Comparison Between the Cassia Fistula`s Emulsion With Polyethylene Glycol (PEG4000) in the Pediatric Functional Constipation: A Randomized Clinical Trial

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Functional constipation in children: What physicians should know

Functional constipation (FC) is considered the most common functional gastrointestinal disorder in children with a pooled global prevalence of 14.4% (95% confidence interval: 11.2-17.6) when diagnosed based on the Rome IV criteria. Its pathophysiological mechanisms are thought be multifactorial and complicated, resulting in difficult management. Currently, the most effective medication, when used in parallel with toilet training, is osmotic laxatives. Children’s adherence to medication and parental concern regarding long-term laxative use are the main contributors to treatment failure. Recently, novel therapies with a high safety profile have been developed, such as probiotics, synbiotics, serotonin 5-hydroxytryptamine 4 receptor agonists, chloride channel activators, and herbal and transitional medicines; nonetheless, well-designed research to support the use of these therapies is needed. This review aims to focus on multiple aspects of FC in children, including global prevalence, pathogenesis, diagnostic criteria, tools, as well as conventional and novel treatment options, such as non-pharmacological management, including adequate fiber and fluid intake, physiotherapy, or neuromodulators. We also report that in very difficult cases, surgical intervention may be required.

Current use of complementary and conventional medicine for treatment of pediatric patients with gastrointestinal disorders

Infants, children, and adolescents are at risk of experiencing a multitude of gastrointestinal disorders (GID). These disorders can adversely affect the quality of life or be life-threatening. Various interventions that span the conventional and complementary therapeutic categories have been developed. Nowadays, parents increasingly seek complementary options for their children to use concurrently with conventional therapies. Due to the high prevalence and morbidity of diarrhea, constipation, and irritable bowel syndrome (IBS) in children, in this review, we decided to focus on the current state of the evidence for conventional and complementary therapies used for the treatment of these diseases in children. Diarrhea treatment focuses on the identification of the cause and fluid management. Oral rehydration with supplementation of deficient micronutrients, especially zinc, is well established and recommended. Some probiotic strains have shown promise in reducing the duration of diarrhea. For the management of constipation, available clinical trials are insufficient for conclusive recommendations of dietary modifications, including increased use of fruit juice, fiber, and fluid. However, the role of laxatives as conventional treatment is becoming more established. Polyethylene glycol is the most studied, with lactulose, milk of magnesia, mineral oil, bisacodyl, and senna presenting as viable alternatives. Conventional treatments of the abdominal pain associated with IBS are poorly studied in children. Available studies investigating the effectiveness of antidepressants on abdominal pain in children with IBS were inconclusive. At the same time, probiotics and peppermint oil have a fair record of benefits and safety. The overall body of evidence indicates that a careful balance of conventional and complementary treatment strategies may be required to manage gastrointestinal conditions in children.

Efficacy of the herbal formula of Foeniculum vulgare and Rosa damascena on elderly patients with functional constipation: A double-blind randomized controlled trial

BACKGROUND

Constipation is a common chronic bowel disorder with an incidence of more than 50% in the elderly population. Complementary and alternative medicine is a cost-effective and satisfactory treatment for constipation used widely by the elderly.

OBJECTIVE

This study evaluates the efficacy of an herbal formula made from Foeniculum vulgare Mill. and Rosa damascena for the treatment of constipation in an elderly population and consequent changes to their quality of life.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

This double-blind randomized active controlled clinical trial, with parallel group allocation ratio of 1:1, was conducted in a referral clinic in Afzalipour Hospital, affiliated to Kerman University of Medical Sciences in Kerman, Southeastern Iran. Individuals over 60 years of age, diagnosed with functional constipation (based on the Rome IV criteria), were included in this study. Participants received a sachet of 10 g F. vulgare and R. damascena (herbal formula group) or polyethylene glycol 4000 (PEG 4000 group) with a glass of warm water two times a day for 4 weeks and were followed up for 4 additional weeks.

MAIN OUTCOME MEASURES

Constipation severity, stool consistency, and the quality of life were used as the primary outcomes. Drug side effects were used as a secondary outcome. The outcomes were assessed using the Constipation Assessment Scale, the Bristol Stool Form Scale, and the Patient Assessment of Constipation Quality of Life questionnaire.

RESULTS

A total of 25 participants in each group completed the four-week treatment cycle and the eight-week follow-up. At the end of the four-week treatment cycle, all clinical outcomes had significant improvements in both groups (P < 0.05). The analysis of constipation severity (P < 0.001), stool consistency (P < 0.001), and the quality of life (P < 0.001) showed significant improvements with fewer side effects (mild diarrhea) and a longer duration of symptom relief in the herbal formula group compared to the PEG 4000 group.

CONCLUSION

Although both interventions significantly improved the treatment outcomes, constipation severity, stool consistency and the quality of life were improved more effectively by the herbal formula than by PEG 4000; however, the mechanism of action is not yet understood.

TRIAL REGISTRATION

This trial was registered in the Iranian Registry of Clinical Trials (IRCTID: IRCT20200108046056N1).

Comparing the Effect of a Herbal-based Laxative (Goleghand®) and Polyethylene Glycol on Functional Constipation among Children: A Randomized Controlled Trial

Objective:

This study aimed to evaluate the effectiveness, safety, and document the reported adverse effect of a herbal-based laxative (Goleghand^®) for the maintenance treatment of functional constipation in young children.

Methods:

We conducted a randomized clinical trial from April 2019 to September 2020. Children aged 2–15 years with functional constipation defined according to the Rome IV criteria were eligible for study inclusion. Eligible children were randomly allocated to receive polyethylene glycol (PEG) or Goleghand^®. The number and consistency of stools per day, painful defecation, abdominal pain, and fecal incontinence were reported weekly by parents. The statistical analyses were performed by determining means and standard deviations, t-test, Chi-square test, ANOVA repeated measures, and Fisher's exact test, with significance, accepted at the 5% level.

Findings:

Sixty patients have been enrolled in the study. Parental satisfaction scores did not change significantly in either group or over the follow-up period. Our results showed that the effect of time (P < 0.001) and also the effect of group type (P = 0.01) on the number of fecal defecations was significant. The mean number of defecations increased first and then decreased significantly over time, but this decrease was more significant in the PEG group than in the Goleghand^® group (P = 0.001). Furthermore, the effect of time on the fecal consistency score was significant (P = 0.047). The mean score of fecal consistency in both groups decreased over time.

Conclusion:

Goleghand^® was similar in efficacy to PEG for 8 weeks of pediatric functional constipation treatment in this randomized clinical trial. Goleghand^® can be considered as a new herbal laxative drug for pediatric functional constipation.

Long-Term Administration of Anthraquinone Rhein on Induction of Constipation in Sprague-Dawley Rats via SCF/c-Kit Signaling Pathways

Background and Study Aims. It has been shown that abuse of laxatives is becoming a serious problem; therefore, a comprehensive understanding of its effect and possible mechanism on colon motility is essential to select effective treatments and avoid their abuse. Herein, we aimed to investigate the long-term stimulation of rhein on induction of constipation in rats and its underlying mechanisms. Materials and Methods. After establishing rat models of constipation, the rats were randomly divided into two equal subgroups and administered daily with normal saline (model control group) or 10 ml/kg PEG4,000 (PEG-treated group). Simultaneously, normal Sprague-Dawley (SD) rats were administered with normal saline (normal group). Physiological and fecal parameters were calculated, and intestinal transmission function was evaluated. After scarification, colonic tissues were freshly prepared for histological localization detected by immunohistochemical analysis and for the expression of stem cell factor (SCF) and c-kit proteins determined by western blot assay. Results. Following the initiation of rhein-induced rat constipation, body weight was lost slightly, the first time of black stool discharge was obviously longer, and the fecal moisture and number of fecal pellets decreased distinctly as compared with normal group. A decreased expression of SCF and c-kit was detected in model control group in comparison with normal group. Notably, compared with model control group, neither the alterations of fecal parameters and intestinal transmission function were effectively restored, nor the expression of SCF and c-kit was markedly elevated after administration of PEG4,000 for 30 d. Conclusion. Long-term stimulation of rhein can develop the constipation via SCF/c-kit signaling pathway, yet the symptoms of constipation and colon power cannot be alleviated or restored by PEG4,000. Collectively, these findings strongly suggest that long-term use of anthraquinone laxatives should be avoided for clinical treatment of constipation.

A Comparison of the Effect of Topical Preparation of Sambucus ebulus L. and Hydrocortisone on Hand Eczema: A Double-Blind Randomized Controlled Trial

Objectives: Corticosteroids as the main treatment of hand eczema can cause major side effects. This study compared the effect of topical preparation of Sambucus ebulus L. leaves and hydrocortisone on the severity of hand eczema. Design: Ninety-four patients with hand eczema aging 18-60 years were recruited in two groups (S. ebulus vs. hydrocortisone). Interventions: The patients used topical medications twice a day and were followed for 4 weeks. The observations were made at the first visit, and also second and fourth weeks of the study. Outcome measures: The primary outcomes were changes in the severity of hand eczema (hand eczema severity index [HECSI]) and life quality (dermatology life quality index [DLQI]). Secondary outcomes were the rate of healing and the severity of itching. Results: Thirty-eight patients in hydrocortisone and 43 in S. ebulus fulfilled all phases of the follow-up. In both groups, the HECSI, itching scores decreased over time without any significant difference between the groups (p = 0.49, 0.57, respectively). The DLQI scores were significantly better in the S. ebulus group (p = 0.02) after 4 weeks of medication. There was no significant difference between the healing rates of the two groups (p = 0.33). Conclusions: Topical use of S. ebulus can be as effective as that of hydrocortisone when it comes to reducing the severity of hand eczema.

Hospital diet for COVID-19, an acute respiratory infectious disease: An evidence-based Protocol of a Clinical Trial

BACKGROUND

COVID-19 caused a global pandemic problem. No confident management is introduced for it yet. This study aimed to propose a dietary protocol for hospitalized patients with the diagnosis of acute respiratory infectious disease caused by COVID-19 based on Persian Medicine.

METHODS

This study was conducted in three phases. In the first phase, any diseases that could be matched with the clinical features of infection with COVID-19 were searched in selected PM references. In the second phase, medicinal herbs and foods that were available and could be used in the hospital diet were extracted and summarized. In the third phase, the new documentation of these pharmaceutical and food items was conducted.

RESULTS

The signs and symptoms of infectious respiratory disease caused by COVID-19 can be categorized in the field of Zato al-rieh that can mainly be matched with pneumonia. Based on the described criteria, some nutrients and medicinal materia medica have been introduced for acute respiratory infection including Cydonia oblonga, Honey, Citrus sinensis, Malus domestica, Citrus medica, Crocus sativus, Raisin, Rosa Damas Cena, D.Carota, Camellia Sinensis, Anethum graveolens dhi, Punica granatum, Petroselinum Crispum, Coriandrum sativum, Urtica dioica, Allium sativum, Sesamum indicum.

CONCLUSION

Most materia medica has documents in current articles including anti-cough suppressants, antiviral properties, anti-bacterial, anti-inflammatory, antioxidant, immunomodulatory etc. A protocol of hospital diet for patients with infectious respiratory syndrome caused by COVID-19 has been introduced in this manuscript.

Traditional, complementary and alternative medicine in children constipation: a systematic review

OBJECTIVES

This review aims to evaluate the efficacy and safety of complementary and alternative medicine methods for constipation in the pediatric population.

EVIDENCE ACQUISITION

Medical literature search was performed in several databases for a variety of Traditional, Complementary and Alternative Medicine in childhood constipation. Databases included Web of Science, Scopus, Embase, Cochrane Library, PubMed, ScienceDirect, Google scholar and a number of Persian databases including IranDoc, Magiran and SID. No time limitation was determined. Clinical trials or case series that had evaluated the effectiveness of CAM therapies in functional constipation of 1-18 year old children were included. Papers not in English or Persian language were excluded. Related articles were screened independently by two reviewers according to their titles and abstracts. A data extraction form was filled in for each eligible paper. Quality assessment of eligible documents was also performed.

RESULTS

30 studies were included, comprising 27 clinical trials and 3 case series. Ten documents were on herbal medicine, nine on traditional medicine, ten on manual therapies and one on homeopathy. Except for two herbal and one reflexology interventions, all studies reported positive effects on childhood constipation, with the majority being statistically significant. As the number of studies in each method was limited, we could not perform a meta-analysis.

CONCLUSION

The scarcity of research on the efficacy and safety of different types of complementary and alternative medicine methods in children with constipation necessitates conducting more studies in each field. Graphical abstract.

Chemical Profiling and Screening of the Marker Components in the Fruit of Cassia fistula by HPLC and UHPLC/LTQ-Orbitrap MSn with Chemometrics

Cassia fistula L. which is known as “Golden Shower”, is used as an ornamental plant due to its flowers, and fruit parts of this plant have a high medicinal value. There are few reports providing a comprehensive overview of the chemical composition of its fruit or explaining the differences between samples from different sources because of the complexity of its chemical components. The purpose of the present study was to establish a fingerprint evaluation system based on Similarity Analysis (SA), Hierarchical Cluster Analysis (HCA) and Principal Component Analysis (PCA) for the composition identification and quality control of this herb. Twelve samples from Xinjiang and Sichuan provinces in China and India were analyzed by HPLC, and there were fifteen common peaks in the twelve batches. Molecular weight and formula information can be derived from thirty-one peaks by UHPLC/LTQ-Orbitrap MSⁿ, molecular structure information of twenty components was obtained, of which ten compounds were identified by comparison with standard materials. Samples of twelve batches were divided according to their similarity into four groups, which were basically consistent with three different C.fistula fruit-producing areas. Five compounds were finally considered to be chemical markers to determine the quality of this herb. A fingerprints method combined with chemometrics was established to differentiate the origin of the fruit of C. fistula which has the advantages of effectivity and convenience, laying the foundation for the quality evaluation of this herb from different sources.