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Wzorek-Łyczko K, Woźniak W, Piwowarczyk A, Kuchar E. The anti-infective effect of β-glucans in children. INT J VITAM NUTR RES 2024; 94:296-307. [PMID: 37779363 DOI: 10.1024/0300-9831/a000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Background: β-glucans are bioactive β-D-glucose polysaccharides of natural origin, presenting antimicrobial and immunomodulation properties, with a low risk of toxicity. Objectives: This scoping review aims to present the current knowledge on the anti-infective properties of β-glucans in the pediatric population. Methods: We used the PRISMA Extension for Scoping Reviews Checklist to prepare this review. Studies were identified by electronic searches of Pubmed, Embase, and Cochrane databases up to May 2021. Results: The primary search allowed us to find 6232 studies, twelve of which were finally included in the analysis. Eight studies were designed as randomized, placebo-controlled trials, while in four studies the intervention outcome was compared with the pre-intervention period in the same group. The type of preparation and doses varied between studies: in five trials pleuran was administered (in dose 10 mg/5 kg of body weight/day), and in one study baker's yeast β-glucan was used (in two doses: 35 mg/day and 75 mg/day). In six other studies, the analyzed preparation comprised β-glucan and other substances. The shortest study lasted seven days, while the most prolonged intervention lasted six months, followed by six months of follow-up. Ten out of twelve trials demonstrated the effectiveness of β-glucans in reducing respiratory tract infection incidence or alleviation of upper respiratory tract infection symptoms. Ten out of twelve studies have reported a good tolerance and safety profile. Conclusions: Good tolerance of β-glucans shows a favorable benefit-risk ratio of this type of intervention. Nevertheless, further monitoring of their efficacy and safety in high-quality research is necessary.
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Affiliation(s)
- Katarzyna Wzorek-Łyczko
- The Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, Poland
| | - Weronika Woźniak
- The Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, Poland
| | - Anna Piwowarczyk
- The Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, Poland
| | - Ernest Kuchar
- The Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, Poland
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2
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Peroni DG, Hufnagl K, Comberiati P, Roth-Walter F. Lack of iron, zinc, and vitamins as a contributor to the etiology of atopic diseases. Front Nutr 2023; 9:1032481. [PMID: 36698466 PMCID: PMC9869175 DOI: 10.3389/fnut.2022.1032481] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023] Open
Abstract
Micronutritional deficiencies are common in atopic children suffering from atopic dermatitis, food allergy, rhinitis, and asthma. A lack of iron, in particular, may impact immune activation with prolonged deficiencies of iron, zinc, vitamin A, and vitamin D associated with a Th2 signature, maturation of macrophages and dendritic cells (DCs), and the generation of IgE antibodies. In contrast, the sufficiency of these micronutrients establishes immune resilience, promotion of regulatory cells, and tolerance induction. As micronutritional deficiencies mimic an infection, the body's innate response is to limit access to these nutrients and also impede their dietary uptake. Here, we summarize our current understanding of the physiological function of iron, zinc, and vitamins A and D in relation to immune cells and the clinical consequences of deficiencies in these important nutrients, especially in the perinatal period. Improved dietary uptake of iron is achieved by vitamin C, vitamin A, and whey compounds, whereas zinc bioavailability improves through citrates and proteins. The addition of oil is essential for the dietary uptake of beta-carotene and vitamin D. As for vitamin D, the major source comes via sun exposure and only a small amount is consumed via diet, which should be factored into clinical nutritional studies. We summarize the prevalence of micronutritional deficiencies of iron, zinc, and vitamins in the pediatric population as well as nutritional intervention studies on atopic diseases with whole food, food components, and micronutrients. Dietary uptake via the lymphatic route seems promising and is associated with a lower atopy risk and symptom amelioration. This review provides useful information for clinical studies and concludes/emphasizes that a healthy, varied diet containing dairy products, fish, nuts, fruits, and vegetables as well as supplementing foods or supplementation with micronutrients as needed is essential to combat the atopic march.
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Affiliation(s)
- Diego G. Peroni
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Karin Hufnagl
- Comparative Medicine, The Interuniversity Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University of Vienna and University of Vienna, Vienna, Austria,Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Pasquale Comberiati
- Section of Paediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Franziska Roth-Walter
- Comparative Medicine, The Interuniversity Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University of Vienna and University of Vienna, Vienna, Austria,Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria,*Correspondence: Franziska Roth-Walter, ;
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3
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Bhoite R, Satyavrat V, Premasudha Sadananda M. Clinical benefits of β-glucan supplementation in children: a review. DISCOVER FOOD 2022. [PMCID: PMC9793387 DOI: 10.1007/s44187-022-00038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AbstractMalnutrition is a global concern since it affects 130 million children under the age of 5 worldwide. The child’s immunity is brutally compromised, making them susceptible to various diseases and infections, leading to a high mortality rate. Multiple strategies have been implemented to strengthen immunity in children with compromised immunity, such as rendering a balanced diet, fortifying food, dietary supplements, and introducing potential natural dietary fibers to maintain good nutrition status, such as β-glucan. A class of biologically active polysaccharides, sourced from yeast, mushroom, bacteria, and cereals with versatile immunomodulatory benefits that potentially primes the host immune system, drives several metabolic health effects, increases infection resistance, shields against the damaging effects of stress, and maintains healthy energy levels. This review focuses on the capabilities, underlying mechanisms, immune-stimulating potency, and clinically meaningful shreds of evidence to substantiate the multiple health benefits of β-glucan in children. Although, more clinical studies are required, current findings confirms the various biological response modifying abilities of β-glucan that may notably aid in the development of a strong immune system in children for their overall health and wellbeing.
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Affiliation(s)
- Rachana Bhoite
- Dr Reddy’s Laboratories Pvt Ltd, Ameerpet, Hyderabad, India
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4
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Brooker PG, Rebuli MA, Williams G, Muhlhausler BS. Effect of Fortified Formula on Growth and Nutritional Status in Young Children: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:5060. [PMID: 36501090 PMCID: PMC9737957 DOI: 10.3390/nu14235060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/19/2022] [Accepted: 11/19/2022] [Indexed: 11/29/2022] Open
Abstract
Previous reviews of the effect of young child formulas on health outcomes in infants and toddlers have been inconclusive. In this study, we undertook a contemporary synthesis of studies investigating the effects of consuming fortified milk beverages (compared to cow’s milk or unfortified comparator formula) on growth and/or nutritional status in children 1−3 years of age. Five electronic databases were searched (PubMed, Web of Science, Scopus, ProQuest, and Cochrane Library) for randomised controlled trials comparing fortified milk against control milk in young children (9−48 months), published between January 1990 and June 2022. Outcomes were growth, body composition, biochemical markers, and/or nutritional status. Mean differences (MD) were pooled using random-effects meta-analysis where there were ≥3 studies. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. Nineteen articles (12 studies; n = 4795) met the inclusion criteria. Heterogeneity was substantial, likely attributable to considerable variation in study characteristics. Fortified milk was associated with increased weight gain (MD = 0.14 kg [95% CI 0.06, 021], p = 0.0003) compared with control milk. Subgroup analyses demonstrated increases in weight in lower-income countries, and in studies with intervention periods > 6 months. There were no effects of fortified milks on other anthropometric measures. Haemoglobin (MD = 3.76 g/L [95% CI 0.17, 7.34], p = 0.04) and ferritin (MD = 0.01 nmol/L [95% CI 0.00, 0.02], p = 0.02) concentrations were increased in infants consuming fortified milks. Fortified milk beverages appear to offer a safe and acceptable source of complementary nutrition as a short-term strategy for addressing nutritional deficits and may modestly promote weight gain in vulnerable populations when provided for periods > 6 months. This study was prospectively registered with PROSPERO (CRD42022339920) and funded by the Infant Nutrition Council.
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Affiliation(s)
- Paige G. Brooker
- Health and Biosecurity, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Adelaide, BC 5000, Australia
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5
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Venter C, Meyer RW, Greenhawt M, Pali-Schöll I, Nwaru B, Roduit C, Untersmayr E, Adel-Patient K, Agache I, Agostoni C, Akdis CA, Feeney M, Hoffmann-Sommergruber K, Lunjani N, Grimshaw K, Reese I, Smith PK, Sokolowska M, Vassilopoulou E, Vlieg-Boerstra B, Amara S, Walter J, O'Mahony L. Role of dietary fiber in promoting immune health-An EAACI position paper. Allergy 2022; 77:3185-3198. [PMID: 35801383 DOI: 10.1111/all.15430] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 06/27/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023]
Abstract
Microbial metabolism of specific dietary components, such as fiber, contributes to the sophisticated inter-kingdom dialogue in the gut that maintains a stable environment with important beneficial physiological, metabolic, and immunological effects on the host. Historical changes in fiber intake may be contributing to the increase of allergic and hypersensitivity disorders as fiber-derived metabolites are evolutionarily hardwired into the molecular circuitry governing immune cell decision-making processes. In this review, we highlight the importance of fiber as a dietary ingredient, its effects on the microbiome, its effects on immune regulation, the importance of appropriate timing of intervention to target any potential window of opportunity, and potential mechanisms for dietary fibers in the prevention and management of allergic diseases. In addition, we review the human studies examining fiber or prebiotic interventions on asthma and respiratory outcomes, allergic rhinitis, atopic dermatitis, and overall risk of atopic disorders. While exposures, interventions, and outcomes were too heterogeneous for meta-analysis, there is significant potential for using fiber in targeted manipulations of the gut microbiome and its metabolic functions in promoting immune health.
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Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | - Isabella Pali-Schöll
- Comparative Medicine, Messerli Research Institute of the University of Veterinary Medicine Vienna, Medical University Vienna, Vienna, Austria
| | - Bright Nwaru
- Krefting Research Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Caroline Roduit
- University Children's Hospital Zurich, Zurich, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Karine Adel-Patient
- Université Paris-Saclay, CEA, INRAE, UMR MTS/SPI/Laboratoire d'Immuno-Allergie Alimentaire (LIAA), INRA, CEA, Université Paris Saclay, Gif sur Yvette Cedex, France
| | | | - Carlo Agostoni
- Pediatric Unit, De Marchi Clinic, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Scienze Cliniche e di Comunita, Universita' degli Studi, Milan, Italy
| | - Cezmi A Akdis
- Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland.,Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Mary Feeney
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, London, UK.,Guy's & St Thomas' Hospital, London, UK
| | - Karin Hoffmann-Sommergruber
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Nonhlanhla Lunjani
- APC Microbiome Ireland, National University of Ireland, Cork, Ireland.,University of Cape Town, Cape Town, South Africa
| | - Kate Grimshaw
- Dietetic Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Imke Reese
- Private Practice for Dietary Advice and Nutrition Therapy, Munich, Germany
| | - Peter K Smith
- School of Medicine, Griffith University, Southport, Australia
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Emilia Vassilopoulou
- Department of Nutritonal Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
| | - Berber Vlieg-Boerstra
- OLVG, Department of Paediatrics, Amsterdam, the Netherlands.,Rijnstate Hospital, Department of Paediatrics, Arnhem, The Netherlands
| | - Shriya Amara
- Undergraduate, University College Los Angeles, Los Angeles, California, USA
| | - Jens Walter
- APC Microbiome Ireland, National University of Ireland, Cork, Ireland.,Department of Medicine, National University of Ireland, Cork, Ireland.,School of Microbiology, National University of Ireland, Cork, Ireland
| | - Liam O'Mahony
- APC Microbiome Ireland, National University of Ireland, Cork, Ireland.,Department of Medicine, National University of Ireland, Cork, Ireland.,School of Microbiology, National University of Ireland, Cork, Ireland
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Reported Prevalence and Nutritional Management of Functional Constipation among Young Children from Healthcare Professionals in Eight Countries across Asia, Europe and Latin America. Nutrients 2022; 14:nu14194067. [PMID: 36235719 PMCID: PMC9572126 DOI: 10.3390/nu14194067] [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] [Received: 08/17/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The prevalence of functional constipation (FC) among children varies widely. A survey among healthcare professionals (HCPs) was conducted to better understand the HCP-reported prevalence and (nutritional) management of FC in children 12−36 months old. Methods: An anonymous e-survey using SurveyMonkey was disseminated via emails or WhatsApp among HCPs in eight countries/regions. Results: Data from 2199 respondents were analyzed. The majority of the respondents (65.9%) were from Russia, followed by other countries (Indonesia (11.0%), Malaysia (6.0%)), Mexico, KSA (5.1% (5.7%), Turkey (3.0%), Hong Kong (2.2%), Singapore (1.1%)). In total, 80% of the respondents (n = 1759) were pediatricians. The prevalence of FC in toddlers was reported at less than 5% by 43% of the respondents. Overall, 40% of the respondents reported using ROME IV criteria in > 70% of the cases to diagnose FC, while 11% never uses Rome IV. History of painful defecation and defecations < 2 x/week are the two most important criteria for diagnosing FC. In total, 33% of the respondents reported changing the standard formula to a specific nutritional solution, accompanied by parental reassurance. Conclusion: The most reported prevalence of FC in toddlers in this survey was less than five percent. ROME IV criteria are frequently used for establishing the diagnosis. Nutritional management is preferred over pharmacological treatment in managing FC.
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Manipulating Microbiota to Treat Atopic Dermatitis: Functions and Therapies. Pathogens 2022; 11:pathogens11060642. [PMID: 35745496 PMCID: PMC9228373 DOI: 10.3390/pathogens11060642] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/27/2022] [Accepted: 05/29/2022] [Indexed: 12/13/2022] Open
Abstract
Atopic dermatitis (AD) is a globally prevalent skin inflammation with a particular impact on children. Current therapies for AD are challenged by the limited armamentarium and the high heterogeneity of the disease. A novel promising therapeutic target for AD is the microbiota. Numerous studies have highlighted the involvement of the skin and gut microbiota in the pathogenesis of AD. The resident microbiota at these two epithelial tissues can modulate skin barrier functions and host immune responses, thus regulating AD progression. For example, the pathogenic roles of Staphylococcus aureus in the skin are well-established, making this bacterium an attractive target for AD treatment. Targeting the gut microbiota is another therapeutic strategy for AD. Multiple oral supplements with prebiotics, probiotics, postbiotics, and synbiotics have demonstrated promising efficacy in both AD prevention and treatment. In this review, we summarize the association of microbiota dysbiosis in both the skin and gut with AD, and the current knowledge of the functions of commensal microbiota in AD pathogenesis. Furthermore, we discuss the existing therapies in manipulating both the skin and gut commensal microbiota to prevent or treat AD. We also propose potential novel therapies based on the cutting-edge progress in this area.
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8
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Williams LM, Stoodley IL, Berthon BS, Wood LG. The Effects of Prebiotics, Synbiotics, and Short-Chain Fatty Acids on Respiratory Tract Infections and Immune Function: A Systematic Review and Meta-Analysis. Adv Nutr 2022; 13:167-192. [PMID: 34543378 PMCID: PMC8803493 DOI: 10.1093/advances/nmab114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/25/2021] [Accepted: 09/14/2021] [Indexed: 11/15/2022] Open
Abstract
Prebiotics, synbiotics, and SCFAs have been shown to decrease systemic inflammation and play a protective role in chronic respiratory conditions. However, their effects on infection and immune function are unclear. The objective of this systematic review was to summarize the current evidence for prebiotic, synbiotic, and SCFA supplementation on respiratory tract infections (RTIs) and immune function. The protocol for this systematic review was registered with PROSPERO (National Institute for Health Research, University of York, UK), accessed online at https://www.crd.york.ac.uk/prospero (CRD42019118786). Relevant English-language articles up to May 2021 were identified via online databases: MEDLINE, EMBASE, CINAHL, and Cochrane Library. Included studies (n = 58) examined the effect of prebiotics, synbiotics, or SCFA, delivered orally, on the incidence, severity, or duration of RTIs and/or markers of immune function (e.g., peripheral blood immunophenotyping, NK cell activity). The majority of studies were randomized controlled trials reporting on RTIs in infants and children. The meta-analysis indicated that the numbers of subjects with ≥1 RTI were reduced with prebiotic (OR, 0.73; 95% CI: 0.62-0.86; P = 0.0002; n = 17) and synbiotic (OR, 0.75; 95% CI: 0.65-0.87; P = 0.0001; n = 9) supplementation compared to placebo. Further, NK cell activity was increased with synbiotic (standardized mean difference, 0.74; 95% CI: 0.42-1.06; P < 0.0001, n = 3) supplementation. This review provides evidence that prebiotic, specifically oligosaccharide, supplementation may play a protective role in RTIs in infants and children. There is less evidence for this effect in adults. Supplementation with prebiotic and synbiotic treatment may alter immune function by increasing NK cell activity, though effects on immunophenotype were less clear.
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Affiliation(s)
- Lily M Williams
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Isobel L Stoodley
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
| | - Bronwyn S Berthon
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Lisa G Wood
- School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton Heights, Australia
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Hon KL, Chu S, Leung AKC, Wong A. Atopic Dermatitis: Conventional and Integrative Medicine. Curr Pediatr Rev 2022; 18:84-96. [PMID: 34279204 DOI: 10.2174/1573396317666210716152325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/24/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
Although Western medicine and ideas about atopic dermatitis (AD) have become popular in many Asian countries, local beliefs about the disease and its treatment often prevail. The multi- racial background of these countries as well as the influence of the diverse religions (such as Taoism and Ramadan) in these regions often lead to diverse belief systems about the causes of AD (such as the Chi concept, also known as the balance of yin and yang) and the types of treatment (e.g. herbal remedies, topical versus concoctions, and decoctions). In addition, many of the cultural practices are preserved among the Southeast Asian minorities residing in the United Kingdom and North America. Eastern treatments typically take a holistic approach to AD and emphasize the psychosomatic component of the disorder. This overview provides a summary of the difference between conventional, complementary, alternative, and integrative medicine in terms of epidemiology, aetiology, therapy, and prognosis in children with AD. There are a number of similarities in genetic and environmental factors in epidemiology and aetiology; however, differences exist in terms of the concept of management. Complementary and alternative medicine, traditional Chinese medicine, and integrative medicine usage are not only prevalent among the Asian population but are also becoming more popular and accepted in Western societies.
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Affiliation(s)
- Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shenzhou, Hong Kong.,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Samantha Chu
- Faculty of Medicine, The Chinese University of Hong Kong, Shenzhou, Hong Kong
| | - Alexander K C Leung
- Department of Paediatrics, The University of Calgary, and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Alex Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
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10
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Rashidi K, Darand M, Garousi N, Dehghani A, Alizadeh S. Effect of infant formula supplemented with prebiotics and probiotics on incidence of respiratory tract infections: A systematic review and meta-analysis of randomized clinical trials. Complement Ther Med 2021; 63:102795. [PMID: 34861367 DOI: 10.1016/j.ctim.2021.102795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Previous investigations have proposed that the consumption of infant formula supplemented with prebiotics, probiotics and synbiotics (PRO-formula) may have protective impacts on respiratory tract infections (RTIs). Nevertheless, the findings of studies are contradictory. This meta-analysis aimed to explore the influence of PRO-formula on RTIs in infants by pooling randomized controlled trials (RCTs). METHODS To obtain eligible RCTs, Scopus and PubMed databases were systematically searched from their inception to November 2020. A random-effects model was applied to pool the relative risks (RR) and corresponding 95% confidence intervals (CI) for RTIs following consumption of PRO-formula. RESULTS A total of 15 RCTs, with a total sample size of 3805 participants (1957 for intervention and 1848 for placebo), were included in the present meta-analysis. In the overall analysis, in comparison to placebo, consumption of PRO-formula had a significant protective impact against RTIs (RR = 0.89, 95%CI: 0.82-0.97) in infants, with a remarkable evidence of heterogeneity across studies (I2 = 61.4%, P < 0.001). In the meta-regression analysis, the effect of PRO-formula on RTIs was not modified by the follow-up duration. No evidence for publication bias was detected. CONCLUSIONS Administration of PRO-formula may be a potential approach for the prevention of respiratory tract infections in infants.
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Affiliation(s)
- Kamil Rashidi
- Department of Food Sciences and Technology, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mina Darand
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Nazila Garousi
- Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Azadeh Dehghani
- Nutrition Research Center, Department of Community Nutrition, faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran; Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Shahab Alizadeh
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran.
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11
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Polak K, Jobbágy A, Muszyński T, Wojciechowska K, Frątczak A, Bánvölgyi A, Bergler-Czop B, Kiss N. Microbiome Modulation as a Therapeutic Approach in Chronic Skin Diseases. Biomedicines 2021; 9:biomedicines9101436. [PMID: 34680552 PMCID: PMC8533290 DOI: 10.3390/biomedicines9101436] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023] Open
Abstract
There is a growing quantity of evidence on how skin and gut microbiome composition impacts the course of various dermatological diseases. The strategies involving the modulation of bacterial composition are increasingly in the focus of research attention. The aim of the present review was to analyze the literature available in PubMed (MEDLINE) and EMBASE databases on the topic of microbiome modulation in skin diseases. The effects and possible mechanisms of action of probiotics, prebiotics and synbiotics in dermatological conditions including atopic dermatitis (AD), psoriasis, chronic ulcers, seborrheic dermatitis, burns and acne were analyzed. Due to the very limited number of studies available regarding the topic of microbiome modulation in all skin diseases except for AD, the authors decided to also include case reports and original studies concerning oral administration and topical application of the pro-, pre- and synbiotics in the final analysis. The evaluated studies mostly reported significant health benefits to the patients or show promising results in animal or ex vivo studies. However, due to a limited amount of research and unambiguous results, the topic of microbiome modulation as a therapeutic approach in skin diseases still warrants further investigation.
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Affiliation(s)
- Karina Polak
- Doctoral School, Medical University of Silesia, 40-055 Katowice, Poland; (K.P.); (K.W.)
| | - Antal Jobbágy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, H-1085 Budapest, Hungary; (A.J.); (A.B.)
| | - Tomasz Muszyński
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, 31-530 Cracow, Poland;
| | - Kamila Wojciechowska
- Doctoral School, Medical University of Silesia, 40-055 Katowice, Poland; (K.P.); (K.W.)
| | - Aleksandra Frątczak
- Chair and Department of Dermatology, Medical University of Silesia, 40-027 Katowice, Poland; (A.F.); (B.B.-C.)
| | - András Bánvölgyi
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, H-1085 Budapest, Hungary; (A.J.); (A.B.)
| | - Beata Bergler-Czop
- Chair and Department of Dermatology, Medical University of Silesia, 40-027 Katowice, Poland; (A.F.); (B.B.-C.)
| | - Norbert Kiss
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, H-1085 Budapest, Hungary; (A.J.); (A.B.)
- Correspondence:
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Ecevit MC, Özcan M, Haberal Can İ, Çadallı Tatar E, Özer S, Esen E, Atan D, Göde S, Elsürer Ç, Eryılmaz A, Uslu Coşkun B, Yazıcı ZM, Dinç ME, Özdoğan F, Günhan K, Bilal N, Korkut AY, Kasapoğlu F, Türk B, Araz Server E, Önerci Çelebi Ö, Şimşek T, Kum RO, Adalı MK, Eren E, Yüksel Aslıer NG, Bayındır T, Çakır Çetin A, Enise Göker A, Adadan Güvenç I, Köseoğlu S, Soylu Özler G, Şahin E, Şahin Yılmaz A, Güne C, Aksoy Yıldırım G, Öca B, Durmuşoğlu M, Kantekin Y, Özmen S, Orhan Kubat G, Köybaşı Şanal S, Altuntaş EE, Selçuk A, Yazıcı H, Baklacı D, Yaylacı A, Hancı D, Doğan S, Fidan V, Uygur K, Keleş N, Cingi C, Topuz B, Çanakçıoğlu S, Önerci M. Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART). Turk Arch Otorhinolaryngol 2021; 59:1-157. [PMID: 34212158 PMCID: PMC8221269 DOI: 10.4274/tao.2021.suppl.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECT To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients. METHODS The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article. RESULTS A detailed guideline about all aspects of allergic rhinitis was created. CONCLUSION The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.
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Affiliation(s)
- Mustafa Cenk Ecevit
- Department of Otorhinolaryngology, Dokuz Eylül University Faculty of Medicine, İzmir
| | - Müge Özcan
- Department of Otorhinolaryngology, University of Health Sciences Turkey Faculty of Medicine, Ankara
| | - İlknur Haberal Can
- Department of Otorhinolaryngology, Yozgat Bozok University Faculty of Medicine, Yozgat
| | - Emel Çadallı Tatar
- Department of Otorhinolaryngology, University of Health Sciences Turkey Faculty of Medicine, Ankara
| | - Serdar Özer
- Department of Otorhinolaryngology, Hacettepe University Faculty of Medicine, Ankara
| | - Erkan Esen
- Department of Otorhinolaryngology, Derince Training and Research Hospital, İzmit
| | - Doğan Atan
- Department of Otorhinolaryngology, Lokman Hekim Hospital, Ankara
| | - Sercan Göde
- Department of Otorhinolaryngology, Ege University Faculty of Medicine, İzmir
| | - Çağdaş Elsürer
- Department of Otorhinolaryngology, Selçuk University Faculty of Medicine, Konya
| | - Aylin Eryılmaz
- Department of Otorhinolaryngology, Adnan Menderes University Faculty of Medicine, Aydın
| | - Berna Uslu Coşkun
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul
| | - Zahide Mine Yazıcı
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Faculty of Medicine, İstanbul
| | - Mehmet Emre Dinç
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul
| | - Fatih Özdoğan
- Department of Otorhinolaryngology, Derince Training and Research Hospital, İzmit
| | - Kıvanç Günhan
- Department of Otorhinolaryngology, Celal Bayar University, Manisa
| | - Nagihan Bilal
- Department of Otorhinolaryngology, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş
| | - Arzu Yasemin Korkut
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul
| | - Fikret Kasapoğlu
- Department of Otorhinolaryngology, Uludağ University Faculty of Medicine, Bursa
| | - Bilge Türk
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul
| | - Ela Araz Server
- Department of Otorhinolaryngology, University of Health Sciences Turkey, İstanbul Training and Research Hospital, İstanbul
| | - Özlem Önerci Çelebi
- Department of Otorhinolaryngology, University of Health Sciences Turkey, İstanbul Training and Research Hospital, İstanbul
| | - Tuğçe Şimşek
- Department of Otorhinolaryngology, Amasya University Sabuncuoğlu Şerefeddin Training and Research Hospital, Amasya
| | - Rauf Oğuzhan Kum
- Department of Otorhinolaryngology, University of Health Sciences Turkey Faculty of Medicine, Ankara
| | - Mustafa Kemal Adalı
- Department of Otorhinolaryngology, Trakya University Faculty of Medicine, Edirne
| | - Erdem Eren
- Department of Otorhinolaryngology, Atatürk Training and Research Hospital, İzmir
| | - Nesibe Gül Yüksel Aslıer
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital, Bursa
| | - Tuba Bayındır
- Department of Otorhinolaryngology, İnönü University Faculty of Medicine, Malatya
| | - Aslı Çakır Çetin
- Department of Otorhinolaryngology, Dokuz Eylül University Faculty of Medicine, İzmir
| | - Ayşe Enise Göker
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul
| | - Işıl Adadan Güvenç
- Department of Otorhinolaryngology, Bakırçay University Faculty of Medicine, Çiğli Training and Research Hospital, İzmir
| | - Sabri Köseoğlu
- Department of Otorhinolaryngology, Sıtkı Koçman University Faculty of Medicine, Muğla
| | - Gül Soylu Özler
- Department of Otorhinolaryngology, Mustafa Kemal University Faculty of Medicine, Hatay
| | - Ethem Şahin
- Bayındır Heathcare Group İçerenköy Hospital, İstanbul
| | - Aslı Şahin Yılmaz
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Ümraniye Training and Research Hospital, İstanbul
| | - Ceren Güne
- Department of Otorhinolaryngology, Atatürk Training and Research Hospital, İzmir
| | - Gökçe Aksoy Yıldırım
- University of Health Sciences Turkey, Bozyaka Training and Research Hospital, Department of Otorhinolaryngology, İzmir
| | - Bülent Öca
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul
| | - Mehmet Durmuşoğlu
- Department of Otorhinolaryngology, Bakırçay University Faculty of Medicine, Çiğli Training and Research Hospital, İzmir
| | - Yunus Kantekin
- Department of Otorhinolaryngology University of Health Sciences Turkey, Kayseri City Hospital, Kayseri
| | - Süay Özmen
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital, Bursa
| | - Gözde Orhan Kubat
- Department of Otorhinolaryngology, Alanya Alaaddin Keykubat University Faculty of Medicine, Antalya
| | - Serap Köybaşı Şanal
- Department of Otorhinolaryngology, Abant İzzet Baysal University Faculty of Medicine, Bolu
| | - Emine Elif Altuntaş
- Department of Otorhinolaryngology, Sivas Cumhuriyet University Faculty of Medicine, Sivas
| | - Adin Selçuk
- Department of Otorhinolaryngology, Bahçeşehir University Faculty of Medicine, İstanbul
| | - Haşmet Yazıcı
- Department of Otorhinolaryngology, Balıkesir University Faculty of Medicine, Balıkesir
| | - Deniz Baklacı
- Department of Otorhinolaryngology, Bülent Ecevit University Faculty of Medicine, Zonguldak
| | - Atılay Yaylacı
- Department of Otorhinolaryngology, Kocaeli University Faculty of Medicine, Kocaeli
| | - Deniz Hancı
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul
| | - Sedat Doğan
- Department of Otorhinolaryngology, Adıyaman University Faculty of Medicine, Adıyaman
| | - Vural Fidan
- Department of Otorhinolaryngology, University of Health Sciences Turkey, Eskişehir City Hospital, Eskişehir
| | - Kemal Uygur
- Department of Otorhinolaryngology, Gazi University Faculty of Medicine, Ankara
| | - Nesil Keleş
- Department of Otorhinolaryngology, İstanbul University İstanbul Faculty of Medicine, İstanbul
| | - Cemal Cingi
- Department of Otorhinolaryngology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir
| | - Bülent Topuz
- Department of Otorhinolaryngology, Pamukkale University Faculty of Medicine, Denizli
| | - Salih Çanakçıoğlu
- Department of Otorhinolaryngology, İstanbul University İstanbul Faculty of Medicine, İstanbul
| | - Metin Önerci
- Department of Otorhinolaryngology, Hacettepe University Faculty of Medicine, Ankara
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De Marco Castro E, Calder PC, Roche HM. β-1,3/1,6-Glucans and Immunity: State of the Art and Future Directions. Mol Nutr Food Res 2021; 65:e1901071. [PMID: 32223047 PMCID: PMC7816268 DOI: 10.1002/mnfr.201901071] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/28/2020] [Indexed: 12/16/2022]
Abstract
The innate immune system responds in a rapid and non-specific manner against immunologic threats; inflammation is part of this response. This is followed by a slower but targeted and specific response termed the adaptive or acquired immune response. There is emerging evidence that dietary components, including yeast-derived β-glucans, can aid host defense against pathogens by modulating inflammatory and antimicrobial activity of neutrophils and macrophages. Innate immune training refers to a newly recognized phenomenon wherein compounds may "train" innate immune cells, such that monocyte and macrophage precursor biology is altered to mount a more effective immunological response. Although various human studies have been carried out, much uncertainty still exists and further studies are required to fully elucidate the relationship between β-glucan supplementation and human immune function. This review offers an up-to-date report on yeast-derived β-glucans as immunomodulators, including a brief overview of the current paradigm regarding the interaction of β-glucans with the immune system. The recent pre-clinical work that has partly decrypted mode of action and the newest evidence from human trials are also reviewed. According to pre-clinical studies, β-1,3/1,6-glucan derived from baker's yeast may offer increased immuno-surveillance, although the human evidence is weaker than that gained from pre-clinical studies.
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Affiliation(s)
- Elena De Marco Castro
- Nutrigenomics Research GroupSchool of Public Health, Physiotherapy, and Sports ScienceConway Institute, and Institute of Food and HealthUniversity College DublinDublin 4D04 V1W8Ireland
- Diabetes Complications Research CentreConway InstituteUniversity College DublinDublin 4D04 V1W8Ireland
| | - Philip C. Calder
- Faculty of MedicineUniversity of SouthamptonSouthamptonSO16 6YDUK
- NIHR Southampton Biomedical Research CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonSO16 6YDUK
| | - Helen M. Roche
- Nutrigenomics Research GroupSchool of Public Health, Physiotherapy, and Sports ScienceConway Institute, and Institute of Food and HealthUniversity College DublinDublin 4D04 V1W8Ireland
- Diabetes Complications Research CentreConway InstituteUniversity College DublinDublin 4D04 V1W8Ireland
- Institute for Global Food SecurityQueens University BelfastBelfastNorthern IrelandBT9 5DLUK
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van der Gaag EJ, Hummel TZ. Food or medication? The therapeutic effects of food on the duration and incidence of upper respiratory tract infections: a Review of the literature. Crit Rev Food Sci Nutr 2020; 61:2691-2704. [PMID: 32648776 DOI: 10.1080/10408398.2020.1784087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Upper respiratory tract infections are common in children and adults. Antiviral treatments are only available for specific groups of patients, stimulating the distribution of over-the-counter medication to relieve the symptoms for the other patients. Studies about whole foods and their effect on the incidence and duration of upper respiratory tract infections were reviewed. METHODS Randomized controlled trials and case-control studies available on MEDLINE, Web of Science, Cochrane Library and Embase were included. RESULTS AND CONCLUSIONS Thirty-three studies were included. The incidence of respiratory infections or symptoms was shown to be reduced in some studies when probiotics, prebiotics, growing-up milk, fish oil, kiwi, garlic and xylitol were taken. Duration was favorably influenced by the intake of elderberry, kiwi, probiotics and fish oil. When the risk of bias and repetition is taken into account, probiotics and elderberry repeatedly show favorable effects. Prudent conclusions can be made in selective patient groups. However, the studies were diverse and were only performed by a few study groups.
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Affiliation(s)
- Ellen José van der Gaag
- Pediatrics, Hospital Group Twente, Almelo, SZ, Netherlands.,Behaviourial Management and Social Sciences, University of Twente, Enschede, AE, Netherlands
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Sestito S, D'Auria E, Baldassarre ME, Salvatore S, Tallarico V, Stefanelli E, Tarsitano F, Concolino D, Pensabene L. The Role of Prebiotics and Probiotics in Prevention of Allergic Diseases in Infants. Front Pediatr 2020; 8:583946. [PMID: 33415087 PMCID: PMC7783417 DOI: 10.3389/fped.2020.583946] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Allergic diseases have been linked to genetic and/or environmental factors, such as antibiotic use, westernized high fat and low fiber diet, which lead to early intestinal dysbiosis, and account for the rise in allergy prevalence, especially in western countries. Allergic diseases have shown reduced microbial diversity, including fewer lactobacilli and bifidobacteria, within the neonatal microbiota, before the onset of atopic diseases. Raised interest in microbiota manipulating strategies to restore the microbial balance for atopic disease prevention, through prebiotics, probiotics, or synbiotics supplementation, has been reported. We reviewed and discussed the role of prebiotics and/or probiotics supplementation for allergy prevention in infants. We searched PubMed and the Cochrane Database using keywords relating to "allergy" OR "allergic disorders," "prevention" AND "prebiotics" OR "probiotics" OR "synbiotics." We limited our evaluation to papers of English language including children aged 0-2 years old. Different products or strains used, different period of intervention, duration of supplementation, has hampered the draw of definitive conclusions on the clinical impact of probiotics and/or prebiotics for prevention of allergic diseases in infants, except for atopic dermatitis in infants at high-risk. This preventive effect on eczema in high-risk infants is supported by clear evidence for probiotics but only moderate evidence for prebiotic supplementation. However, the optimal prebiotic or strain of probiotic, dose, duration, and timing of intervention remains uncertain. Particularly, a combined pre- and post-natal intervention appeared of stronger benefit, although the definition of the optimal intervention starting time during gestation, the timing, and duration in the post-natal period, as well as the best target population, are still an unmet need.
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Affiliation(s)
- Simona Sestito
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Enza D'Auria
- Department of Pediatrics, Vittore Buzzi Children's Hospital-University of Milan, Milan, Italy
| | - Maria Elisabetta Baldassarre
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, Bari, Italy
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Valeria Tallarico
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ettore Stefanelli
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Flora Tarsitano
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Daniela Concolino
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.,Department of Health Sciences, School of Medicine and Surgery, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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