Herbal Medicines for the Treatment of Active Ulcerative Colitis: A Systematic Review and Meta-Analysis

Herbal medicines are used by patients with IBD despite limited evidence. We present a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating treatment with herbal medicines in active ulcerative colitis (UC). A search query designed by a library informationist was used to identify potential articles for inclusion. Articles were screened and data were extracted by at least two investigators. Outcomes of interest included clinical response, clinical remission, endoscopic response, endoscopic remission, and safety. We identified 28 RCTs for 18 herbs. In pooled analyses, when compared with placebo, clinical response rates were significantly higher for Indigo naturalis (IN) (RR 3.70, 95% CI 1.97-6.95), but not for Curcuma longa (CL) (RR 1.60, 95% CI 0.99-2.58) or Andrographis paniculata (AP) (RR 0.95, 95% CI 0.71-1.26). There was a significantly higher rate of clinical remission for CL (RR 2.58, 95% CI 1.18-5.63), but not for AP (RR 1.31, 95% CI 0.86-2.01). Higher rates of endoscopic response (RR 1.56, 95% CI 1.08-2.26) and remission (RR 19.37, 95% CI 2.71-138.42) were significant for CL. CL has evidence supporting its use as an adjuvant therapy in active UC. Research with larger scale and well-designed RCTs, manufacturing regulations, and education are needed.

Superior Efficacy of Infliximab Versus Adalimumab for First-Line Treatment of Crohn's Perianal Fistulae

BACKGROUND

Crohn's disease perianal fistulae (CD-PAF) occur in 25% of patients and are notoriously challenging to manage. Tumor necrosis factor inhibitors are first line agents.

AIMS

The aim of this study was to compare infliximab (IFX) versus adalimumab (ADA) efficacy in CD-PAF healing over time.

METHODS

A retrospective study at two large-tertiary medical centers was performed. Inclusion criteria were actively draining CD-PAF and initial treatment with IFX or ADA following CD-PAF diagnosis. The primary endpoints were perianal fistula response and remission at 6 and 12 months. Secondary endpoints included biologic persistence over time and dose escalation at 6 and 12 months.

RESULTS

Among 151 patients included in the study, 92 received IFX and 59 received ADA as first line agents after CD-PAF diagnosis. At 6 months, the 64.9% of the IFX group and 34.8% of the ADA group demonstrated CD-PAF clinical improvement (p < 0.01). Univariate and multivariate analyses demonstrated significant differences among the IFX and ADA groups for clinical response at 6-months and 12-months (p = 0.002 and p = 0.042, respectively). There were no factors that predicted response, with the exception of concomitant immunomodulator affecting the 6-month clinical response (p = 0.021). Biologic persistence, characterized by Kaplan Meier methods, was significantly longer in the IFX group compared to the ADA group (Log-rank p = 0.01).

CONCLUSION

IFX induction and maintenance is associated with higher rates of response and remission in CD-PAF healing as well as higher treatment persistence compared to ADA. Additionally, our study supports the use of concomitant immunomodulator therapy for CD-PAF healing and remission.

Machine Learning-based Characterization of Longitudinal Health Care Utilization Among Patients With Inflammatory Bowel Diseases

BACKGROUND

Inflammatory bowel disease (IBD) is associated with increased health care utilization. Forecasting of high resource utilizers could improve resource allocation. In this study, we aimed to develop machine learning models (1) to cluster patients according to clinical utilization patterns and (2) to predict longitudinal utilization patterns based on readily available baseline clinical characteristics.

METHODS

We conducted a retrospective study of adults with IBD at 2 academic centers between 2015 and 2021. Outcomes included different clinical encounters, new prescriptions of corticosteroids, and initiation of biologic therapy. Machine learning models were developed to characterize health care utilization. Poisson regression compared frequencies of clinical encounters.

RESULTS

A total of 1174 IBD patients were followed for more than 5673 12-month observational windows. The clustering method separated patients according to low, medium, and high resource utilizers. In Poisson regression models, compared with low resource utilizers, moderate and high resource utilizers had significantly higher rates of each encounter type. Comparing moderate and high resource utilizers, the latter had greater utilization of each encounter type, except for telephone encounters and biologic therapy initiation. Machine learning models predicted longitudinal health care utilization with 81% to 85% accuracy (area under the receiver operating characteristic curve 0.84-0.90); these were superior to ordinal regression and random choice methods.

CONCLUSION

Machine learning models were able to cluster individuals according to relative health care resource utilization and to accurately predict longitudinal resource utilization using baseline clinical factors. Integration of such models into the electronic medical records could provide a powerful semiautomated tool to guide patient risk assessment, targeted care coordination, and more efficient resource allocation.

Prof. Peter G. FEDOR-FREYBERGH, MD, DSc, Dr.h.c. mult

Our dear Professor, the Editor-in-Chief of Neuroendocrinology Letters (NEL) has left us. We, the Editors, Associated Editors and the Editorial Board continue our work without interruption and will follow the steps and traditions established by Professor Fedor-Freybergh, point to point, without exception. As it was, so will it be. On this sad occasion, we would like to reproduce some excerpts from an article published in Activitas Nervosa Superior Rediviva (ANSR), on the occasion of Professor Fedor-Freybergh's 80th birthday: "Let us to note - at least telegraphically - the profound milestones in his professional curriculum: Doctor of Medicine (1959); Doctor of Psychology (1965), Certificate in Psychiatry (1962) all 3 from Comenius University in Bratislava; Certificate in Pedopsychiatry (1965) and PhD in Psychiatry (1967) both from Charles University in Prague); Certificate and Doctorate in Obstetrics and Gynaecology (1977 Sweden); since 1968 appointments in Psychiatric Clinics in Austria, Switzerland, England, Sweden and Czech Republic; in 1974, he read the Introductory Lecture Psychotropic Action of Hormones at the 1st World Congress of Biological Psychiatry in Buenos Aires which significantly contributed to the global development of this discipline in both educational and scientific fields, Lecturer in Psycho-neuroendocrinology 1978 and in 1982 appointed the 1st University Professor in Europe in this field (University of Salzburg);. In 1978 Professor Fedor-Freybergh founded and Edited the peer reviewed International Journal of Prenatal and Perinatal Psychology and Medicine; in 1986, he elevated the International Study-Group for Prenatal Psychology to transform into the International Society of Prenatal and Perinatal Psychology & Medicine, in 1988, he published in English and German languages the world's first textbook Prenatal & Perinatal Psychology & Medicine; from 1983-1992 he served as Elected President of the International Society of Prenatal Psychology and Medicine and since 1992 as its Honorary Life President; in 1996, he won an audition for the post of Professor of Child Psychiatry at the 3rd Medical Faculty of Charles University in Prague which he held until 2004; in 1997 he became Director of the Institute of Prenatal and Perinatal Psychology, Medicine and Social Work at the University of Health and Social Work of St. Elisabeth University in Bratislava, in 2009, the Rector of the University granted Prof. Fedor-Freybergh the title of Professor of Prenatal and Perinatal Psychology and Medicine - the first such Professorship in the world". "As the Editor-in-Chief of ANSR [besides Neuroendocrinology Letters, Editors note], he became a member of the CIANS Executive Committee and actively participated in CIANS' international conferences and symposia. In recent years, his health has not allowed him to travel, but he has not stopped watching these events. In face-to-face meetings, we discussed much of the knowledge presented. Discussing with him was always a great experience. The dialogue gradually shifted from the professional level to cultural issues from literature, music, history and art to contemporary political aenigmas as well. He never imposed his opinion; he only said the reasons why he thinks it is so. Professor Fedor-Freybergh was a real gentleman who was always willing to help another. We bow to his life's work. We miss him deeply".

Effect of interleukin (IL)-8 on benzo[a]pyrene metabolism and DNA damage in human lung epithelial cells

It has been well established that inflammation and concurrent mutagenic exposures drive the carcinogenic process in a synergistic way. To elucidate the role of the inflammatory cytokine IL-8 in this process, we studied its effect on the activation and deactivation of the chemical mutagen benzo[a]pyrene B[a]P in the immortalized pulmonary BEAS-2B cell line. After 24h incubation with B[a]P in the presence or absence of IL-8, the B[a]P induced cytochrome P450 1A1 and 1B1 (CYP1A1 and CYP1B1) gene expression and CYP1A1 enzyme activity was significantly higher in the presence of the cytokine. Consistent with these findings, we observed higher concentration of the metabolite B[a]P-7,8-diol under concurrent IL-8 treatment conditions. Interestingly, we also found higher concentrations of unmetabolized B[a]P. To explain this, we examined the downstream effects of IL-8 on NADPH oxidases (NOXes). IL-8 lowered the intracellular NADPH level, but this effect could not explain the changes in B[a]P metabolism. IL-8 also significantly depleted intracellular glutathione (GSH), which also resulted in enhanced levels of unmetabolized B[a]P, but increased concentrations of the metabolite B[a]P-7,8-diol. No differences in B[a]P-DNA adducts level were found between B[a]P and B[a]P combined with IL-8, and this might be due to a 3-fold increase in nucleotide excision repair (NER) after IL-8 treatment. These findings suggest that IL-8 increased the formation of B[a]P-7,8-diol despite an overall delayed B[a]P metabolism via depletion of GSH, but DNA damage levels were unaffected due to an increase in NER capacity.

Acidic cellular microenvironment modifies carcinogen-induced DNA damage and repair

Chronic inflammation creates an acidic microenvironment, which plays an important role in cancer development. To investigate how low pH changes the cellular response to the carcinogen benzo[a]pyrene (B[a]P), we incubated human pulmonary epithelial cells (A549 and BEAS-2B) with nontoxic doses of B[a]P using culturing media of various pH’s (extracellular pH (pH_e) of 7.8, 7.0, 6.5, 6.0 and 5.5) for 6, 24 and 48 h. In most incubations (pH_e 7.0–6.5), the pH in the medium returned to the physiological pH 7.8 after 48 h, but at the lowest pH (pH_e < 6.0), this recovery was incomplete. Similar changes were observed for the intracellular pH (pH_i). We observed that acidic conditions delayed B[a]P metabolism and at t = 48 h, and the concentration of unmetabolized extracellular B[a]P and B[a]P-7,8-diol was significantly higher in acidic samples than under normal physiological conditions (pH_e 7.8) for both cell lines. Cytochrome P450 (CYP1A1/CYP1B1) expression and its activity (ethoxyresorufin-O-deethylase activity) were repressed at low pH_e after 6 and 24 h, but were significantly higher at t = 48 h. In addition, a DNA repair assay showed that the incision activity was ~80% inhibited for 6 h at low pH_e and concomitant exposure to B[a]P. However, at t = 48 h, the incision activity recovered to more than 100% of the initial activity observed at neutral pH_e. After 48 h, higher B[a]P-DNA adduct levels and γ-H2AX foci were observed at low pH samples than at pH_e 7.8. In conclusion, acidic pH delayed the metabolism of B[a]P and inhibited DNA repair, ultimately leading to increased B[a]P-induced DNA damage.

Inflammation-associated extracellular β-glucuronidase alters cellular responses to the chemical carcinogen benzo[a]pyrene

Neutrophils infiltrate tissues during inflammation, and when activated, they release β-glucuronidase. Since inflammation is associated with carcinogenesis, we investigated how extracellular β-glucuronidase changed the in vitro cellular response to the chemical carcinogen benzo(a)pyrene (B[a]P). For this we exposed human liver (HepG2) and lung (A549) cells to B[a]P in the presence or absence of β-glucuronidase. β-Glucuronidase reduced B[a]P-induced expression of CYP1A1 and CYP1B1 at 6 h after exposure, which did not depend on β-glucuronidase activity, because the inhibitor D-saccharic acid 1,4-lactone monohydrate did not antagonize the effect of β-glucuronidase. On the other hand, the inhibitory effect of β-glucuronidase on CYP expression was dependent on signalling via the insulin-like growth factor receptor (IGF2R, a known receptor for β-glucuronidase), because co-incubation with the IGF2R inhibitor mannose-6-phosphate completely abolished the effect of β-glucuronidase. Extracellular β-glucuronidase also reduced the formation of several B[a]P metabolites and B[a]P-DNA adducts. Interestingly, at 24 h of exposure, β-glucuronidase significantly enhanced CYP expression, probably because β-glucuronidase de-glucuronidated B[a]P metabolites, which continued to trigger the aryl hydrocarbon receptor (Ah receptor) and induced expression of CYP1A1 (in both cell lines) and CYP1B1 (in A549 only). Consequently, significantly higher concentrations of B[a]P metabolites and DNA adducts were found in β-glucuronidase-treated cells at 24 h. DNA adduct levels peaked at 48 h in cells that were exposed to B[a]P and treated with β-glucuronidase. Overall, these data show that β-glucuronidase alters the cellular response to B[a]P and ultimately enhances B[a]P-induced DNA adduct levels.

Detection of intestinal protozoa in paediatric patients with gastrointestinal symptoms by multiplex real-time PCR

The performance of a multiplex real-time PCR for the detection of Blastocystis, Dientamoeba fragilis, Giardia lamblia, Cryptosporidium species and Entamoeba species in faecal samples was evaluated in an observational prospective study. Paediatric patients (0-18 years) presenting with gastrointestinal symptoms and suspected of having enteroparasitic disease were included. A questionnaire on gastrointestinal symptoms and the chosen treatment was completed at the start of the study and after 6 weeks. Of 163 paediatric patients (mean age, 7.8 years), 114 (70%) had a PCR-positive faecal sample. D. fragilis was detected most frequently, in 101 patients, followed by Blastocystis in 49. In faecal samples of 47 patients, more than one protozoan was detected, mainly the combination of D. fragilis and Blastocystis. Reported gastrointestinal symptoms were abdominal pain (78%), nausea (30%), and altered bowel habits (28%). Eighty-nine of the PCR-positive patients were treated with antibiotics. A significant reduction in abdominal pain was observed both in treated and in untreated patients. This study demonstrated that multiplex real-time PCR detects a high percentage of intestinal protozoa in paediatric patients with gastrointestinal symptoms. However, interpretation and determination of the clinical relevance of a positive PCR result in this population are still difficult.

Nutrition awareness before and throughout different trimesters in pregnancy: a quantitative study among Dutch women

OBJECTIVE

To examine the nutrition awareness of women before and during pregnancy in order to provide a greater understanding of the life course perspective (LCP) in relation to nutrition behaviours and pregnancy.

METHOD

Data were collected in a cross-sectional study with the aid of a face-to-face interview, based on our conceptualization of nutrition awareness and the 'rules of thumb' designed by the Dutch Nutrition Centre. The sample consisted of five groups each of ~100 Dutch nulliparous women: women not trying to conceive a child, women trying to conceive a child and women in their first, second or third trimesters of pregnancy.

RESULTS

The measurement tool based on our conceptualization of nutrition awareness resulted in a Cronbach's alpha of 0.84. Pregnant women are significantly more aware of their nutrition than women who are not trying to conceive. The scores on nutrition awareness do not differ significantly between the three trimester groups of pregnant women. Women who are trying to conceive do not have a significantly higher nutrition awareness than women who are not trying to conceive.

CONCLUSIONS

Our conceptualization of nutrition awareness has shown to be fruitful in obtaining a better understanding of behavioural changes in health. The study provided indications in favour of the LCP; pregnancy could indeed be an event in a woman's life that causes increased nutrition awareness. This should be kept in mind when healthy nutrition promotion activities are being developed.

Biological monitoring the exposure to polycyclic aromatic hydrocarbons of coke oven workers in relation to smoking and genetic polymorphisms for GSTM1 and GSTT1

Occupational exposure to polycyclic aromatic hydrocarbons (PAH) increases the risk of developing lung cancer. Human exposure is often demonstrated by increased internal levels of PAH metabolites and of markers for early biological effects, like DNA adducts and cytogenetic aberrations.

OBJECTIVE

This study aimed to assess whether the current exposure to PAH of coke oven workers in a Dutch plant induced biological effects, and to determine if these effects are influenced by tobacco smoking and by genetic polymorphisms for the glutathione S-transferase genes GSTM1 and GSTT1.

METHODS

Urinary 1-hydroxypyrene (1-OHpyr) levels were used to monitor the internal dose, while the internal effective dose was assessed by monitoring PAH-DNA adducts, DNA strand breaks (Comet assay), sister-chromatid exchanges (SCE) and cells with a high frequency of SCE (HFC) in lymphocytes together with micronuclei (MN) in exfoliated urothelial cells.

RESULTS

Occupational exposure to PAH resulted in statistically significant increased 1-OHpyr levels (P<0.001), but it did not cause a significant induction of SCE, HFC, MN, DNA strand breaks or DNA adducts. Smoking caused a significant increase of 1-OHpyr (P<0.05), SCE (P<0.001), HFC (P<0.001) and DNA adducts (P<0.05), but not of MN or DNA strand breaks. Following correction for the smoking-related effects, no occupational induction of the effect biomarkers could be discerned. Multi-variate analysis did not show a significant influence of GSTM1 and GSTT1 polymorphisms on any biomarker. Also no significant interactions were observed between the various biomarkers.

CONCLUSION

This study shows that in the examined plant, the occupational exposure to PAH does not result in measurable early biological effects

Effect of a dioxin-like PCB (CB 126) on the biotransformation and genotoxicity of benzo

Two experiments were performed to study the interaction between benzo[a]pyrene (BaP) and the planar, dioxin-like PCB congener 3,3',4,4',5-pentachlorobiphenyl (CB 126) in the flatfish dab (Limanda limanda). The first experiment involved four groups. Group I was treated with 10 µg/kg CB 126, group II was treated with 2 mg/kg BaP, group III was first treated with 10 µg/kg CB 126 and exposed to 2 mg/kg BaP 6 days later, and group IV was a control group. The second experiment was similar, except that the BaP dosage level was increased to 50 mg/kg. Pre-treatment with 10 µg/kg of CB 126 always caused the induction of hepatic cytochrome P450 1A (CYP1A), as measured by significant increases of the model reaction 7-ethoxyresorufin-O-deethylase (EROD) in microsomal preparations. Treatment of dab with BaP caused a significant EROD induction at the 50 mg/kg, but not at the 2 mg/kg level. Concurrent with EROD induction by either CB 126 or 50 mg/kg BaP, was a significant change in the biliary metabolite pattern in favour of 1-hydroxybenzo[a]pyrene and 3-hydroxybenzo[a]pyrene and towards a lower fraction of the procarcinogen BaP-7,8-dihydrodiol (7,8-DIOL). Pre-treatment with CB 126 did not cause an increase of hepatic BaP DNA adducts formed after treatment with either 2 or 50 mg/kg BaP. Glutathione S-transferase (GST) activities remained also unaffected by any of the treatments. The results of this study suggest that the pattern of BaP metabolites in bile depends on the level of CYP1A induction. Moreover, the concurrence of a potent CYP1A inducer and BaP does not necessarily lead to an increase in DNA adduct levels in liver tissue. The observation that the level of 7,8-DIOL is decreased despite a higher (CYP1A mediated) EROD activity explains, at least in part, the lack of induction of DNA adducts.

CA-125 tumor-associated antigen in a patient with tuberculous peritonitis

A 64-year-old woman with a history of chronic hepatitis B had abdominal pain and ascites, a serum albumin ascitic gradient (SAAG) of 0.8, and an elevated serum CA-125 value. Exploratory laparotomy revealed ascites and obliteration of the abdominal cavity by advanced adhesive disease consistent with carcinomatosis. Surgical biopsy revealed noncaseating granulomas. She responded well to antituberculous therapy and is presently asymptomatic.

Health education in television entertainment--Medisch Centrum West: a Dutch drama serial

World-wide a number of groups have sought ways to incorporate health messages into television entertainment like popular drama and soap serials. In the Netherlands, the Heart Foundation incorporated its cardiovascular health message in several episodes of a popular Dutch hospital serial called Medisch Centrum West. To obtain greater insight into the impact of this so-called 'entertainment-education (E & E) strategy', an evaluation study was carried out. Medisch Centrum West was both entertaining and informative at the same time. Although viewers were well aware that the programme included a health message, they did not find it intrusive to their enjoyment of the storyline. It was interesting to learn that fans were more tolerant and positive towards the E & E strategy than non-fans. Age, sex and education level explained only 5% of the variance.

Lymphadenopathy in celiac sprue, not necessarily a malignant disease

A 47-year-old woman who was studied for other reasons proved to have abdominal lymphadenopathy, some nodes measuring up to 2 cm. The patient, through biopsy and other studies, was diagnosed with celiac sprue; however, on a gluten-free diet, abdominal computed tomography scans several months later showed marked reduction in the size of the mesenteric nodes.

c-Jun NH2-terminal kinase regulation of the apoptotic response of small cell lung cancer cells to ultraviolet radiation

Exposure of cultured small cell lung cancer (SCLC) cells to UV radiation induces apoptosis. We observed that the UV sensitivity of a panel of SCLC lines and the activation of c-Jun NH2-terminal kinases (JNKs) by UV in the individual SCLC lines, assessed by binding and phosphorylation of glutathione S-transferase (GST)-c-Jun fusion proteins, ranged widely. In fact, increased JNK activity in this assay was closely correlated with decreased sensitivity to apoptosis following UV irradiation. Increased JNK activity was also detected in anti-JNK1 immune complexes collected from UV-irradiated SCLC cells, although the level of activity was similar among the various SCLC lines and correlated poorly with UV sensitivity. Immunoblot analysis of JNK polypeptides that bound to GST-c-Jun revealed at least two JNK polypeptides, one of which appeared only in extracts from UV-irradiated SCLC. To test the role of JNKs in UV-induced apoptosis, nonphosphorylatable mutants of JNK1 or JNK2 in which the phosphorylation site Thr-Pro-Tyr is changed to Ala-Pro-Phe (JNK-APF) and are predicted to behave as competitive inhibitors were stably expressed in SCLC. Expression of JNK1-APF or JNK2-APF significantly reduced UV-stimulated JNK activity. However, JNK1-APF markedly increased the resistance of the cells to UV-induced apoptosis, while JNK2-APF did not influence SCLC sensitivity to UV. The findings suggest that UV-stimulated JNK1 activation promotes UV-induced SCLC apoptosis, while a JNK isoform that is variably activated among the SCLC lines may signal a UV-protective response. We hypothesize that integration of distinct JNK activities dictates the relative responsiveness of SCLC to UV and ionizing radiation.

Spontaneous noncardiac chest pain. Evaluation by 24-hour ambulatory esophageal motility and pH monitoring

Noncardiac chest pain can be a diagnostic dilemma because patients rarely experience spontaneous chest pain in the laboratory. Therefore, we studied 24 patients with chronic, daily, substernal chest pain with a prototype 24-h ambulatory esophageal motility and pH system. Spontaneous chest pain episodes were correlated with pH less than 4 and abnormal motility changes (mean amplitude and duration, maximum amplitude and duration, or percentage of abnormal peristalsis) defined as exceeding the patient's normal esophageal motility pattern. Twenty-two patients experienced a total of 92 spontaneous chest pain episodes. Eleven chest pain episodes (12%) occurred during abnormal motility, whereas 18 episodes (20%) were associated with pH less than 4 and four episodes (4%) had both abnormalities. The majority of chest pain episodes, 59 events (64%), did not have any association with motility or pH. Abnormal maximum duration and amplitude were the motility changes most frequently associated with chest pain. Overall, 13 of 22 patients (59%) had at least one chest pain episode correlating with abnormal motility or pH (range 33%-100%). Therefore, we conclude that ambulatory esophageal motility and pH monitoring is useful in the evaluation of noncardiac chest pain. pH abnormalities (20%) are more commonly associated with chest pain than motility abnormalities (12%). However, the majority of chest pain episodes (64%) did not correlate with either abnormality and may be the result of lowered esophageal pain threshold for distention, i.e., the "irritable esophagus."