Cheng Y, Wei Y, Yang W, Cai Y, Chen B, Yang G, Shang H, Zhao W. Ghrelin Attenuates Intestinal Barrier Dysfunction Following Intracerebral Hemorrhage in Mice. Int J Mol Sci 2016; 17:ijms17122032. [PMID: 27929421 PMCID: PMC5187832 DOI: 10.3390/ijms17122032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 02/07/2023] Open
Abstract
Intestinal barrier dysfunction remains a critical problem in patients with intracerebral hemorrhage (ICH) and is associated with poor prognosis. Ghrelin, a brain-gut peptide, has been shown to exert protection in animal models of gastrointestinal injury. However, the effect of ghrelin on intestinal barrier dysfunction post-ICH and its possible underlying mechanisms are still unknown. This study was designed to investigate whether ghrelin administration attenuates intestinal barrier dysfunction in experimental ICH using an intrastriatal autologous blood infusion mouse model. Our data showed that treatment with ghrelin markedly attenuated intestinal mucosal injury at both histomorphometric and ultrastructural levels post-ICH. Ghrelin reduced ICH-induced intestinal permeability according to fluorescein isothiocyanate conjugated-dextran (FITC-D) and Evans blue extravasation assays. Concomitantly, the intestinal tight junction-related protein markers, Zonula occludens-1 (ZO-1) and claudin-5 were upregulated by ghrelin post-ICH. Additionally, ghrelin reduced intestinal intercellular adhesion molecule-1 (ICAM-1) expression at the mRNA and protein levels following ICH. Furthermore, ghrelin suppressed the translocation of intestinal endotoxin post-ICH. These changes were accompanied by improved survival rates and an attenuation of body weight loss post-ICH. In conclusion, our results suggest that ghrelin reduced intestinal barrier dysfunction, thereby reducing mortality and weight loss, indicating that ghrelin is a potential therapeutic agent in ICH-induced intestinal barrier dysfunction therapy.
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Affiliation(s)
- Yijun Cheng
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Yongxu Wei
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Wenlei Yang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Yu Cai
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Bin Chen
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Guoyuan Yang
- Department of Neurology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
- Neuroscience and Neuroengineering Research Center, Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, China.
| | - Hanbing Shang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Weiguo Zhao
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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27
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Ren W, Wang K, Yin J, Chen S, Liu G, Tan B, Wu G, Bazer FW, Peng Y, Yin Y. Glutamine-Induced Secretion of Intestinal Secretory Immunoglobulin A: A Mechanistic Perspective. Front Immunol 2016; 7:503. [PMID: 27933057 PMCID: PMC5121228 DOI: 10.3389/fimmu.2016.00503] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/27/2016] [Indexed: 12/23/2022] Open
Abstract
Secretory immunoglobulin A (SIgA) is one important line of defense in the intestinal mucosal surface to protect the intestinal epithelium from enteric toxins and pathogenic microorganisms. Multiple factors, such as intestinal microbiota, intestinal cytokines, and nutrients are highly involved in production of SIgA in the intestine. Recently, glutamine has been shown to affect intestinal SIgA production; however, the underlying mechanism by which glutamine stimulates secretion of intestinal SIgA is unknown. Here, we review current knowledge regarding glutamine in intestinal immunity and show that glutamine-enhanced secretion of SIgA in the intestine may involve intestinal microbiota, intestinal antigen sampling and presentation, induction pathways for SIgA production by plasma cells (both T-dependent and T-independent pathway), and even transport of SIgA. Altogether, the glutamine-intestinal SIgA axis has broad therapeutic implications for intestinal SIgA-associated diseases, such as celiac disease, allergies, and inflammatory bowel disease.
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Affiliation(s)
- Wenkai Ren
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences, Changsha, China; University of the Chinese Academy of Sciences, Beijing, China
| | - Kai Wang
- Institute of Apicultural Research (IAR), Chinese Academy of Agricultural Sciences (CAAS) , Beijing , China
| | - Jie Yin
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences, Changsha, China; University of the Chinese Academy of Sciences, Beijing, China
| | - Shuai Chen
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences, Changsha, China; University of the Chinese Academy of Sciences, Beijing, China
| | - Gang Liu
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences , Changsha , China
| | - Bie Tan
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences , Changsha , China
| | - Guoyao Wu
- Department of Animal Science, Texas A&M University , College Station, TX , USA
| | - Fuller W Bazer
- Department of Animal Science, Texas A&M University , College Station, TX , USA
| | - Yuanyi Peng
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University , Chongqing , China
| | - Yulong Yin
- Key Laboratory of Agro-ecological Processes in Subtropical Region, Institute of Subtropical Agriculture, Chinese Academy of Sciences, Changsha, China; College of Animal Science, South China Agricultural University, Guangzhou, China
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Abstract
Traumatic brain injury (TBI) is a complex disorder that affects millions of people worldwide. The complexity of TBI partly stems from the fact that injuries to the brain instigate non-neurological injuries to other organs such as the intestine. Additionally, genetic variation is thought to play a large role in determining the nature and severity of non-neurological injuries. We recently reported that TBI in flies, as in humans, increases permeability of the intestinal epithelial barrier resulting in hyperglycemia and a higher risk of death. Furthermore, we demonstrated that genetic variation in flies is also pertinent to the complexity of non-neurological injuries following TBI. The goals of this review are to place our findings in the context of what is known about TBI-induced intestinal permeability from studies of TBI patients and rodent TBI models and to draw attention to how studies of the fly TBI model can provide unique insights that may facilitate diagnosis and treatment of TBI.
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Affiliation(s)
| | - Barry Ganetzky
- a Laboratory of Genetics; University of Wisconsin-Madison ; Madison , WI USA
| | - David A Wassarman
- a Laboratory of Genetics; University of Wisconsin-Madison ; Madison , WI USA
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29
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Neis EPJG, Sabrkhany S, Hundscheid I, Schellekens D, Lenaerts K, Olde Damink SW, Blaak EE, Dejong CHC, Rensen SS. Human splanchnic amino-acid metabolism. Amino Acids 2016; 49:161-172. [PMID: 27714515 PMCID: PMC5241341 DOI: 10.1007/s00726-016-2344-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 02/06/2023]
Abstract
Plasma levels of several amino acids are correlated with metabolic dysregulation in obesity and type 2 diabetes. To increase our understanding of human amino-acid metabolism, we aimed to determine splanchnic interorgan amino-acid handling. Twenty patients planned to undergo a pylorus preserving pancreatico-duodenectomy were included in this study. Blood was sampled from the portal vein, hepatic vein, superior mesenteric vein, inferior mesenteric vein, splenic vein, renal vein, and the radial artery during surgery. The difference between arterial and venous concentrations of 21 amino acids was determined using liquid chromatography as a measure of amino-acid metabolism across a given organ. Whereas glutamine was significantly taken up by the small intestine (121.0 ± 23.8 µmol/L; P < 0.0001), citrulline was released (−36.1 ± 4.6 µmol/L; P < 0.0001). This, however, was not seen for the colon. Interestingly, the liver showed a small, but a significant uptake of citrulline from the circulation (4.8 ± 1.6 µmol/L; P = 0.0138) next to many other amino acids. The kidneys showed a marked release of serine and alanine into the circulation (−58.0 ± 4.4 µmol/L and −61.8 ± 5.2 µmol/L, P < 0.0001), and a smaller, but statistically significant release of tyrosine (−12.0 ± 1.3 µmol/L, P < 0.0001). The spleen only released taurine (−9.6 ± 3.3 µmol/L; P = 0.0078). Simultaneous blood sampling in different veins provides unique qualitative and quantitative information on integrative amino-acid physiology, and reveals that the well-known intestinal glutamine–citrulline pathway appears to be functional in the small intestine but not in the colon.
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Affiliation(s)
- Evelien P J G Neis
- Top Institute Food and Nutrition, P.O. Box 557, 6700 AN, Wageningen, The Netherlands.,Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - S Sabrkhany
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, P.O. Box 5800, 6229 HX, Maastricht, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - I Hundscheid
- Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - D Schellekens
- Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - K Lenaerts
- Top Institute Food and Nutrition, P.O. Box 557, 6700 AN, Wageningen, The Netherlands.,Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - S W Olde Damink
- Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - E E Blaak
- Top Institute Food and Nutrition, P.O. Box 557, 6700 AN, Wageningen, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, P.O. Box 5800, 6229 HX, Maastricht, The Netherlands
| | - C H C Dejong
- Top Institute Food and Nutrition, P.O. Box 557, 6700 AN, Wageningen, The Netherlands.,Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.,Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Sander S Rensen
- Department of General Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
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30
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Tan S, Yu W, Lin Z, Chen Q, Shi J, Dong Y, Duan K, Bai X, Xu L, Yu Z, Li J, Li N. Berberine Ameliorates Intestinal Mucosal Barrier Damage Induced by Peritoneal Air Exposure. Biol Pharm Bull 2015; 38:122-6. [DOI: 10.1248/bpb.b14-00643] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Shanjun Tan
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Wenkui Yu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Zhiliang Lin
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Qiyi Chen
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Jialiang Shi
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Yi Dong
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Kaipeng Duan
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Xiaowu Bai
- Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Second Military Medical University
| | - Lin Xu
- Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Second Military Medical University
| | - Zhen Yu
- Department of General Surgery, Shanghai Tenth People’s Hospital Affiliated to Tongji University
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University
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31
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Mujagic Z, Ludidi S, Keszthelyi D, Hesselink MAM, Kruimel JW, Lenaerts K, Hanssen NMJ, Conchillo JM, Jonkers DMAE, Masclee AAM. Small intestinal permeability is increased in diarrhoea predominant IBS, while alterations in gastroduodenal permeability in all IBS subtypes are largely attributable to confounders. Aliment Pharmacol Ther 2014; 40:288-97. [PMID: 24943095 DOI: 10.1111/apt.12829] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 04/21/2014] [Accepted: 05/19/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intestinal permeability has been studied in small groups of IBS patients with contrasting findings. AIMS To assess intestinal permeability at different sites of the GI tract in different subtypes of well-characterised IBS patients and healthy controls (HC), and to assess potential confounding factors. METHODS IBS patients and HC underwent a multi-sugar test to assess site-specific intestinal permeability. Sucrose excretion and lactulose/rhamnose ratio in 0-5 h urine indicated gastroduodenal and small intestinal permeability, respectively. Sucralose/erythritol ratio in 0-24 h and 5-24 h urine indicated whole gut and colonic permeability, respectively. Linear regression analysis was used to assess the association between IBS groups and intestinal permeability and to adjust for age, sex, BMI, anxiety or depression, smoking, alcohol intake and use of medication. RESULTS Ninety-one IBS patients, i.e. 37% IBS-D, 23% IBS-C, 33% IBS-M and 7% IBS-U and 94 HC were enrolled. Urinary sucrose excretion was significantly increased in the total IBS group [μmol, median (Q1;Q3): 5.26 (1.82;11.03) vs. 2.44 (0.91;5.85), P < 0.05], as well as in IBS-C and IBS-D vs. HC. However, differences attenuated when adjusting for confounders. The lactulose/rhamnose ratio was increased in IBS-D vs. HC [0.023 (0.013;0.038) vs. 0.014 (0.008;0.025), P < 0.05], which remained significant after adjustment for confounders. No difference was found in 0-24 and 5-24 h sucralose/erythritol ratio between groups. CONCLUSIONS Small intestinal permeability is increased in patients with IBS-D compared to healthy controls, irrespective of confounding factors. Adjustment for confounders is necessary when studying intestinal permeability, especially in a heterogeneous disorder such as IBS.
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Affiliation(s)
- Z Mujagic
- Division Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
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