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INTERNATIONAL CONFERENCE
“THE BIENNALE SIBIU – CHIŞINĂU”,
organized by
Pediatric Clinic Sibiu, Faculty of Medicine,
“Lucian Blaga” University of Sibiu, România
and
IMSP, Mother and Child Institute,
“Nicolae Testemiţanu” State University of Medicine and
Pharmacy,
Chişinău, Republic of Moldova
September 8-9th 2017
Sibiu, Pediatric Clinic, 2-4, Pompeiu Onofreiu street
ACTUALITIES IN PEDIATRICS
TABLE OF CONTENTS
INTERNATIONAL CONFERENCE
“THE BIENNALE SIBIU-CHISINAU”
ORGANIZERS:
Ministry of Health, Romania;
LBUS -“Lucian Blaga”University Sibiu,
Pediatric Clinic, Sibiu, Romania;
SUMP - “Nicolae Testemiţanu” State
University of Medicine and Pharmacy,
PMSI-Mother and Child Institute,
Chisinau, Republic of Moldova;
National Public Health Institute - Public
Health Centre of Sibiu;
Center of Research and Telemedicine in
Neurologic Diseases in Children Sibiu
ORGANIZING COMMITTEE:
Honorary President – Professor Florian-
Dorel Bodog, Ministry of Health, Romania;
Vice-presidents:
Professor Claudiu Kifor, vice-
rector of LBUS;
Professor Mihai-Leonida Neamţu,
vice-president of Romanian
Society of Pediatrics;
Professor Ninel Revenco, vice-head
of Research, Transfer of
Technology and Innovation
Department, PMSI-Mother and
Child Institute, President of
Republic Society of Pediatrics,
Republic of Moldova;
Professor Carmen Domnariu, Head
of Public Health Centre of Sibiu;
ORGANIZING COMMITTEE MEMBERS:
Assistant professor Corina Cazan,
Pediatric Clinic Hospital Sibiu, Chief of II
Pediatric Department, LBUS;
Assistant professor Luminiţa Dobrotă,
Pediatric Clinic Hospital Sibiu, Chief of I
Pediatric Department, LBUS;
Assistant professor Bogdan Neamţu,
Pediatric Clinic Hospital Sibiu, Chief of
Research Department, LBUS;
Raluca Costea, MD, researcher, Pediatric
Clinic Hospital Sibiu;
Instructor Ioana Octavia Mătăcuţă-
Bogdan, MD PhD, senior specialist,
Pediatric Clinic Hospital Sibiu, LBUS;
Assistant professor Berghea-Neamţu
Cristian-Stefan, Pediatric Clinic Hospital
Sibiu, Chief of Pediatric Surgery
Department, LBUS;
Professor Mihaela Maria Cernuşcă
Miţariu, Dean, Faculty of Medicine, LBUS
SCIENTIFIC COMMITTEE MEMBERS:
Professor Carmen Domnariu, Head of Public
Health Centre of Sibiu;
Professor Mihai-Leonida Neamţu, LBUS;
Professor Ninel Revenco, SUMP;
Assistant profesor Corina Cazan, LBUS;
Assistant professor Luminita Dobrotă, LBUS;
Assistant professor Bogdan Neamţu, LBUS;
Assistant profesor Berghea Neamtu Cristian Stefan,
LBUS.
SPONSORS: Nestlé Romania, SunWave
Pharma Romania.
INTERNATIONAL CONFERENCE
“THE BIENNALE SIBIU – CHIŞINĂU” 1. HEALTH PROMOTION THROUGH
INTERVENTIONS REGARDING HEALTHY
FOOD AND PHYSICAL EDUCATION IN
CHILDREN
Carmen Daniela Domnariu
……………………………...1
2. GUT MICROBIOTA, TYPE 2 DIABETES
MELLITUS, LOW-GRADE SYSTEMIC
INFLAMMATION. ETIOPATHOGENIC,
CLINIC AND THERAPEUTIC
CORRELATION
Cristian-Ştefan Berghea-Neamţu
………………………...3
3. THE ROLE OF GUT MICROBIOTA IN
CARBOHYDRATES DEGRADATION
Luminiţa Dobrotă
……………………………………….10
4. CLINICAL PECULIARITIES OF
CEREBROVASCULAR ACCIDENTS IN
NEWBORNS, INFANTS AND CHILDREN OF
SMALL AGE
Svetlana Hadjiu, Mariana Sprincean, Nadejda Lupusor,
Cornelia Calcii, Ramina Pasari, Vladimir Iacomi, Alina
Bantas, Andriana Gruzinschi, Ninel Revenco
………....13
5. GUT MICROBIOTA AND CENTRAL
NERVOUS SYSTEM IN HEALTH AND
AUTOIMMUNE DISEASES REVIEW
Mihai Bogdan Neamţu, Andreea Barbu, Ionela
Maniu.....17
6. TETANY OR DIAGNOSTIC PITFALL
TABLE OF CONTENTS
Raluca Maria Costea, Bogdan Neamţu
…………………22
7. GUT MICROBIOTA AND FOOD ALLERGY
Corina Cazan
…………………………………………...25
8. MICROBIOTA AND THE IMMUNE SYSTEM,
A COMPLEX LIAISON
Ioana Mătăcuţă-
Bogdan.………………………...............28
9. RISK FACTORS FOR BRONCHIOLITIS IN
INFANTS AND THE ROLE OF FECAL
MICROBIOTA PROFILES
Olga Cîrstea, Oxana Turcu, Ninel Revenco
…………….32
10. GUT MICROBIOTA AND IRRITABLE
BOWEL SYNDROME
Corina Cazan
………………………………………….…35
11. THE IMPACT OF ANTIBIOTICOTHERAPY
ON GUT MICROBIOTA IN CHILDREN
Oxana Turcu, Olga Cirstea, Ala Holban, Ninel Revenco
…………………………………………………………..
38
12. LEFT INGUINAL HERNIA AND
CRYPTORCHIDISM. PARTICULARITIES OF
TREATMENT AND EVOLUTION. CASE
REPORT
Cristian-Ştefan Berghea-Neamţu
…………….………....41
INTERNATIONAL CONFERENCE “THE BIENNALE SIBIU – CHIŞINĂU”
September 8-9th 2017
AMT, vol. 22, no. 3, 2017, p. 1
HEALTH PROMOTION THROUGH INTERVENTIONS
REGARDING HEALTHY FOOD AND PHYSICAL EDUCATION
IN CHILDREN
CARMEN DANIELA DOMNARIU
1
1“Lucian Blaga” University of Sibiu
Keywords: health
education, health
promotion, children, interventions
Abstract: Childhood obesity is one of the most serious public health issues of the 21st century. The
problem is global and prevalence has increased at an alarming rate. According to a report issued by the
World Health Organization, in 2015, the number of overweight children under the age of five was estimated to be over 42 million worldwide.(1) In response to these alarming rates, the World Health
Organization member states have agreed on strengthening and coordinating their efforts to implement
strategies to improve nutrition and physical activity at states’ level. Romania, as well, has understood
the importance of increasing the percentage of children and adolescents who live a healthy lifestyle.
1Corresponding author: Carmen Daniela Domnariu, Str. Luptei, Nr. 21, Sibiu, 550330, România, E-mail:cdomnariu@yahoo.com, Phone +40269
212812
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):1-2
INTRODUCTION
The importance of healthy nutrition and regular
physical activity has been well established.(2) Children who are overweight and obese during their childhood are most likely to
remain obese into adulthood, too and more likely to develop
noncommunicable diseases, such as diabetes and cardiovascular
diseases at a younger age. Overweight and obesity, as well as their related diseases, can be prevented. Therefore, prevention of
childhood obesity needs high priority.(1)
Strategies targeted to behaviour change include:
increase physical activity, promote breastfeeding, increase fruit and vegetable consumption and reduce television viewing-time.
Such strategies have been elaborated and revised regularly by
the health authorities at every state’s level. The USA have
issued the Dietary Guidelines for Americans, which are a science-based diet and physical activity recommendations to
promote health and prevent illnesses.(3)
At European level, there has been drawn up a School-
based Nutrition Education Guide, which places healthy nutrition education in the health-promoting school.(4)
In Romania, in 2016, the Ministry of Health, through
the Presidential Administration, has launched the Multiannual
Integrated Plan to Promote Healthcare and Education for Health, which aims to constantly increase in the next 5 years the
proportion of the population with healthy behaviours, especially
among children. The document reflects the Health 2020
principles that form the basis of the Romanian National Health Strategy 2014–2020, thus strengthening the cooperation between
Romania and WHO/Europe.(5)
One of Romania’s experiences in increasing primary
prevention services in the field of healthy eating and physical activity among children and adolescents has been materialized
in a national level strategic project, “The increasing access to
primary medical prevention services for children and adolescents from Romania. The healthy nutrition and physical
activity among the children and adolescents from Romania”.(6)
The project was earned through competition within the
Norwegian Cooperation Programme with Romania and Bulgaria, funded by the Norwegian Government through
Innovation Norway and co-financed by the Ministry of Health
and ran from August 2009 and April 2011.
The aim of the project was to build capacity for implementing interventions for healthy nutrition and physical
activity in children and adolescents (age: 3 – 19) at national and
local level.
The project had has as main partners the Romanian Ministry of Health – as the project promoter – and the National
Institute of Public Health through the Regional Centre of Public
Health of Sibiu – as the implementation unit. The institutional
partners were: the Public Health Institute of Oslo, Norway, the Education, Research, Young People and Sports Minister from
Romania and the Romanian Association of Health Psychology.
In order to accomplish the objectives of the European
Strategies on Nutrition, Physical Activity and Health, the project targeted many levels, from the individual one – the child, to
family, school, health professionals and the community (figure
no. 1).
Figure no. 1. Targeted levels in changing behaviours
The project was aimed at children aged between 3 and
19 years old and addressed the field of promotion of healthy eating and physical activity.
The project has four main components.
INTERNATIONAL CONFERENCE “THE BIENNALE SIBIU – CHIŞINĂU”
September 8-9th 2017
AMT, vol. 22, no. 3, 2017, p. 2
The first component, the research component, started
from the analysis of the current situation regarding the school
children behaviours, which was accomplished through the Health Behaviour in School-aged Children (HBSC) study, following the methodology established by the World Health
Organization and validated for Romania in the previous research
carried out in 2005.(7) This component also included a social marketing
analysis, targeting children and families, to understand why they
are acting like this and what was wrong. In this research, there
have been identified four unhealthy behaviours among children: lack of breakfast, reduced intake of fruits and vegetables,
drinking juice instead of water and low physical activity level.
There have also been pilot interventions and schools and
kindergartens to test the appropriateness of the tools developed within this project.
The targeted behaviours were: to drink water instead
of juice; to eat 5 portions of fruits, vegetables daily; to eat
breakfast daily and to have at least one hour of vigorous physical activity /day.
The second component aimed at public awareness
campaign, and included TV and radio spots, printed materials, a
website of the project etc. All these actions developed within this component aimed at empowering the child, the family,
physician, the teacher to lead a healthy lifestyle. The most
important campaign, LIFE, is a model of an interdisciplinary
and interinstitutional approach to make aware the population of the importance of changing the unhealthy behaviours.
The third component, capacity building, related to the
institutional development at local levels through the eight
facilitators employed within the project. There have been signed local partnerships among stakeholders, and there have been
developed local action plans for healthy nutrition and physical
activity in children. Also, this component targeted micro-
projects which took place in schools and kindergartens, as well as coaching and training for local stakeholders.
The capacity building component has issued a
communication tool, namely the Intervention Guidelines at
Community Level, designed to be a model of good practice for
defining the implementing the changing behaviours campaigns
regarding healthy nutrition and physical activity (figure no. 2).
Figure no. 2. Intervention guidelines at community level –
communication tool
The fourth component, the legislative component, addressed
proposals of amendments to the legislative framework to support the sustainable implementation of changing behaviour
patterns at local, county and national levels.(6)
The actions and activities developed within this
project have been materialized in 42 partnership agreements signed among stakeholders, county actions plans developed in
all the counties of the country and endorsed by the local
stakeholders, and more than 500 micro-projects that started in
schools and kindergartens with a small financing from the project and a local contribution.
The project was a success for our country
taking into account the target population, the good subject, the
good international evidence and the good transfer of results to the institutions. Also, it was awarded (Best Poster Award),
following the presentation in Budapest, Hungary at the
Conference “Action for Prevention”, held on the occasion of the
Hungarian Presidency of the European Union, in May 2011 (an Expert Level Conference on Member States’ Activities on
Nutrition, Physical Activity and Smoking Related Health Issues,
Jointly Organized and Co-Financed by The Hungarian
Presidency of the Council of The European Union and the European Commission May 30-31, 2011). But, as any other
projects of such size, it also had weaknesses: the project
duration, of only 20 months, no time to implement the micro-
projects, no outcome evaluation, just process evaluation. This project represented a first step in approaching
and developing primary prevention politics regarding the
healthy nutrition and physical activity in children in Romania.
REFERENCES 1. World Health Organization. Global Strategy on Diet,
Physical Activity and Health. Childhood overweight and
obesity. http://www.who.int/dietphysicalactivity/childhood/en/
Accessed on 17.07.2017.
2. Macera CA. Division of Nutrition and Physical Activity
National Center for Chronic Disease Prevention and Health
Promotion Centers for Disease Control and Prevention.
Promoting healthy eating and physical activity for a
healthier nation. https://www.cdc.gov/healthyyouth/publications/.../pp-ch7.pd.Accessed on 16.07.2017.
3. Stang J, Story M, Kossover R. Guidelines for Adolescent
Nutrition Services Stang J, Story M (eds) Guidelines for
Adolescent Nutrition Services (2005) http://www.epi.umn.edu/let/pubs/adol-book.shtm.
Accessed on 18.07.2017.
4. Dixey R, Heindl I, Loureiro I, Pérez-Rodrigo C, Snel J,
Warnking P. Healthy Eating For Young People In Europe. School-Based Nutrition Education Guide; 1999.
5. http://www.euro.who.int/en/countries/romania/news/news/
2016/02/who-regional-director-visits-romania. Accessed on 10.07.2017.
6. Domnariu CD, Furtunescu F. Intervention pattern regarding
healthy nutrition and physical activity in Romania. Acta
Medica Transilvanica. 2011;2(1):143-144. 7. http://insp.gov.ro/sites/1/wp-
content/uploads/2014/11/Raport-HBSC-Romania-bun.pdf.
Accessed on 17.07.2017
INTERNATIONAL CONFERENCE “THE BIENNALE SIBIU – CHIŞINĂU”
September 8-9th 2017
AMT, vol. 22, no. 3, 2017, p. 3
GUT MICROBIOTA, TYPE 2 DIABETES MELLITUS, LOW-
GRADE SYSTEMIC INFLAMMATION. ETIOPATHOGENIC,
CLINIC AND THERAPEUTIC CORRELATION
CRISTIAN-ŞTEFAN BERGHEA-NEAMŢU1
1“Lucian Blaga” University of Sibiu, Sibiu Pediatric Clinical Hospital
Keywords: gut
microbiota, metabolic
diseases, low-grade
inflammation, microbiome,
therapeutic
manipulation
Abstract: The gut microbiota plays an essential role in health promotion. Any kind of gut microbiota
ecosystem changes can trigger the low-grade inflammation, loss of insulin sensitivity, type 2 Diabetes
Mellitus. The low-grade inflammation is the common link for obesity, insulin resistance. On the other
hand, metabolic endotoxemia triggers the low-grade inflammation by lipopolysaccharides mechanism, which in turn plays a major role in the obesity linked diseases. Based on these metabolic interactions a
various studies have approached the concept of therapeutic manipulation of the microbiome with the
final scope of combating and preventing the metabolic diseases in humans. Although it is acknowledged
that the pre~ and probiotics use improves the gut microbial equilibrium and glucose homeostasis, this relationship needs to be extensively investigated. The further studies will allow identifying the
population at risk of metabolic diseases and the basic therapy focus needs to be adapted on individual
habits and predispositions.
1Corresponding author: Cristian-Ştefan Berghea-Neamţu, Str. Gh. Baritiu, Nr. 1-3, Sibiu, Romania, E-mail: cristineamtu@hotmail.com Phone:
+40722 641331
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):3-9
1. The essential role of gut microbiota in human health
In human gut are living trillions of microbes making
up what is known as gut microbiota (GM);(1) the colonization
with these microbes begins in the prenatal period, by mother to fetus transmission, which continues after birth, being modulated
by gestational age, the type of birth (natural/caesarean section),
nutrition (natural/artificial), hygiene and antibiotics exposure.(2)
GM community genes are involved in encoding of the basic functions too, such as digestion and degradation of
indigestible nutrients, immune system and host digestive tract
development and stimulation.(3-7)
GM generate signaling molecules, pharmacologically active ones, which interacts with host metabolism;(8-10) e.g.,
short chain fatty acids (SCFA) produced by dietary fiber
fermentation by intestinal bacteria coupled with G proteins
receptors (GPCRs) affects insulin sensitivity in adipocytes and peripheral organs too, thereby adjusting the energy
metabolism.(11) These transient changes of the intestinal
ecosystem take place all of the time, and can lead to GM-host
symbiosis interruption, sometimes.(12) Also, the intestinal ecosystem change can trigger some
disturbances, like: low-grade inflammation, metabolic disorders
(excessive lipids accumulation, loss of insulin sensitivity),
which create the risk of metabolic disease.
2. Type 2 Diabetes Mellitus (T2D) and gut microbiota
The recent advances in DNA sequencing allowed the
microbial communities collection related to human intestine.(13)
The GM changes are associated with different states, e.g., obese/weak people.(14) GM related to T2D has been recently
described, the specific bacterial sequencing being characteristic
to hyperglycemia.(15) Amar and collab. (16) concluded that 16S rSNA is
considered as a marker of T2D risk, reinforcing the concept
according to which the tissue bacteria are involved in human
diabetes mellitus onset, (16) also demonstrating that in the case of hyperglycemia due to lipids and insulin resistance the gut
bacteria are transposed in adipose tissue, as well as in blood,
where bacteria can induce the inflammation.(17) This bacterial
transposition can be reversed by probiotic treatment, with the
improvement of the global inflammatory status, finally.(17)
3. The gut microbial ecosystem changes in obesity GM is modified in obesity, proven fact by animal
studies and animal models, also. GM in weak wild mice vs.
obese ones (obese mice/leptin deficiency obese mice) attests the
Bacteroidetes/Firmicutes differences, Firmicutes/Bacteroidetes ratio being positively correlated with “obese” phenotype, diet
independent one.(18)
Turnbaugh and collab. (19) compared the GM of mice
vs. weak mice with obesity due to diet. They found the increase of Firmicutes, Mollicutes respectively, and the complete
reversibility of the compositional changes after returning of
normal diet. It has been suggested that the diet represents the
main factor contributory to GM changes related to obesity. The studies of Murphy and collab. (20) revealed the
increase of Firmicutes/Bacteroidetes ratio at obese mice/obese
mice fed with fat-rich diet vs. weak mice. This increasing was
significant in mice fed with fat-rich diet than obese mice. Ridaura and collab. (21) proved the existence of a
causal relationship between GM and obesity by feces samples
transplant from obesity co-discordant twins to separate mice
groups without germs, thereby demonstrating that: - the mice colonized with feces microbiota from obese co-
twins have a greater increase in weight and adipose tissue
vs. mice colonized with feces microbiota from weak co-
twins; - the obese mice held together with weak mice showed a
lower weight gain than mice held together with obese mice,
conjunctively with a GM compositional changes in the sense of a poor state of GM, related with Bacteroidetes
improvement, also with a protein expression improvement,
those involved in branched-chain amino-acids catabolism,
and SCFA production, finally.(21) The intestinal production of SCFA (although a calories
source for host) was especially associated with low-grade
INTERNATIONAL CONFERENCE “THE BIENNALE SIBIU – CHIŞINĂU”
September 8-9th 2017
AMT, vol. 22, no. 3, 2017, p. 4
systemic inflammation, and with the global positive metabolic
effects. (22,23)
These results show: - weak or obese murine model GM is largely influenced by
diet, and to a lesser extent by weak with obese mice
habitation;
- the effects of weak-obese habitation were highly transferable in mice without germs, with a big contribution
for a weak model preservation or for obesity onset.
In humans, the results of the studies of GM changes related
to obesity are controversial. Turnbaugh and collab. (19) observed: differences
between distal GM in obese vs. weak people, respectively
Bacteroidetes relative abundance together with weight loss of
individuals subjected to low-fat diet or low-carb one, with fewer calories (reduced Bacteroidetes/Firmicutes ratio in obese vs.
weak people due to more effective hydrolysis of undigested
polysaccharides along intestinal lumen, and, finally, with the
removal of more food calories and fats in obese).(11) Other studies, which compared GM structure in weak
people vs. obese, failed to compared obesity and
Bacteroidetes/Firmicutes ratio partnership.(24,25)
Recently, it has been suggested that GM in obese and weak people has a different response to the calories content.(26)
The nutrients absorption has caused a change in gut microbial
composition, only in weak people, not in obese, increasing the
Firmicutes relative abundance and decreasing the Bacteroidetes relative abundance simultaneous.(25)
Other study indicated the changes in GM related to
obesity and correlated with microbial genotype. Its decreasing
could play a role in host inflammatory status, also linked to obesity:
- the obese people with a great number of bacterial genes
have a higher proportion of species related to inflammatory
status (e.g. Firmicutes prausnitzii) and a lower proportion of species related to pro-inflammatory status (e.g.
Bacteroides spp.);
- the number of bacterial genes related to oxidative stress
was greater in people with a few number of bacterial genes
than people with a high number of bacterial genes;(26)
- because the difficulty of performing an interventional diet-
controlled study in humans the complex interaction
between diet, host age, environment and host genetic status is not fully understood.
Nevertheless, a recent report suggests that GM
alterations related with behavioral changes, eating habits
inclusively (27) and antibiotics use could be the main stimulus in pandemic obesity.(28,29)
GUT MICROBIOTA AND INSULIN RESISTANCE.
METABOLIC ENDOTOXEMIA (LPS HIGH SERUM
CONCENTRATION) AND LOW-GRADE
INFLAMMATION
The change in GM induces the low-grade
inflammation (LGI), which is the common link for chronic non-communicable diseases, obesity, insulin resistance and T2D,
inclusively. The metabolic endotoxemia trigger the LGI by
lipopolysaccharides (LPS) mechanism, LPS playing a major role
in the obesity linked diseases, (30-36) also in T2D onset, and CD14/toll like (TLR) dependent mechanism.(37)
The mice deprived by CD14 activity resist to fat or
LPS-rich diets. The binding of LPS to mCD145-TLR4 complex
on the surface of the innate immune cells activates the inflammation.(38,39) The pro-inflammatory stimulators (LPS,
lipids, fatty acids, chemokines) activates the intracellular
pathways of c-Jun N-terminal kinase (JNK) and lkβ kinase
(lKK-β):
- the lKK-β activation stimulates the transcription of nuclear
factors (NF-kB), increasing at the same time the expression of the inflammation mediators that can cause the insulin
resistance;
- the JNK activation induces the phosphorylation of the
insulin receptor substrate from serum sites (IRS-1) that inhibits the signal transduction through insulin receptor
axis, thus generating the insulin resistance.(40)
Therefore, the LPS accumulation (metabolic endotoxemia)
is related to inflammation and insulin resistance
CHRONIC INFLAMMATION BINDS INTESTINAL
MICROBIOTA TO OBESITY AND INSULIN
RESISTANCE In humans, the circulating endotoxin levels have 20 %
grown in obese and glucose intolerance people and 125 % in
T2D people by comparison with weak people.(41)
The circulating endotoxin values have also been
associated with high levels of adipocyte TNF-α and IL-6.(42) The LPS secretion, also the expression of TLR4, NF-
kB and 3 cytokine suppressor (SOC), are activated by fat or
carbohydrates-rich diet (not by fiber or fruits-rich ones), getting
involved in the pathways that regulate the insulin secretion.(42) Together, all these results show the important role of
LPS as inflammatory pathways mediator in obesity and obesity
related diseases. The aromatic amino-acids metabolites
(tyrosine, tryptophan, phenylalanine) can interact with the host signaling pathways, in this way affecting the host immunity.
The indole is one of the main tryptophan metabolites,
(43) produced by the action of bacterial tryptophanase (present
in Bacteroides thetaiotamicron, Proteus vulgaris, Escherichia coli).(44) The indole metabolism implies the hepatic sulphation,
with 3-indoxilsulphate production, consequently, or additional
metabolism, with related compounds production (indol-3-
piruvate, indol-3-lactate and indol-3-acetate).(45) All of whom give a broad perspective to tryptophan bacterial metabolism
impact on health damage and human diseases:
- 3-indoxylsulphate and indol-3-propionate interact with the
inflammation linked process in human host;(46)
- 3-indoxylsulphate activates the aryl hydrocarbon receptor
(AhR), with the regulation of IL-6 transcription and also
with the regulation of a several enzymes, compounds of
P450 complex (e.g. CYP1A1, CYP1A2, CYP2S1);(47) - 3-indol-propionate is a X pregnane receptor agonist (PXR),
with a benefic role in intestinal barrier function, either by
up-regulation of junctional protein expression or by
regulation of enterocytes TNF-α productivity; by reducing the intestinal barrier permeability, indol-3-propionate limits
the antigen and pathogen agents translocation, also the LPS
infiltration in blood stream; therefore, can reduce the
metabolic endotoxemia and the host inflammation.(48) Thereupon, an unaffected gut microbiota maintain the
host intestinal metabolic health by intestinal physiology
modulation mechanism; a disbiotic gut microbiota affects the host intestinal metabolic health by LPS infiltration; caloric
input, fat-accumulation and insulin reaction are also very
important. A health GM comprises an equilibrate symbionts
(health promotion bacteria) and pathobionts (disease promotion bacteria) representation.
As a partial conclusion, LGSI is the common element of obesity, insulin resistance and T2D. (49) LPS (also called endotoxins), derived by the membrane cells of gram-negative bacteria, initiate the inflammation related with the onset of obesity and insulin resistance, passes the intestinal mucosa at the level of junctional intestinal cells, and finally, by infiltration of
INTERNATIONAL CONFERENCE “THE BIENNALE SIBIU – CHIŞINĂU”
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AMT, vol. 22, no. 3, 2017, p. 5
chylomicrons responsible for triglyceride and cholesterol intestine-plasma absorption, (50-52) reach in plasma: - plasmatic LPS infiltrates the liver and adipocyte tissues,
with the secondary innate immune response; (50)
- LPS link plasma LPS-binding protein (LBP), with the
secondary CD14 protein receptor activation in macrophages plasmatic membrane;(52)
- thus generated, the complex binds to toll-like 4 receptor
(TLR4) at the macrophages surface, triggering the
transduction signals which act the genes expression which encode the inflammatory effectors cells, such as NF-kB and
1 activator protein (AP-1);(52,53)
- LPS also adjust the nucleotide oligomerization`s type
receptors (NOD) from macrophage and dendritic cells, which collaborate with TLR for inducing NF-kB;
- LPS participate to the recruitment of other effector
molecules, such as leucine-rich protein (NLR), adaptor
protein (ASC) and 1-caspase (inflammasom compounds), and all, finally, activate the innate immune system (54)
After bacterial translocation in other tissues, LPS from
blood stream and some organs act inflammatory macrophages
signals and their link with insulin pathways transcription.
THERAPEUTIC POTENTIAL OF MANIPULATION
GUT MICROBIAL ECOLOGY
The studies of metabolic interaction, or of the
immunity between gut microbiota and host, also the way in which these interaction modulate the brain, muscle, liver and
intestine host activity motivate the concept of the
THERAPEUTIC MANIPULATION of the MICROBIOME,
with the final scope of combating and preventing the diseases in humans.(4,10) The selection of specific intestinal strains
and the improvement of the intestinal microbial ecology
represent a promising therapeutic approach for energy input control and for reducing the obesity and metabolic syndrome
prevalence. The pro~ and prebiotics use in the improvement of GM and obesity (and other metabolic diseases) relationship has been extensively investigated.(55) The probiotics are live microorganisms, used like food supplements, improve the gut microbial equilibrium and change the gut microbiota composition.(56) Some bacterial species, such as Bifidobacterium spp., have demonstrated that improve glucose homeostasis, with the following effects: weight loss, lipid-mass loss, glucose mediate insulin secretion restoration.
The probiotics are food ingredients which have a
good host influence, by selective growth stimulation and/or
limited number of gut bacteria activities. The prebiotics are oligosaccharides or short-chain polysaccharides, are found in
ordinary diet (vegetables, integral grain) or can be added in milk
and yogurt.
Fructosyl-oligosaccharides (FOS), inulin, galactosyl-oligosaccharides (GOS), inclusively, are transformed, via gut
microbiota, in SCFA which stimulate the selection of intestinal
commensal bacteria proliferation.(57-60) For example, inulin
stimulates the bifidobacteria, reduces the caloric input and fat-mass in experimental animals.(58)
The prebiotic stimulation regarding bifidobacteria
growth is correlate with increasing glucose tolerance, the
improvement of the insulin secretion induced by glucose and the normalization of murine inflammation.(61)
GOS also modulate the intestinal monosaccharides
absorption by stimulation of host monosaccharides transporters,
which in their turn stimulate glycolytic pathways, (59) reduce hepatic, renal and plasmatic lipids level in rodents.(57,58)
In healthy mice, GOS supplement decrease the hepatic
triglycerides level by some mechanisms: low lipogen enzyme
activity, fatty acids synthesis and microsomal triglycerides
transfer proteins involved in VLDL synthesis. (58,62)
Therefore, prebiotic input may decreases the lipogenic activity and increase the lipolytic one.
The increasing of lipolytic activity. In rodents, the effects of pre~ and probiotics on inflammation pathways, weight gain, glucose metabolism were largely attributed to SCFA production.(63)
SCFA interact with GPCR41 and GPCR43 from intestinal immune cells and promote the specific chemokine expression in intestinal epithelium.(64,65) SCFA repress NF-kB and affect the production of leukocytes inflammatory markers (Il-2, IL-10), (66) increase the satiety by increasing PYY synthesis, increase the epithelial cells pro-glucagon secretion by decreasing leptin expression.(67)
Other studies show that the probiotic effects on intestinal health and inflammation, too, are mediated by glucagon type proteins secretion (GLP-1 and GLP-2) in L enteric-endocrine cells.(60,68) Cani and collab (48) demonstrate that the obese mice/obese mice fed with carbohydrates-rich diet with oligofructose supplement present an increase of bifidobacteria and lactobacillus in intestine, an improvement of close junctions interconnection, a reduction of intestinal permeability, a reduction of systemic endotoxemia and systemic/hepatic inflammation; at the opposite pole stand obese mice/obese mice fed with carbohydrates-rich diet. These physiologic changes were correlated with GLP-2 levels and disappeared when the mice was treated with GLP-2 antagonist.(48) Another study stressed that a symbiotic treatment which combined polydextrose with B420 Bifidobacterium lactis decreased the abundance of Porphyromonadaceae in mice fed with fatty-rich diet.(69) This later food supplement is considered an effector of 17 T helper cells inhibition in the small intestine, and a marker of metabolic inflammation and T2D prevention.(69)
In humans, the probiotic intervention studies show a positive effects on glucose metabolism.(70) For example, a randomized, placebo-controlled, 6 weeks study shows in 60 healthy (Indians) subjects a decrease of glucose level and systemic insulin after ingestion of VSL #3 probiotic mixture.(71) However, the evidences of anti-obesity effects of prebiotics remain to be demonstrated. In humans, many studies show only moderate or not weight losses after prebiotics interventions.(72) The randomized controlled studies have identified surrogate markers of prebiotics treatment (plasmatic PYY, GLP-1, ghrelin), negative correlation with weight gain, impaired inflammation and glucose metabolism, which support the observed mechanisms in rodents.(73,74) On the other hands, does not exist evidences that can suggested if prebiotics supplement in infant formula improves growth or causes long-term side effects in infants, because the studies in children, adults or elders varies regarding quality and results. However, has been shown that probiotics modulate feces microbiota and the immune system in elders, and reduce metabolic syndrome markers level in overweight adults.(75-78) The effect of pre~ and probiotics concerning obesity and its pathology in humans requires further investigations; the studies using adequate doses of pre~ and probiotics, and controlled diets need to be carefully designed to be truly valuable to support the individual answers to different types of interventions and its dependence by microbial, genetics, environment and intestinal factors.
CONCLUSIONS
The proofs of strong contribution of gut microbiota at the appearance of obesity and metabolic diseases, in rodents and humans, are growing. The changes in gut microbiota ecology due to nutrient factors, antibiotics, pre~ and probiotics, observed both in rodents and humans, have been further highlighted the essential role of modulation of gut microbiota. Noting the fact of some host metabolic disorders related to inflammation-like composition of gut microbiota. However, the way in which the
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extern factors (such as, diet, stress, age, drug use and circadian cycles) affect the intestinal microbial composition and the efficacy of microbial functions in rodents and humans is still unclear. It is necessary that future studies to promote analytic approaches from up to down on an epidemiological scale, and to integrate into questionnaires dietetic data, relevant environment factors (stress, circadian cycles influential factors), drug and antibiotics use history.
Need to be deepened those studies of intestinal bacterial functions related to physio-pathogeny of human obesity. In combination with animal experiments, the integration of epidemiological analysing will facilitate deciphering missing links of the metabolic chain that binds intestinal microbes to the host, and optimizing the therapeutic strategies for remodelling intestinal microbial ecology.
The further knowledge will allow to identify the population at risk of occurrence of metabolic diseases, and to concretize some perspectives for personalized medical assistance which will permit the adaptation of basic therapy focus on individual habits and predispositions.
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THE ROLE OF GUT MICROBIOTA IN CARBOHYDRATES
DEGRADATION
LUMINIŢA DOBROTĂ
1
1“Lucian Blaga” University of Sibiu, Pediatric Clinic, Research and Telemedicine Center in Neurological Diseases in Children,
Sibiu Pediatric Clinical Hospital
Keywords: gut
microbiota, carbohydrates
fermentation, energy
gain
Abstract: The gut microbiota can be considered as a “new organ” inside the body. Many carbohydrates
are fermented by gut microbiota, with energy gain and with the impact on health via its metabolites. This review focused on gut microbiota and responsible mechanisms for degradation, also fermentation
of polysaccharides. Gut microbiota will impact the glucose or lipid metabolism. It is a strong
relationship between gut microbiota, diet and metabolic diseases. The carbohydrates research open the
opportunities for treatment of obesity, type 2 diabetes mellitus and other metabolic disorders.
1Corresponding author: Luminiţa Dobrotă, Str. Pompeiu Onofreiu Street, Nr. 2-4, Sibiu, România, E-mail: luminitadobrota@yahoo.com, Phone:
+40722501145
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):10-12
INTRODUCTION
In humans, the gut microbiota is considered a “new
organ” inside the body, because its important role in the diseases preventing and in the maintaining health.(1)
The complex carbohydrates are degraded and fermented
by the human gut microbiota in sense of increased the whole
capacity of energy.
Figure no. 1. Energy intake and expenditure. Flint HJ.
Obesity and the gut microbiota. J Clin Gastroenterol 2011;
45:Suppl S128 - 32; http://dx.doi.org/10.1097/MCG.0b013e
31821f44c4; PMID: 21992951 [CrossRef], [PubMed], [Web
of Science ®], [Google Scholar]
On the other hand, the question about how much is the
impact of gut microbiota in the metabolism of energy in human
host is increasingly attractive. This question is relevant mostly in highly developed countries, where fat-rich diet in simple
sugars predisposes to metabolic disorders, such as obesity,
insulin resistance, and type II Diabetes mellitus.(2)
The polysaccharides are the most important class of components derived from diet which are metabolized by the gut
microbiota. The fermentation of carbohydrates originated from
diet produces short-chain of fatty acids (SCFA) which mediate
in turn the repercussions of gut microbiota on host energetic metabolism.(3)
Several recent studies have demonstrated the
relationship between gut microbiota-induced obesity and the
increased output of energy provided by diet.(2,4) Coming back to SCFA, butyrate is certainly an
important SCFA component, as well as the others (propionate
and acetate), which contribute as substrate in liver and intestinal
gluconeogenesis, and lipogenesis, too. Starting from here, liver lipogenesis plays a major role in fatty storage regulation.(5)
The same SCFA components are also a signaling
molecules by coupled to the receptors of fatty acids, known as
Gpr41, respectively Gpr43. Gpr41 helps adiposity process of human host.(6,7) The above mentioned couple, SCFA-receptors
of fatty acids, is involved in very important hormones secretion
(glucagon-like, GLP-1 and YY peptide, PYY), including insulin
secretion.(8) Therefore, the mechanism of microbiota influence
about host metabolism of energy contains three major aspects:
- the increasing of energy provided by diet;
- the fatty storage regulation; - gut hormones synthesis.
Over them all, stands the digestion of carbohydrates.
1. The increasing of energy provided by diet. Starting from
the studies with focus on the weight gain in the colonized mice
vs. germ-free ones, the linked mechanisms are: accessible-
carbohydrates degradation and fermentation of gut microbiota
(MAC), SCFA absorption and its liver transportation, adipocytes lipids storage.(4)
The obese microbiota seems to be more productive to
extract diet-induce energy than weak people microbiota.
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In healthy people the dominant species of bacteria are:
Bacteroidetes spp., Firmicutes spp, and Actinobacteria. This
normal composition of gut microbiota have a short, and maybe a long-term implications.(9,10)
In obese individuals microbiota, an altered microbiota,
is about 50 % abundant in Firmicutes species, and less
Bacteroidetes, consecutively, than weak individuals microbiota. The Firmicutes species are the major producers of
SCFA; at the opposite pole, a microbiota abundant in
Bacteroidetes species leads to weight loss.(11)
The chromatography analysis of obese microbiota revealed a significant concentration of butyrate and acetate,
whose metabolism pathways including active enzymes, also
called CAZ, derived from families of glycoside hydrolase.(2)
2. The fatty storage regulation. The studies show that the weight gain occurs despite of the food intake reduction, because
of the host gene modulation due to polysaccharides from diet.
This kind of process affect adipocytes energy
storage,(4) and leads to liver new triglyceride production and its adipose tissue incorporation.
The propionate component of SCFA act to liver
lipogenesis.(12)
Some factors, as Fiaf (fasting-induced adipose factor), regulate the liver lipogenesis. The gauge of storage energy is
activated by a protein kinase (AMPK) and the final effect is
catabolic one, to restore the level of energy.
But, an altered microbiota causes the AMPK inactivation.(12,13)
3. The gut hormones synthesis. GLP-1 produce secretion of
insulin, and the process is more important than the glucose
does.(14) This GLP-1 insulin secretion continued despite of levels of glucose or glucagon.(14)
PYY is negative correlated with body mass indices,
and suffered some action changes in obese individuals. For
example, a PYY deficiency leads to obesity, with a good response at substitution therapy, fortunately.(15)
The receptor ligands of fatty acids, especially FFAR3
(active in adipocyte tissues) become a new research area in the
treatment of obesity and type 2 Diabetes Mellitus.(16)
Regarding the digestion of carbohydrates, two aspects
are very important: the synthesis of butyrate and β-
porphyranases use in Bacteroidetes plebeius.
The pathway of synthesis of butyrate is modified by the higher amount of Firmicutes species in gut microbiota.(17)
The Japanese individuals gut microbiota present the
Bacteroidetes plebeius specie able to release porphyran, an
unaccessible/non-digestible source of carbon.(18,19) It insists on the idea that the type, balance, and amount
of diet components, namely carbohydrates, have an important
impact on microbiota.
The SCFA, butyrate, acetate, propionate, are the end-mainly products from the microbial carbohydrates degradation
in the gut microbiota. The SCFA have many effects on human
host (see, their oxidation and energy release). Macfarlane & Macfarlane(20) show in their study that
a neutral pH in the distal part of colon creates a good conditions
for Bacteroidetes species growth.(21)
Certain intake carbohydrates from diet cannot directly digested, and, in this way, represent an important source of
energy, and can be referred like prebiotics.
Prebiotics can stimulate the growth of bifidobacteria,
oligofructose and fructooligosacharides.(22,23). Some recent studies have observed that a diet
supplementing with SCFA had modified the composition of
microbiota, the changes being linked with weight and glucose
control, for example.
These changes were connected with gut gluconeogenesis via butyrate and propionate metabolism.
The prebiotic stimulation regarding bifidobacteria
growth is correlate with increasing glucose tolerance, the
improvement of the insulin secretion induced by glucose and the normalization of murine inflammation.
Understanding these source of carbon and its
microbial degradation is important for promoting the health by
dietary improvement (by understand how kind of bacteria is linked by dietary or host origin carbohydrates).(24)
The studies of metabolic interaction, or of the
immunity between gut microbiota and host, also the way in
which these interactions modulate the brain, muscle, liver and intestine host activity motivate the concept of the therapeutic
manipulation of the microbiome, with the final scope of
combating and preventing the diseases in humans.
It is observed an inter-individual diversity of microbiota in individuals by fermentation in vitro studies. It
makes to put a question about the efficacy of dietary microbiota
in dietary and drug application. Or, about the manipulation of
gut microbiota to defined a nutritional pattern. And, not the end, the question about how many of bacteria are required to obtain
some benefits? And, what happen when the intervention in diet
stops?(25)
It is necessary that future studies to promote analytic approaches from up to down on an epidemiological scale, and to
integrate into questionnaires dietetic data, relevant environment
factors (stress, circadian cycles influential factors), drug and
antibiotics use history.
Acknowledgement: Part of this work has been conducted in the Pediatric
Clinical Hospital Sibiu, within the Research and Telemedicine
Center in Neurological Diseases in Children - CEFORATEN project (ID 928 SMIS-CSNR 13605) financed by ANCSI with the
grant number 432 / 21. 12. 2012 thru the Sectoral Operational
Programme “Increase of Economic Competitiveness”.
CONCLUSIONS The Bacteria of the gut microbiota have larger genes
diversity, and also an amount of degradation enzymes, having as final the carbohydrates fermentation.
The Bacteroidetes species possess a lot of number of CAZymes.
Together with Firmicutes species, these components of gut microbiota must be a future research priority.
The carbohydrates from diet must be put in a relationship with gut microbiota and metabolic diseases, as a complex interaction group.
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CLINICAL PECULIARITIES OF CEREBROVASCULAR
ACCIDENTS IN NEWBORNS, INFANTS AND CHILDREN
OF SMALL AGE
SVETLANA HADJIU
1, MARIANA SPRINCEAN², NADEJDA LUPUSOR
3,
CORNELIA CALCII4, RAMINA PASARI
5, VLADIMIR IACOMI
6, ALINA BANTAS
7,
ANDRIANA GRUZINSCHI8, NINELI REVENCO
9
1,2,3,4,5,6,7,8,91„Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Republic of Moldova,
1,2,3,4,9Institute for Maternal and Child Healthcare, Chisinau, Republic of Moldova
Keywords: cerebrovascular accident, hemoragic
stroke, acute ischemic
stroke, neonatal,
pediatric
Abstract: Cerebrovascular accident (CVA) in children is one of the most complicated pathologies due to
nonspecific clinical manifestations and remote neurological sequelae. The aim: to study causes and symptoms suggestive for clinical preventive diagnosis of CVA in children depending on their age.
Material and methods: retrospective analysis of a group of 216 children with CVA during the years 2010
– 2017. Medical records were obtained from Department of Neurology, Institute of Mother and Child.
For statistic analysis were used software Statistica 7.0 (Statsoft Inc.) and MS EXCEL. Results. The results of analysis of clinical symptomatology of CVA by method of logistic regression allowed
demonstration of the most important symptoms suggestive for CVA in children depending on their age.
Conclusions. CVA in children is evolving with the subtle and nonspecific symptoms, being initially
attributed to other causes. Recognition of clinical symptoms which are characteristic for different ages improves diagnosis of CVA.
1Corresponding author: Svetlana Hadjiu, Str Burebista, Nr. 93, MD-2060, Chișinău, Republic of Moldova, E-mail: svetlana.hadjiu@usmf.md, Phone:
+37369142479
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):13-16
INTRODUCTION
Cerebrovascular accident (CVA) is defined as "a clinical syndrome with rapid evolution, manifested by global or focal
disorders of cerebral functions, which lasts longer than 24 hours
or which lead to death without any obvious nonvascular
causes".(1).Another definition denotes a correlation between the clinical and imaging aspects of CVA as "CVA is a clinical
syndrome characterized by a neurological deficit related to the
area of a cerebral artery perfusion and with neuro-radiological
evidences of an ischemic lesion".(2) Being a rare neurological disease in children, CVA may
be hemorrhagic, ischemic or mixed origin, caused by occlusion
or rupture of cerebral blood vessels.(3) The overall incidence of
CVA is estimated from 2 to 13 for 100000 of population.(4) Other studies estimated the incidence as 1 – 6 to 100000 of
population, with well shown impact on infant mortality, along
with the results and effects of CVA on the quality of life of
patients and their families.(5) Ischemic CVA is more frequent in prenatal period and during the first 28 days after birth, with a
frequency of 1:4000 of live newborns. Hemorrhagic CVA
(HCVA) sharing about half of all CVA revealed in
children.(6,7) Risk factors for CVA in children differ significantly from those found in adults are related with
predisposing conditions, but CVA can be considered as an
independent nosologic entity.(5) Clinical manifestations of CVA in children vary according to age, artery involved and
cause.(3,4) Focal symptoms, especially hemiplegia, are most
commonly present in hemorrhagic CVA (HCVA) and vary in
different authors.(3) Ischemic CVA (ICVA) manifests by various clinical symptoms that can be registered also in HCVA,
e. g., disorders of conscience asyou may encounter, seizures of
various types, etc.(8)
Diagnosis of CVA in children is often delayed because
the signs and symptoms can be subtle and nonspecific, treatment options are often limited.(9) Several authors showed that the
causes of the majority cases of pediatric CVA, especially
neonatal, have not been established, and large-scale case-control
studies are necessary to understand the early clinical manifestations and pathogenesis, where the results should be
improved.(10)
PURPOSE The preliminary study was to make a retrospective
analysis of causes and primary clinical symptoms, significant for
preventive diagnosis of CVA in children in dependence from the
age, of a group of 216 children with CVA, hospitalized departments of Neurology of Newborns and Neuropsychiatrics
of Small Children, Institute of Mother and Child, in the years
2010 – 2017.
MATERIALS AND METHODS The study was carried out at the Department of
Pediatrics of the „Nicolae Testemițanu” State University of
Medicine and Pharmacy during the years 2017 – 2018, as a part of the project "Evaluation of the incidence, prevalence, and risk
factors, studying of clinical and neuro-imaging and
neurophysiological aspects of CVA in children and methods of neurotrophic treatment" being conducted under the aegis of the
State program "The system of risk factors, nursing service
optimization, sustainable evaluation and mathematical modeling
of cerebrovascular accident". One of the compartments of the study consists in evaluation of the causes and clinical
particularities of CVA in children depending on the age.
Retrospective analysis was made on a group of 216 children, of
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whom 202 newborns (93.5%, 95 CI 91,82 – 95,18), which
suffered from CVA during the years 2010 – 2017. Medical
records were selected in the Departments of Neurology of the Institute of Mother and Child. Were determined and classified
causes and clinical symptoms characteristic of CVA. The work
contains preliminary data. For the statistical analysis of the
obtained data have been used software Statistica 7.0 (Statsoft Inc.) and MS EXCEL. It has been calculated the arithmetic
mean, the standard error, the method of logistic regression.
RESULTS The sharing of CVA in studied children was as
follows: ICVA in 134 cases (62%, 95 CI 58,7 – 65,3), HCVA in
68 cases (31,5%, 95 CI 28,34 – 34,66), mixed CVA in 18 cases
(8,3%, 95 CI 6,42 – 10,18). Neonatal CVA was determined in 202 cases (93,5%; 95 CI 91,82 – 95,18), and CVA in early
childhood in 14 cases (6,5%, 95 CI 4,82 – 8,18). Of the total
number of children included in the study 15 cases (6,9%, 95 CI
5,17 – 8,63) children had heart congenital anomalies. In some children who have suffered from CVA were diagnosed genetic
syndromes: Marfan syndrome in one case, tuberous sclerosis in
one case, homocysteinuria in one case. Systemic diseases were
common at 56 newborns (27,7%, 95 CI 24,55 – 30,85). Among children with neonatal CVA 123 cases (60.9%, 95 CI 57,47 –
64,33) were boys, 20 (9,9%, 95 CI 7,8 – 12) were premature.
The pregnancies were complicated with placenta pathology in
22 cases (10,9%, 95 CI 8,81 – 13,09) or pathology of amniotic membranes in 25 cases (12,4%, 95 CI 10,08 – 14,72). Detailed
results of the causes responsible for the CVA will be presented
in another study. Clinical picture in CVA in newborns differs
from the pathology in other ages. The pathology was symptomatic and manifests by more generalized symptoms
(Table 1), related to the features of child development
characteristic for this age.
Table no 1. Clinical manifestations of CVA in newborns
(n=202)
Clinical
symptoms Abs.
P±SE
(%) 95CI P
Seizures 158 78,2 75,3-81,1 0,001
Non-focal
neurological
signs
136 67,3 64,0-70,6 0,001
Disorders of
mental status 147 72,8 69,67-75,93 0,001
Irritability 55 27,2 24,07-30,33 0,05
Breathing
disorders 76 37,6 34,19-41,01 0,01
Tremor 44 21,8 18,9-24,7 0,05
Generalized
motor disorders 128 63,4 60,01-66,79 0,001
Need in
resuscitation 78 38,6 35,17-42,03 0,05
Imaging data also allowed determining the affected part of the brain. In newborns enrolled in the study predominant
regions were anterior and medium areas in 129 cases (63,9%;
60,52 – 67,28), and the left hemisphere in 137 cases (67,8%; 95 CI 64,51 – 71,09). Multifocal lesions were determined in one
third of all the cases (67) (33,2%, 95 CI 29,89 – 36,51). Lack of
focal symptoms often led to errors in diagnosis, as it was
determined in 112 cases in our study (55,4%, 95 CI 51,9 – 58,9),
being assumed as the "neonatal encephalopathy". However, in
the presence of generalized symptoms, it must be considered the
diagnosis of CVA, which requires confirmation by visualization
and continuous EEG monitoring, especially in intensive care
units. Clinical manifestations of pediatric CVA also differ
according to age, involved vessel and cause. In young children
the symptoms are commonly symptomatic, and in older children, resemble those of adults. Retrospective analysis was
made of a group of 14 children (6.5%, 95 CI 4,82 – 8,18),
selected from the general group of 216 children aged from 28
days to 3 years, suffered from pediatric CVA (boys 10 – 71.4%, 95 CI 59,33 – 83,47). The most common symptoms recorded in
pediatric CVA were focal neurological deficits as hemiplegia or
severe focal motor deficit. CVA was developed in 5 cases
(35,7%, 95 CI 22,89 – 48,51) up to age one year and manifested by many clinical symptoms (Table 2). Often the pathology
manifested on one side of the body, often on the right in 4 cases
(80%, 95 CI 62,11 – 97,89).
Table no 2. Clinical manifestations of CVA in children of
small age (n=14)
Clinical symptoms Abs
.
P±ES
(%) 95CI P
Age: 28 days – 1 year (n=5)
Focal neurologic
deficit 5 35,7 22,89-48,51 0,05
Decreasing of
muscular force on the
one side of the body
3 60 38,09-81,91 0,001
Preferential using of
one hand 2 40 18,09-61,91 0,01
Fist squeezing 3 60 38,09-81,91 0,001
Foot squeezing 2 40 18,09-61,91 0,01
Breathing disorders 2 40 18,09-61,91 0,01
Seizures 4 80 62,11-97,89 0,001
Disorders of
conscience 3 60 38,09-81,91 0,001
Age: from 1 to 3 years (n=9)
Decreasing of
muscular force on the
one side of the body
5 55,6 39,04-72,16 0,01
Hemiparesis 3 33,3 17,59-49,01 0,05
Focal disorder of
movement 6 66,7 50,99-82,41 0,001
Sensorial disorders 7 77,8 63,94-91,66 0,001
Visual disorders 3 33,3 17,59-49,01 0,05
Speech disorders 5 55,6 39,04-72,16 0,01
Seizures 7 77,8 63,94-91,66 0,001
Alert status 4 44,4 27,84-60,96 0,01
Disorders of
coordination 2 22,2 8,34-36,06 0,05
Nystagmus 1 11,1 0,62-21,58 0,05
Breathing disorders 3 33,3 17,59-49,01 0,05
Tremor 2 22,2 8,34-36,06 0,05
Vomiting 2 22,2 8,34-36,06 0,05
In 9 cases (64,3%, 95 CI 51,49 – 77,11) over 1 year were
assessed neurological symptoms in acute period of CVA (Table
2). Neuroimaging has allowed the determining of artery involved, often middle cerebral artery (55,6%, 95 CI 39,04 –
72,16) and in left hemisphere (77,8%, 95 CI 63,94 – 91,66).
Other tests allowed for the assessment the cause of CVA, i. e., 4 cases of heart congenital anomaly (44,4%, 95 CI 27,84 – 60,96),
in 3 cases were genetic syndromes (33,3%, 95 CI 17,59 –
49,01), in 1 case of blood disease (11,1%, 95 CI 0,62 – 21,58).
The simultaneously presence of clinical symptoms, imaging data and age reported significant results of logistic
regression. Results of the analysis by modeling the relationship
between a lot of independent variables and a dichotomous
dependent variable allowed demonstration of the most important symptoms suggestive for the diagnosis of CVA in children
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according to age:
1. In newborns: seizures (p=0,000; OR=5.118), non-focal
neurological signs (p=0,002; OR=2.861), disorder of conscience (p=0,006; OR=2.909), generalized motor
disordes (p=0,004; OR=3.963).
2. In children from 28 days to one year: seizures (p=0,006;
OR=3.377), decreasing the force on the one side of the body (p=0,000; OR=4.324), squeezing the fist (p=0,004;
OR=8.588), disorders of conscience (p=0,003; OR=1.143).
3. In children from one to three years: decreasing the force on
the one side of the body (p=0,003; OR=3.438), seizures (p=0,000; OR=3.348), sensorial disorders (p=0,004;
OR=4.163), focal disorders of movements (p=0,002).
Thus, diagnosis of CVA in children often delayed
because the clinical symptoms are subtle and unspecific, initially being conferred on other causes. Recognition of symptoms
suggestive of CVA, attributed to the category of age, improve
the share of correct diagnosis from 66 to 99,7%.
DISCUSSIONS
CVA manifests with a focal disturbance of cerebral
circulation secondary to rupture or embolisation of arteries or
veins, confirmed by neuroimaging or neuropathological investigations. Children who suffer from CVA often develops
persistent dramatic consequences for the rest of his life. Despite
the clinical and socioeconomic significance, there are no clinical
strategies effective to treat this disease. Strategies of using neuroprotective measures that can be derived from the
pathophysiological mechanisms of CVA are in progress of
clinical and experimental trials. Pathogenesis and early clinical
manifestations of CVA are questionable anyway. CVA, regardless of age of first manifestations, can be
hemorrhagic (subarahnoidal or intracerebral) or ischemic. The
type of CVA varies depending the age and etiology, which is
different in children and in adults. Are described more than 70 potential risk factors of CVA in children and adults. However
the ischemies are the result of vascular pathology which is not
related to atherosclerotic process, of cardiac emboli, or
coagulopathies.In children CVA can be result of congenital
heart diseases, acquired heart diseases, infectious or
inflammatory diseases, vascular disorders, haematological
diseases, cerebrovascular anomalies or brain trauma; however,
in a third of all cases of CVA etiology remains undetermined.(11)
Perinaral ICVA is the most common form of cerebral
infarction in children, with an incidence from 1 to 2800 up to 1
to 5000 live births. One of the main causes of perinatal cerebral ICVA is embolus, which comes from the placenta through the
foramen ovale. The majority of risk factors in newborn related
to vascular placental pathology and trauma, i.e., injuries of
cervical cerebral arteries, leading to cerebral embolus formation during delivery.(12)
Some authors assume that maternal-fetal inflammation
leads to vasculitis selective affecting carotid system and promotes a focal thrombosis and a subsequent CVA. Obtained
preclinical results suggest that the combination of prothrombotic
stress and selective intracranial arteriitis caused by immune
activation of pregnant women at the end of pregnancy seems to play a role in patophysiology of ICVA.(13)
However, in the study conducted within our
institution, most of the causes which lead to perinatal CVA and
its mechanisms often are unknown and remain to be identified. Similarly, as part of an international study was carried
out clinical and imaging analysis of neonatal symptomatic
ICVA. Study of the clinical presentations summarized different
clinical manifestations, risk factors, investigations, methods of
treatment and immediate results of the ICVA. The most
important clinical symptoms are: seizures (72%) and neurological non-focal signs (63%).(10) Some authors showed
that in 60% of children occur early symptoms, expressed by
recurrent focal seizures within the first 3 days of life.(12) In our
study were noted in the presence of epileptic seizures and non-focal neurologic signs the presence of symptoms such as: altered
mental status, and generalized motor disorders.
However, some studies state that about 40% of
children have no specific symptoms in the neonatal period and are recognized later with the appearances of motor disorders,
developmental delay, cognitive deficiency or seizures.(12) Our
study showed delay in diagnosis in 55,4% of cases.
Prenatal diagnosis of cva is difficult, but it can be easily confirmed by ecoencephalographic examination and
cerebral MRI carried out on early stages. MRI has a key role in
diagnosing the ICVA, and also has a significant prognostic
value to predict the outcome of neurological development of the child. In most children who have suffered CVA develops the
following neurological sequelae: cerebral palsy, epilepsy,
cognitive or behavioral disorders.(12) Children with a history of
unilateral neonatal CVA are at increased risk for cognitive skills deficits during development. Many of them will develop
evolving speech disorders and other higher cognitive deficits
that occur later in the pre-school and school age.(3) Some
authors showed that it is important to find the predictors of outcome and measures of preventing or improving these
problems. In such cases there are different groups of newborn
with CVA: birth at term or premature newborn, symptomatic
newborns and children with delayed manifestations. However, at present there is no evidence for the preventative use of
anticoagulants for the purpose of neonatal protection.(12)
The results of several studies showed that pediatric
CVA leads to significant morbidity and mortality. Among children with pediatric CVA approximately 10 – 25% will die,
up to 25% will have a recurrence and up to 66% will have
persistent neurological deficiency, or develop epilepsy, learning
problems or developmental problems.(3,15,16,17) Neurological
impairment during childhood will have a major impact on the
quality of life of the child and the family, as well as lead to
emotional and economic burden for the state economy.(3)
Regarding infants and small children there are current studies related to the question how the symptoms appear is of
great importance, and up to one-third of children who suffered
from ICVA have a history of recent events which can be
attributed to transient ICVA.(14) Early diagnosis of pediatric CVA includes timely
neurological consultation, hospitalization of the child in
appropriate departments of hospital, to provide diagnostic
assistance, i. e., brain imaging, and for adequate etiological and pathogenetic treatment, in order to improve the results.
Diagnosis of pediatric CVA is based on recognition of
the clinical picture depending on the age and the vessel involved. Symptoms of CVA in early childhood are usually
nonspecific, and in older children are often manifests by focal
neurological deficits, such as acute hemiplegia.(14) Neurologic
examination should reveal the most subtle symptoms suspicious for a CVA, including monitoring of vital parameters, to identify
the neurological damage and to make the presumed diagnosis
with determining the topography of the vessel involved. Usually
it is necessary to exclude some systemic diseases that increase risk of CVA.(4-18) Symptoms suggestive of vascular lesions on
some area of cerebral perfusion are the following: (1) internal
carotid artery – hemiparesis, aphasia and hemianopsia; (2) the
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anterior cerebral artery – hemiparesis, especially of the lower
limbs; (3) middle cerebral artery – hemiparesis of upper limb,
hemianopsia and aphasia; (4) posterior cerebral artery – hemiparesis, hemianopsia, ataxia and dizziness; (5) basilar
artery – breathing difficulties, sensory or balance disorders,
ataxia, nystagmus, opisthotonus, tremor and vomiting; (6)
cerebellar artery – sensory difficulties, headaches, fever, vomiting and cerebellar signs.(18)
It is known that acute neurological deficits may be
caused by tumors, central nervous system disorders, including
acute disseminated leukoencephalitis, cerebellitis, posterior reversible leukoencephalopathy, alternating hemiplegia,
metabolic disorders, epilepsy and psychogenic diseases. Thus,
the differential diagnosis of CVA in children must exclude all
pathologies associated with acute neurological deficits. In the present study were carried out selection the most important
symptoms for diagnosis of suspected CVA using logistic
regression. However neuroimaging is crucial in defining the
diagnosis, other tests are needed depending on the clinical picture. We are plan the following study of important prognostic
factors within the our project.
Pediatric CVA, while it is becoming increasingly
recognized among practitioners as an clinically significant entity, remains challenging for clinicians and researchers.(19)
CONCLUSIONS
Neonatal and pediatric CVA represents one of main causes of severe handicaps throughout the life: epilepsy, motor
and cognitive consequences. Diagnosis of CVA in newborn and
young child is difficult, caused by scarce symptomatology and
the presence of specific symptoms common to other pathologies. Disease history and clinical examination have a primary role in
confirmation or exclusion of disease and factors predisposing
for CVA. Logistic regression method allowed highlighting the
most important symptoms suggestive for CVA, depending the age, i. e., in newborns (seizures, neurological non-focal signs,
altered state of conscience, generalized motor disorders), in
infants (seizures, decreased force on the one side of the body,
fist squeezing, disorders of conscience) and small children
(decreased force on the one side of the body, seizures, sensorial
disorders and focal movement disorder). On the basis of the
presence of generalized symptoms a possible diagnosis of CVA
must be considered, which require confirmation by imaging and EEG monitoring.
Future studies represent a priority direction and should
determine major clinical syndromes are related to risk factors
and predictors of neonatal and pediatric CVA, to advance preventive treatment and improve the neurological outcome of
survivors.
REFERENCES 1. Aho K, Harmsen P, Hatano S. Cerebrovascular disease in
the community: results of a WHO collaborative study.
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şi Psihiatrie a Copilului şi Adolescentului din România. 2014;17(3):27-38.
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6. Earley CJ, Kittner SJ, Feeser BR, et al. Stroke in children and sickle-cell disease: Baltimore-Washington cooperative
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12. Chabrier S, Husson B, Dinomais M, et al. New insights
(and new interrogations) in perinatal arterial ischemic
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Arterial Ischemic Stroke Is Associated to Materno-Fetal
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15. Lanthier S, Carmant L, David M, et al. Stroke in children: the coexistence of multiple risk factors predicts poor
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16. DeVeber G. In pursuit of evidence-based treatments for
paediatric stroke: the UK and Chest guidelines. The Lancet Neurology. 2005;4(7):432-436.
17. Kolk A, Ennok M, Laugesaar R, et al. Long-term
cognitive outcomes after pediatric stroke. Pediatr Neurol.
2011;44(2):101-109.
18. Lopez-Vicente M, Ortega-Gutierrez S, Amlie-Lefond C,
Torbey MT. Diagnosis and management of pediatric
arterial ischemic stroke. Stroke and Cerebrovascular
Diseases. 2010;(3):175-183. 19. Cárdenas JF, Rho JM, Kirton A. Pediatric stroke. Childs
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GUT MICROBIOTA AND CENTRAL NERVOUS SYSTEM IN
HEALTH AND AUTOIMMUNE DISEASES
REVIEW
MIHAI BOGDAN
NEAMŢU
1, ANDREEA BARBU
2, IONELA MANIU
3
1,3”Lucian Blaga” University of Sibiu, 1,2,3 Research and telemedicine center of neurological diseases in children, 2Clinical Pediatric Hospital Sibiu,
2University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca
Keywords: Human
microbiota, Central
Nervous System
Disorders, Gut-Brain Axis
Abstract: Gut microbiome is highly connected with the central nervous system (CNS) in a bidirectional
manner by top-down and bottom-up signalling systems. We present a review with an update on the most
important mechanisms and pathways by which probiotic strains modulate autoimmune CNS diseases
such as Multiple Sclerosis(MS), Neuromyelitis optica (NMO), Guillain-Barre Syndrome (GBS). Lactobacillus, Bifidobacterium, Bacteroides probiotic species were intensively studied for their
beneficial effects on metabolism and regeneration (butyric, propionic acids), neurotransmission
(tryptophan, serotonin, γ-aminobutiric acid, dopamine, norepinephrine, acetylcholine, histamine,
agmantine), antiinflammatory effects with a decrease in specific cytokine levels. In autoimmune diseases, pathogenic strain antigens were found to trigger proinflammatory Th1, Th17 cells and elevate
proinflammatory biomarkers (TNF-α IL-1, IL-6, IL-12, IL-17, MIP-10, MCP-1, IFN-γ). Probiotic strains
reduced the inflammatory outcomes stimulating Treg cells subsets and IL-10 profiles both in humans
and in experimental animal models.
1Corresponding author: Neamtu Mihai Bogdan Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, România, E-mail: bogdan.neamtu@ulbsibiu.ro, Phone: +40773
994375
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):17-21
INTRODUCTION
In the last 30 years, numerous studies concerning
human microbiota have shown a special interest in network links between various pathophysiological phenomena and commensal
bacteria. Whether orally administered or manipulated with
specific diet nutrients (the so-called gut microbiota shaping),
probiotic bacteria are associated with impressive pleiotropic effects: anti-inflammatory, metabolism modulation,
antihypertensive, anticancer and neurodevelopmental to mention
the most important of them. There is a complex interaction
between gut microbiota, intestinal epithelium, GALT(Gut Associated Lymphoid Tissue), gut endocrine tissue
(enterochromaffin cells) and gut-associated nervous system.
Considerable attention is addressed to nervous system
interaction with human microbiota. The gut microbiome is highly connected with the central nervous system(CNS) in a
bidirectional manner.(1,2,3) It is a network that functions in
both directions: top-down and bottom-up signalling. For this
reason, many hypotheses and research designs aimed to study this interrelationship between human microbiota and CNS
autoimmune or neurodegenerative disorders such as Multiple
Sclerosis(MS), Neuromyelitis optica(NMO), Guillain-Barre
Syndrome(GBS).
The purpose of our review was to present an update on
the most important mechanisms and pathways by which
probiotic strains modulate autoimmune CNS diseases evolution.
MATERIAL AND METHOD
We performed an analysis of PUBMED database and
Google Scholar using criteria like “Human microbiota, CNS, Gut-Brain Axis”. Seventy-nine articles have emerged. Further
on, we considered the most important references for probiotic
and/or gut microbiota potential to modulate neural pathways and
their impact on autoimmune CNS disorders (MS, NMO, GBS).
A special consideration was given to microbiota capacity to
produce antiinflammatory responses corelated with the disease
specificity.
RESULTS AND DISCUSSIONS
Human microbiota has a dynamic architecture
throughout the lifespan. Human gut is colonised starting with intrauterine life (placenta and amniotic fluid). Its organisation is
modulated up the 3rd year of age.(4-9) The most important
species mentioned in the literature in the prenatal period are
Propionibacterium, Streptococcus, Staphylococcus. The proposed mechanism is the translocation of mother’s gut
microbiota using placenta and umbilical cord blood.(10) At birth
and during the first months infant's gut is populated mainly with
bifidobacteria. Both Bifidobacteria and Lactobacillus species were identified in human milk.(11,12) After 4-6 months a
multiplication of Clostridial species takes place. At 2-3 years of
age, the architecture is mainly composed of Bacteroidaceae,
Lachnospiraceae, and Ruminococcaceae and a relative equilibrium is preserved until adulthood.(13) In adults, we refer
to a steady state status with Bacteroides and Firmicutes the most
prominent phyla.(14,15) Poor diversity in composition was
incriminated in many diseases(15). In elderly people, the
Bacteroides are more numerous than Firmicutes which is an
inverted trend related to the adult period.(16,17)
Human gut microbiota contains thousands of species
(between 500 and 3000) counting more than 7000 strains with an outstanding gene network. This network is approximately
150 times bigger than the human genome.(18-21) Our body cells
are 10 times outnumbered by an approximately 105 billions of cells within the microbiota.(20,21,22) Therefore microbiota is
considered as a true organ with complex implications in
neurodevelopment, endocrine pathways, metabolism, immune
modulation.(19) Gut-brain axis (GBA) is a system that
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integrates these connections in a bottom-up and top-down
signalling pathways.(4,23,24)
Bottom-up signalling Microbiota modulates through its biomolecules
metabolic, endocrine or immune functions but most importantly,
a part of nervous system activity. Probiotic strains of
Bacteroides, Bifidobacterium, Lactobacillus turn nondigestible fermented carbohydrates into short-chain fatty acids(SCFAs).
Acetate, propionate or butyrate SCFAs are of paramount
importance for intestinal epithelium integrity in neonates (25-
27) and epithelial cell signalling pathways.(28-30) SCFAs actions were associated with host gene expression (epigenetic
control), stimulation of leptin production by adipocytes through
enterochromaffin cells (31), suppression of pathogens expansion
(19), modulation of lymphocytes and neutrophil functions or Treg subset anti-inflammatory activity.(32-35) It is hypothesised
that SCFAs enter the systemic circulation and influence blood-
brain barrier permeability (36,37) and CNS functions including
sympathetic nervous system (38,39). Moreover, it seems that SCFAs could affect neuropeptide regulation.(40,41) In neonates,
probiotic microflora synthesises lower concentrations of SCFAs
than in adults.(42) Interesting experimental designs revealed
autistic-like features in direct animal brain tissue exposure to propionate while butyrate synthesis had an opposite effect
suggesting a complex and poorly understood role for SCFAs
pathways in brain activity.
Other metabolites such as conjugated linoleic acids (CLAs) were described to possess a substantial role in obesity,
diabetes and immune function (43) but also in CNS
development. Different types of commensal bacteria can
produce CLAs. In newborns, Bifidobacteria, Lactobacillus, Propionibacterium, Lactococcus, Enterococcus are capable of
yielding CLAs necessary for growth.(19) In experimental
models, CLAs producing Bifidobacterium breve strains
administered daily for 8 weeks to male mice were responsible for an increased concentration of brain fatty acids.(44) The
mechanism remains unclear.
Besides SCFAs and CLAs synthesis, microbiota can
exert neurological effects by neuroactive biomolecules:
tryptophan, serotonin, γ-aminobutiric acid, dopamine,
norepinephrine, acetylcholine, histamine, agmantine.(9,45,46)
Tryptophan, an essential aminoacid is crucial for CNS
development in neonatal behavioral traits. Probiotic strains modulate its levels presumably by kynurenine pathway.
Serotonin is the metabolite of tryptophan controlling appetite,
mood, sleep, anxiety.(19) It is released from intestinal
enteroendocrine cells. Bifidobacterium longum ssp infantis administered in rat models induced an increment in tryptophan
levels, the inhibition of proinflammatory actions and
antideppresive effects.(47,48,49) Strain specific influences were
hypothesized to be directly on vagal terminals and/or enteric nervous system.(50)
Applied research using germ free mice reported
anxious and augmented motor behavior with a decline in levels of serotonin receptor in the hippocampus and N-methyl D-
aspartate receptor in amygdale.(51,52) In addition, a raise in the
expression of the brain-derived neurotrophic factor receptor
(BDNFR) was observed in the hippocampus as a consequence of decreased levels for BDNF.(51,52) After repopulating the gut
with Bifidobacterium infantis these changes seemed to be to a
certain degree changeable at an early period of life and
changeless at a later phase.(51-55) Another notably anxiety-like behavior effect was remarked in relation to synaptogenesis for
different gut colonisations in mice with a diminished expression
for synatophysin and pSD-95 proteins in the striatum.
Consequently, there were increased local levels of different
neurotransmitters such as serotonin, dopamine and
noradrenaline.(56) Conversely, Lactobacillus acidophillus and fermentum and Bifidobacterium lactis strains were found to
enhance synaptic transmission in the hippocampus after an
eight-week treatment.(57,58)
Enterochromaffin or enteroendocrine cells (EECs) are considered veritable biosensors for aminoacids, SCFAs, LCFAs
(long chain fatty acids). They are organized in a large gut
associated endocrine network. Microbiota modulating EECs can
activate hormonal pathways (leptin and insulin production) or regulate neural circuits (serotonin release).
Enteric nervous system (ENS) has more than 500
million neurons.(40,59,60-63) By far, the most important
bidirectional signaling route for ENS is vagal.(64-68) It seems that behavioral effects after vagal stimulation are strain specific.
Pathobiots such as Clostridium jejuni activate vagal ascendings
inducing an anxious behavior while probiotic strains like
Lactobacillus rhamnosus present an opposite, beneficial effect reducing the deppresive behavior. The proposed mechanism for
Lactobacillus rhamnosus strains actions was connected with the
transcription stimulation of γ-aminobutiric acid(GABA)
receptors. The vagal component represented the key factor for this actions because the vagotomized mice couldn’t reveal the
same pattern.(60,69-72)
Lastly, a speculated mechanism for bottom-up
signaling involves the immune system. In this theory, there is an activation in the gut for specific subsets of immune cells and
another one in the CNS, after these cells cross the blood-brain
barrier and make the contact with local DC (dendritic
cells).(73,74) Evidence based research in neonates showed a strong impact from gut microbiota on brain development in a
specific developmental window.(73-77) The mediators might be
TNF-α, IL-1, IL-6, and HMGB-1 as well as immune cells (DCs,
macrophages, T, B cells).
Top-down signaling
The prominent component is represented by HPA axis
(hypothalamus-pituitary-adrenal axis). Human brain undergoing
a stressful event stimulates the sympathetic system which in turn
release IL-6.(73-77) Therefore, HPA axis is activated increasing
gut permeability to bacterial metabolites and antigens and the
mucosal immune response. The outcome is an extended period
rise in serum levels inflammatory biomarkers in experimental models.(73-78) Furthermore, catecholamine high concentrations
in the gut can stimulate pathobiots aggressiveness. This is the
case of Campylobacter Jejuni and norepinephrine testing in vitro
but this phenomenon was also noticed for other pathogenic strains (Escherichia Coli).(78) A cholinergic route using vagal
pathway has been confirmed with a decline in immune cells and
cytokines in inflammatory states after stimulation.(75,78)
Multiple sclerosis (MS) Multiple sclerosis is an autoimmune disorder affecting
brain and spinal cord. The main incriminated pathophysiological
process implies demyelinating events with the damage of nerve cells insulating covers. The clinical picture is dominated by
muscle weakness, double vision, sensory and coordination
problems, dizziness. To this suite of symptoms, cognitive,
memory deficits and behavioural problems are frequently described. The most common findings at the cellular and
molecular levels indicate an inflammatory process with CD4,
CD8 T-cells, B-cells and activated monocytes, microglia,
macrophages and elevated levels of TNF-α, IL-1, IL-6, IL-12, IL-17, MIP-10, MCP-1, IFN-γ. Neurodegeneration is claimed to
be a consequence of prolonged oxidative stress.(32,78)
Important risk factors were mentioned concerning this
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disease: vitamin D deficiency in patients with haplotype HLA-
DR, vitamin A deficiency, obesity in early life, diet, smoking,
infections with herpetic family viruses and genetic variants (100 types of minor risk alleles, HLAs, IL2R, IL7RA, CD6,40,80,86,
genes). A mild disbiosis has been reported in MS with a lower
number for Bacteroides species.(32-35,78)
In experimental models, susceptible mice were exposed to oligodendrocyte glycoproteins while the gut was
colonised with segmental filamentous bacteria. An inflammatory
response was induced by Th1, Th17 T-cell subsets proliferation
and CD40-CD154 expression, axonal loss, and gliosis, mimicking the events in MS. This experimental autoimmune
encephalomyelitis model (EAE) has been proposed to test anti-
inflammatory effects of specific strains. Hence, research
approaches using Lactobacillus casei Shirota, Bifidobacterium Animalis and Bacteroides Fragilis were associated with a
decline in TNF-α IL-1, IL-6, IL-12, IL-17, MIP-10, MCP-1,
IFN-γ levels. An explanation for the changes referred to SCFAs
(butyric and propionic acids) binding to the G-protein coupled receptors (GPCRs) stimulating Treg activity and IL-10
production.(78)
Another particular finding in EAE was recorded after
antibiotic treatment with a decrease in the proinflammatory biomarkers and improvements in symptoms.
Neuromyelitis optica(NMO)
NMO appears to be similar to MS, but there are
specific pathophysiological hallmarks. It belongs to the same family (CNS autoimmune disorder), but the inflammation and
demyelination processes are due to astrocyte impairment
(astrocytopathy or astrocytic channelopathy). A T-cell-mediated
immune response against aquaporin 4 (AQP4) marks the pathogenesis. Anti-AQP IgG positive or negative states were
discovered. Monophasic or recurrent forms include optical
neuritis with blindness and spinal cord injury (myelitis) with
different degrees of weakness or paralysis in arms, legs, bladder and bowel dysfunction. So far, the relationship with gut
microbiota dysfunctions seemed to be both direct and indirect.
AQP4 sensitised T-cells were shown to react also against
Clostridium perfringens proteins (molecular mimicry) while
Anti-AQP IgG positive forms revealed antibodies against
dietary proteins.(78)
Guillain-Barre Syndrome(GBS)
GBS is considered an acute autoimmune polyneuropathy affecting myelin insulation with a rapid onset.
The main complaint is muscular weakness involving the upper
and lower limbs and the upper body. Life threatening events can
ensue, naming weakness of breathing muscles, heart rate and blood pressure anomalies. Again molecular mimicry mechanism
leading to neuronal damage is alleged. A prior viral, atypical
germ or even bacterial infection sets up the inflammatory paths.
Different strains of Campylobacter were mentioned to correlate with these abnormal immune responses. At least three Th
subsets were identified in GBS evolution: Th1 with TNF-α,
IFN-γ and IL-1 as triggers for the acute inflammation, Th17 subset with IL-2,12,17,22 TNF-α/β as proinflammatory
populations and the last but not the least Th2 type cells with IL-
10 and TGF-β in the remission phases.(78,79)
CONCLUSIONS
There is a complex interplay between gut microbiota
and brain development at different life stages. A crucial role in
brain maturation is already acknowledged for gut synbiots in a particular time window after birth. The messengers for these
data transfers are metabolites, cytokines, neurotransmitters, and
hormones. In the autoimmune diseases affecting the nervous
system, a molecular mimicry mechanism and a pathogenic strain
were invoked in most of the instances triggering
proinflammatory cells and biomarkers whereas probiotic strains proved to alleviate the disease pathogenesis both in human and
in experimental animal models.
Acknowledgment:
This work has been conducted in the Pediatric Clinical Hospital Sibiu, within the Research and Telemedicine
Center in Neurological Diseases in Children - CEFORATEN
project (ID 928 SMIS-CSNR 13605) financed by ANCSI with the
grant number 432 / 21. 12. 2012 thru the Sectoral Operational Programme “Increase of Economic Competitiveness”.
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TETANY OR DIAGNOSTIC PITFALL
RALUCA MARIA COSTEA
1, BOGDAN NEAMŢU
2
1Clinical Pediatric Hospital Sibiu, 2Research and Telemedicine Center of Neurological Diseases in Children
Keywords: congenital
myotonia, tetany,
muscle stiffness
Abstract: The authors present the case of a female patient, aged 17 years, diagnosed with congenital
myotonia. The patient with a history of painless intermittent muscle stiffness and restriction in executing
rapid movements for about 7-8 years addressed our outpatient clinic tardly. The patient described a
slow progression of symptoms and was diagnosed with autoimmune thyroiditis and treated for two years for, hypocalcemia and tetany, with no improvement. The athletic allure, age at onset, percussion
myotonia, EMG confirmation of the myotonic discharge and the lack of significant progression of the
symptoms, represented pathognomonic criteria for congenital myotonia. In the absence of suggestive
family history and with a borderline phenotype no assignation in the Becker or Thomson form could be done. The screening of the CLCN1A mutations remains the “gold standard” for establishing the
congenital myotonia type. Under membrane stabilizer treatment with Carbamazepine moderate
improvement of the myotonic phenomenon was obtained.
1Corresponding author: Raluca Maria Costea, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, România, E-mail: ralucacostea2004@yahoo.com, Phone:
+40728981091
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):22-24
INTRODUCTION
Myotonia is defined by continued active contraction
and impaired muscle relaxation following cessation of voluntary
effort or stimulation. Several clinical disorders of different
etiologies are characterised by myotonia. The inheritance
pattern, clinical history and assessment of systems are all
important in establishing the different causes. Clinically the age
of onset, temperature effects, food composition effects, associated transient or predominant weakness are essential in
working out the underlying illness. The electromyography and
molecular genetic testing are able to confirm the final
diagnose.(1,2,3,4,5) Congenital myotonia is a rare hereditary
musculoskeletal disorder characterised by myotonia- muscle
stiffness, muscular hypertrophy, sometimes muscular weakness,
with onset in childhood. Both dominant (Thomson) and recessive (Becker) variants are considered to be chanellopathies.
There is a high variability in the mutations involving the
chloride channel gene (CLCN1), located on 7q35.
This mutations reduce the stabilising chloride conductance causing a electrical instability of the muscle fibre
membrane expressed in myotonia and muscle
stiffness.(1,2,3,4,5)
No etiological treatment is available with mainly conservative and supportive therapy. Easy-moderate intensity
adaptive physical education and sport activities could improve
the transitory muscle stiffness.(6)
Mexiletine response, a Na+ channel blocker, is effective in treating the myotonia. The best responses obtained
when the drug blocks voltage-dependent mutant channels, but
there is also a partial effect in more severe cases with the blockade of wild type channels. It seems that the Me7
derivative, that inhibits the Na+ channels in M2 gating mode, is
more effective than Mexiletine. Other membrane stabilizers are
also available.(7,8,9,10,11,12,13)
CASE PRESENTATION
The proband, a 17 years old female, born of a non-
consanguineous marriage, complained of difficulty in rising up
quickly from the bed in the morning describing a,,muscle
tension “ sensation when standing up from sitting position. As
an only child she had unremarkable antenatale and perinatal
history. She was born at 40 weeks of pregnancy with a weight of
3300g, 51 cm length, in cephalic presentation. She presented with normal motor and cognitive development. With a family
history of diabetes (maternal grandmother), thyroid nodules (the
mother) she was diagnosed at the age of 16 years with
autoimmune thyroiditis. The probable onset was in childhood at the age of 9-
10 years. She described a painless intermittent muscle tension
and restriction in executing rapid movements for short periods
of time (seconds/minutes) with poor localization in the lower limbs. The complains were limited to movement initiation after
prolonged rest –sleep with slight improvement with repeated
movements. No relation to intense physical activity, rest after
physical activity, fasting or carbohydrates or potassium rich food was noticed. No episodes of prolonged motor deficit,
myalgia, history of constipation/respiratory dysfunction or
recurrent infections were mentioned. The mother denied early
symptoms, in infancy or early childhood, as difficult eye opening during cry, sucking or mastication. Latterly she
presented with fatigue, moderate effort dyspnea and tachycardia,
mild decline in attention and memory skills, hypersomnia and
episodic speech impairment. First evaluated by the pediatrician at the age of 15
years she was diagnosed and repeated treated for tetany due to
low plasmatic calcium levels (8.32 mg/dl NV 8.5-11 mg/dl) and 25-OH vitamin D (12.66 ug/L NV 20-70 ug/L), with no clinical
improvement. The endocrinological investigations: high
antitireoglobuline antibodies (157 UI/ml NR <4.11 UI/ml) and
TSH plasma levels, with normal hormonal thyroid and pituitary
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levels and ATPO levels concluded chronic autoimmune
thyroiditis with euthyroidia.
On careful clinical examination in our clinic the 17 years old patient presented with a mild athletic aspect, short
stature T=155 cm (perc 10-25 CDC), W= 46 kg (perc 3-10
CDC), BMI=19 (perc 10-25 CDC), no alopecia or skin lesions.
The clinical examination of both parents was normal. The first neurological examination, in summer,
revealed intermittent latency in tongue movement with normal
eye movement, no ptosis, lid lag, facial weakness, dysphonia or
dysphagia. The calf muscles, thighs and proximal muscles in the upper limbs were mildly hypertrophied. There was evidence of
provoked myotonia, on percussion of the thenar eminence,
emphasized by cold water immersion, mild active (hand grip)
myotonia. No tongue or eye orbicular myotonia was obtained. Extensive investigations were performed:
echocardiogram, cardiac ultrasound, creatinkinase levels, lipid
profile, imunogramme, blood glucose were all normal. The
electromyography revealed the presence of typical myotonic runs and a myogenic aspect (Figure 1).
Figure no. 1. Myotonic discharges on needle EMG
The cerebral MRI revealed a pituitary microadenoma
with normal sella turcica and no cortical atrophy or white matter
lesions( Figure 2).
Figure no. 2. T1-weighted sagital acquisition shows a small
pituitary adenoma
The ophthalmological examination excluded posterior
subcapsular cataract or other anomalies. The diagnoses was done based on the nonprogressive
painless myotonia, athletic appearance, percussion myotonia and
EMG confirmation of the myotonic discharges.
Although the disease was diagnosed by corroborating the anamnestic, clinical data and the EMG route “the gold
standard" for diagnosis remains the screening for CLCN1
mutation.
The disease has no etiological treatment, the therapy being conservative and supportive: thermal protection of
extremities is recommended the cold stressing the myotonic
phenomenon. Easy-moderate intensity adaptive physical
education and sport activities could improve the transitory
muscle stiffness. To reduce the myotonia and due to the lack of
Mexiletine another membrane stabilizer treatment with
Carbamazepine 10 mg/kg/day was initiated. Moderate
improvement of the myotonic phenomenon was obtained. Late prognosis does not imply severe disability due to
the lack of progression of the symptoms in the adulthood. Life
expectancy is not affected.
A genetic testing should be undergone because some mutations (Gly230Glu, T310 M) are correlated with aggravated
myotonia and weakness during pregnancy. Appropriate
professional orientation was recommended. Advise regarding
aggravating medication was given: β2-agonists: Fenoterol, Ritodrine, monocarboxylic amino acids and depolarizing muscle
relaxants.
DISCUSSIONS There were several difficulties in establishing a
diagnose.
The patient denied any exacerbation of the myotonia
by cold, hunger or stress exposure or ,,warm up phenomenon”- reduced myotonia after repeated activity, but the follow up
confirmed them as triggers. The absence of correlation with
carbohydrate and potassium rich food and episodic paralysis
excluded other chanellopathies- hyper K periodic paralysis, K sensitive myotonia.
The electromyography confirmed the myotonic
discharges, therefore excluding a possible pseudomyotonic
phenomenon associated to the autoimmune thyroiditis. Acquired myotonia due to drug toxicity was rapidly
excluded. Myotonia permanens, a Sodium Channel - α subunit
(SCN4A; Nav1.4) chanellopathy, was excluded due to the
intermittence of symptoms. The lack of exacerbation after potasium rich foods and the absence of delayed,,paradoxical “.
myotonia made a diagnoses of myotonia fluctuans improbable.
The recent complaints of fatigue, intolerance to
moderate effort, mild decline in attention and memory skills,
hypersomnia and episodic speech impairment, family history of
diabetes, together with the mildly myopathic EMG pattern,
could have been clues for a slow progressive myotonic
dystrophy. The absence of muscle wasting or other physiognomy features, eye, brain and other systems
involvement excluded Steinert myotonic dystrophy and
proximal myotonic myopathy (PROMM) .
The mild athletic allure, age at onset, lack of significant progression of the myotonia represented
pathognomonic criteria for congenital myotonia. In the absence
of suggestive family history and with a borderline phenotype on
clinical bases no assignation in the Becker or Thomson form could be done. The screening of the CLCN1A mutations
remains the only framing resource.
CONCLUSIONS
Myotonia does exist! Awareness of the myotonic
phenomenon could have hasten the diagnosis and treatment. It is
important to differentiate between tetany and other types of muscle stiffness like myotonia. Hypocalcaemia associated with
intermittent muscle stiffness can be a diagnostic pitfall.
Acknowledgment:
This work has been conducted in the Pediatric Clinic Hospital Sibiu, within the Research and Telemedicine Center in
Neurological Diseases in Children - CEFORATEN project (ID
928 SMIS-CSNR 13605) financed by ANCSI with the grant
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AMT, vol. 22, no. 3, 2017, p. 24
number 432 / 21. 12. 2012 thru the Sectoral Operational
Programme “Increase of Economic Competitiveness”.
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AMT, vol. 22, no. 3, 2017, p. 25
GUT MICROBIOTA AND FOOD ALLERGY
CORINA CAZAN
1
1“Lucian Blaga” University of Sibiu, Pediatric Clinic, Research and Telemedicine Center of Neurological Diseases in Children
Keywords: food
allergy, dysbiosis,
probiotics
Abstract: In the last decade, the role of the intestinal microbiota in the development of immune tolerance
to food is increasingly appreciated. An altered microbiota and an early life dysbiosis were suggested in
food allergy pathogenesis with the possibility to be involved in disease persistence. The factors that
induce dysbiosis involved in food allergy are caesarian, lack of natural feeding, antibiotics use and low fibers diet or high-fat diet. The data suggest that dysbiosis occurs before the onset of clinical
manifestations of food allergy. Modulation of microbiota by probiotics and prebiotics represents an
encouraging strategy for prevention and treatment of food allergy.
1Corresponding author: Corina Cazan, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Romania, E-mail: corinacazan2000@yahoo.com, Phone: +40745
998833
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):25-27
Food allergy is a real health problem, and the
prevalence increased dramatically over the last decade. Food
allergy affects 6% of children under five years of age and 3% of
adolescents. Increasing prevalence of food allergy and that of other atopic diseases suggests an important role for
environmental factors in early childhood.(1)
The mechanisms of food allergy seem to be promoted
by gut dysbiosis. Recent studies report a pathogenetic role of gut
microbiota in the development of food allergy. The interaction
between gut microbiota and immune or non-immune cells
supports oral tolerance. The maturation of microbiota is related
to Th1/Th2 ratio, with a shift in Th1 cell response. Alteration of gut microbiota or dysbiosis, affects
microbiota homeostasis producing a shift of the Th1/Th2
cytokinic production, with a predominance in favor of the Th2
response.(1) Several factors responsible for gut microbiota alteration and the onset of food allergy are caesarian, artificial
feeding, drugs use such as antibiotics or gastric acidity inhibitors
and low fibers diet or high-fat diet.(2) The data suggest that the
use of antibiotics induces an increase in the prevalence of food allergy. Several studies demonstrated that neonatal or maternal
antibiotic treatment reduced intestinal microbial diversity in
both faecal and ileal samples and improved food allergen
sensitization. Antibiotic use during pregnancy and the treatment in
the newborns increase the risk of cow’s milk allergy in infants
and children.(1) Recent data support the concept that intestinal
dysbiosis or some changes or alteration in intestinal microbiota composition during early life can influence the development of
food allergy and other allergic diseases.(1)
DNA-based gut microbiota studies suggest the
existence of placenta microbiome in relation to the innate Toll-like receptor. This data correlates the maternal exposures during
pregnancy and the increased risk of allergic diseases. Some
authors demonstrated that in vaginal birth the skin and intestinal tract are colonized by Lactobacillus species.(3) Caesarian-born
babies have a bacterial pattern of the skin and intestinal tract
composed of Staphylococcus and Streptococcus species
overlapping with the bacterial strains on the mother’s skin. The cesarian-born infants have a higher risk to develop the allergic
diseases compared with vaginally newborn.(3) Several studies
demonstrated that the neonates have a complex gut microbial
communities in the first week of life, with dynamic fluctuations
in bacterial microbiota from 1 to 3 years of age.(4) Bifidobacterium, Proteobacteria, Bacteroides, and much less
Firmicutes (including the Lactobacillus spp., from the vaginal
flora) massively colonize the neonatal gut in the early life. In
neonates weighing less than 1200 g, gut microbiome is
dominated by both Firmicutes and Tenericutes and with much
less dominance of Actinobacteria. The collective data improve
the concept that the infant may be first seeded in utero by the
placenta-associated microbiome by length of gestation.(4) Another study, suggests that infants diagnosed with atopic
dermatitis, IgE-mediated, present an increased level of faecal
Escherichia coli.(5) Current data reported risk factors for
allergic disease including early-life antimicrobial exposure, caesarian birth and formula feeding.(6) Other studies support the
association of formula-feeding without prebiotics and allergic
diseases. Formula supplemented with prebiotics provides
support and diversity for Bifidobacterium longum, a protective species, in allergic children.(7,8)
Both maternal and neonatal gut microbiota in the early
postnatal life are considered as risk factors involved in allergic
diseases. This concept has been demonstrated for infants diagnosed with allergic disease and decreased Bifidobacterium
in the gut.(3) Allergic sensitization in early-life involved
microbiota imbalance in the stage of immunological
development.(3) Kalliomäki and colleagues presented the patterns of early microbiota linked to dysbiosis with increased
pathogenic agents and decreased commensal species involved in
development and maintenance of immune homoeostasis.(3,5)
The commensal gut microbiota target different cellular components of the innate and adaptive immune compartments to
promote oral tolerance. One mechanism by which the
commensal microbiota influence the outcome of the allergic response is by modulating the innate lymphoid cells
(ILC).(9,10) The commensal microbiota also targets the
adaptive immune response to promote tolerance, in part by
direct action on T cells and B cells. Depletion of the commensal flora by antibiotic treatment is associated with the development
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of T helper type 2 (Th2) cell-type allergic responses and higher
serum IgE levels.(11) Another tolerance promoting mechanism
is based on short chain fatty acids (SCFAs) production. SCFAs are end-products resulting from bacterial fermentation of dietary
fibers.(12). A high-fiber diet protects against allergic
inflammation by altering the composition of the microbiome by
increased Bacteroidetes and decreased Firmicutes abundances with a subsequent increase in circulating levels of SCFAs.(13)
Gut Microbiota in Allergic Disease.
Novel research approaches based on next-generation
sequencing systems have highlighted potential biomarkers species in allergic patients. Bacteroidaceae and Clostridium
species were suggested by Melli et al.(14,15) as relevant
candidates. It seems that Bacteroidaceae are responsible for
intestinal mucin secretion while Clostridium strains are related to the immune response.
Early exposures in non-breast feeding infants to
Clostridium species have been proposed for an increased risk of
associated allergic conditions.(16,17) Moreover, an elevated ratio of Firmicutes vs Bacteroidetes were described in food
allergic infants.(9,18) Prediction of food allergy at one year of
age has been computed in a study group of 166 infants (the
Canadian Healthy Infant Longitudinal Development-CHILD). The patients were profiled for gut microbiota
composition at three months of age. Data were retrieved from
next gene sequencing reports denoting a higher proportion of
Enterobacteriaceae versus Bacteroidaceae and pointing to a possible parameter of immaturity.(9,19). Bacteroidaceae species
reaches to dominate the intestinal flora with increasing
age.(9,20) Bacteroidetes deficiency was revealed in pregnant
mothers of eczematous atopic infant but without correlation of the same microbiota deficiency in infants (9,21).
Probiotics and Prebiotics in Allergic Diseases.
Probiotics are considered as living micro-organisms
modulating the health of the host if given in appropriate amounts. Probiotics have a potential role in gut microbiota and
immune responses regulation. In the last decade, considerable
interest and efforts were invested in preventing and treating the
allergic diseases. Strains of Bifidobacterium bifidum, lactis,
breve or longum, Lactobacillus reuteri, rhamnsosus GG,
acidophilus, casei, salivarius and paracasei were evaluated in the
management of allergic disease.(22)
Although many systematic reviews tackled the probiotic supplementation to prevent allergic disease, there was
insufficient facts and statistics in the proposed panel of WAO
(World Allergy Organization) to sustain this approach for the
high risk pairs mother-child in the cases of allergic family history(22,23).
Moreover, there was no caveat concerning the type or
dose of the probiotic strain for clinical applications.(9,23).
However we found some research papers with positive data in this respect. For example, a meta-analysis performed by
Cao et al. showed a 14% prevalence reduction in atopic
dermatitis, administering probiotics in pregnancy and early infancy.(24) Another meta-analysis of 25 probiotic trials
reported significant clinical improvement in children receiving
probiotics. A new study on 43 children reported that a four-week
use of Lactobacillus salivarius convincingly alleviated clinical symptoms while a randomized trial of 40 infants claimed that
four weeks Bifidobacterium bifidum treatment notably
improved symptoms compared with placebo.(25,26,27). Still, in
infants there isn’t enough evidence to support the benefit of probiotic use (9,28). Furthermore, in the same note with WAO,
recent guidelines proposed by European Academy of Allergy
and Clinical Immunology, couldn't point out any premise to
recommend the use of probiotics for food allergy and
anaphylaxis prevention.(29) It seems that probiotic association
to oral immunotherapy is showing notably results (30) Prebiotics have the ability to stimulate probiotic
strains in gut microbiota. Oligosaccharides in human milk
provide beneficial effects in maintaining the balance of
intestinal microbiota in infants. The synthetic oligosaccharides are added as a supplement to infant formulas to foster gut
microbiota development.(31)
CONCLUSIONS New intervention targets are needed to document
alteration or change of intestinal colonization and involvement
of the microbiota in the pathogenesis of allergic disease.
Acknowledgement: Part of this work has been conducted in the Pediatric
Clinical Hospital Sibiu, within the Research and Telemedicine
Center in Neurological Diseases in Children - CEFORATEN
project (ID 928 SMIS-CSNR 13605) financed by ANCSI with the grant number 432 / 21. 12. 2012 thru the Sectorial Operational
Program “Increase of Economic Competitiveness”.
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a target for food allergy, Journal of Pediatric
Gastroenterology and Nutrition, Volume 63, Supplement 1,
2016. 2. Canani R.Berni, Gilbert JA, Nagler CR, The role of the
commensal microbiota in the regulation of tolerance to
dietary antigens, Curr Opin Allergy Clin Immunol, 2015,
15:243–9. 3. Lynch SV, Gut Microbiota and Allergic Disease, New
Insights, Ann Thorac Soc.13 (Suppl 1), 2016, S51-S54.
4. Aagaard K, Ma J, Antony KM, Ganu R, Petrosino J,
Versalovic J. The placenta harbors a unique microbiome. Sci Transl Med. 2014.
5. Penders J, Thijs C, van den Brandt PA, Kummeling I,
Snijders B, Stelma F, Adams H, van Ree R, Stobberingh
EE, Gut microbiota composition and development of atopic manifestations in infancy: the KOALA Birth Cohort Study.
Gut . 2007.
6. Stensballe LG, Simonsen J, Jensen SM, Bonnelykke K,
Bisgaard H. Use of antibiotics during pregnancy increases the risk of asthma in early childhood. J Pediatr . 2013,
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7. Akay HK, Bahar Tokman H, Hatipoglu N, Hatipoglu H,
Siraneci R, Demirci M, Borsa BA, Yuksel P, Karakullukcu A, Kangaba AA, et al. The relationship between
bifidobacteria and allergic asthma and/or allergic
dermatitis: a prospective study of 0-3 years-old children in
Turkey. Anaerobe. 2014, 28:98–103. 8. Barrett E, Deshpandey AK, Ryan CA, Dempsey EM,
Murphy B, O’Sullivan L, Watkins C, Ross RP, O’Toole
PW, Fitzgerald GF, et al. The neonatal gut harbours distinct bifidobacterial strains. Arch Dis Child Fetal Neonatal
Ed. 2015.
9. Rachid R, Chatila TA, The role of the gut microbiota in
food allergy, Curr Opin Pediatr 2016. 10. Sicherer SH, Sampson HA. Food allergy: epidemiology,
pathogenesis, diagnosis, and treatment, J Allergy Clin
Immunol 2014, 133:291–307.
11. Hill DA, Siracusa MC, Abt MC, et al. Commensal bacteria-derived signals regulate basophil hematopoiesis and
allergic inflammation, Nat Med 2012, 18:538–546.
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12. Smith PM, Howitt MR, Panikov N, et al. The microbial
metabolites, short-chain fatty acids, regulate colonic Treg
cell homeostasis. Science 2013, 341:569– 573. 13. Trompette A, Gollwitzer ES, Yadava K, et al. Gut
microbiota metabolism of dietary fiber influences allergic
airway disease and hematopoiesis. Nat Med 2014, 20:159–
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14. Bridgman SL, Kozyrskyj AL, Scott JA, Becker AB, Azad
MB, Gut microbiota and allergic disease in children, Ann
Allergy Asthma Immunol 116, 2016.
15. Melli LC, do Carmo-Rodrigues MS, Araujo-Filho HB, Sole
D, de Morais MB, Intestinal microbiota and allergic diseases: a systematic review, Allergol Immunopathol
(Madr), 2015.
16. Almqvist C, Oberg AS. The association between caesarean
section and asthma or allergic disease continues to
challenge. Acta Paediatr., 2014, 103:349e351.
17. Lodge CJ, Tan DJ, Lau M, et al. Breastfeeding and asthma
and allergies: a systematic review and meta-analysis, Acta
Paediatr, 2015.
18. Ling Z, Li Z, Liu X, et al. Altered fecal microbiota composition associated with food allergy in infants. Appl
Environ Microbiol. 2014, 80:2546e2554.
19. Azad MB, Konya T, Guttman DS, et al. Infant gut
microbiota and food sensitization: associations in the first
year of life. Clin Exp Allergy. 2015, 45:632e643.
20. Arrieta MC, Stiemsma LT, Dimitriu PA, et al. Early
infancy microbial and metabolic alterations impact risk of
childhood asthma. Sci Transl Med.2015, 7: 307ra152.
21. West CE, Ryden P, Lundin D, et al. Gut microbiome and
innate immune response patterns in IgE-associated eczema.
Clin Exp Allergy.2015, 45:1419e1429.
22. Cuello-Garcia CA, Brozek JL, Fiocchi A, et al. Probiotics
for the prevention of allergy: a systematic review and meta-
analysis of randomized controlled trials, J Allergy Clin Immunol., 2015.
23. Fiocchi A, Pawankar R, Cuello-Garcia C, et al. World
Allergy OrganizationeMcMaster University Guidelines for Allergic Disease Prevention (GLAD-P): probiotics. 2016.
24. Cao L, Wang L, Yang L, et al. Long-term effect of early-
life supplementation with probiotics on preventing atopic dermatitis: a meta-analysis. J Dermatol Treat, 2015.
25. Ismail IH, Licciardi PV, Tang ML. Probiotic effects in
allergic disease. J Paediatr Child Health., 2013, 49:709e715.
26. Niccoli AA, Artesi AL, Candio F, et al. Preliminary results
on clinical effects of probiotic Lactobacillus salivarius LS01 in children affected by atopic dermatitis. J Clin
Gastroenterol., 48(suppl 1):S34eS36, 2014.
27. Lin RJ, Qiu LH, Guan RZ, et al. Protective effect of
probiotics in the treatment of infantile eczema. Exp Ther
Med. 2015, 9:1593e1596.
28. Kim SO, Ah YM, Yu YM, et al. Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of
randomized controlled trials. Ann Allergy Asthma
Immunol. 2014, 113:217e226.
29. Muraro A, Halken S, Arshad SH, et al. EAACI food allergy
and anaphylaxis guidelines. Primary prevention of food
allergy. Allergy., 2014, 69:590e601.
30. Tang RB, Chang JK, Chen HL. Can probiotics be used to
treat allergic diseases? J Chin Med Assoc., 2015,
78:154e157.
31. Vandenplas Y, Zakharova I, Dmitrieva Y. Oligosaccharides
in infant formula: more evidence to validate the role of
prebiotics. Br J Nutr., 2015, 113: 1339e1344.
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MICROBIOTA AND THE IMMUNE SYSTEM, A COMPLEX
LIAISON
IOANA MĂTĂCUŢĂ-BOGDAN
1
1“Lucian Blaga“University of Sibiu, Pediatric Clinical Hospital of Sibiu, Research and Telemedicine Center in Neurological
Diseases in Children
Keywords: microbiota,
immune system, complex liaison
Abstract: Based on millennia of symbiotic relationship, gut microbiota and the human organism can be
viewed as a whole. Recent evidence support the fact that microbiota shapes the human organism at many levels: tissues, cells, immune system and connection between them. It appears natural that such a
long complex and dynamic interdependence in not yet fully understood. The relationship goes up to the
molecular level and one of the major implications is the intimate liaison between microbiota and
immune system with divergent effects on several aspects such as: regulatory and modulatory effects, shaping both local and systemic immune mechanisms, implication in immune disorders, cancerogenesis
and immune therapy.
1Corresponding author: Ioana Mătăcuţă-Bogdan, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Romania, E-mail: ioanaoctavia_bogdan@yahoo.com Phone:
+40740 024274
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):28-31
INTRODUCTION
GUT MICROBIOTA
Over the years more and more evidence appear
concerning the complex relation between the microbiota and the
immune system. The human organism, the microbiota and the immune system interconect in ways far from being completly
descovered. Every study in the field brings more and more
arguments of the remarkable link between these components.
The gut microbiota and the human body can be considerred a meta-organism – community of biological entities
that comunicate between them. Microbiota reunites an enormous
number of bacteria, viruses, fungi and other microbial species.
(1, 2, 3) The mathematically calculated number of cells in the human body is 3,72 x1013.(4) Over 100 trillion cells compose
the gut microbiota, which outnumbers host’s cells, with a
complexity of 500-1000 species (2), 7000 strains (3) and over
600.000 genes (compared to the 22.000 genes of the human body). (4)
The microbiome represents a biomass of aproximately
2 kilograms.(5,6) Adding the enormous enzymatic capabilities
the posibilities of interaction with the host are unlimited and not only in terms of digestion, nutrients production, detoxification,
defense against pathogens, but also regulatory function over the
immune system.(1,7)
Relationship between the microbiota and the human host depends of many factors such as: genetic particularities of
the host, co-infection, nutritional conditions. Mutualistic,
parasitis and commensal interaction can be described based on
the benefits of both the host and the microbe. Therefore, mutualism implies benefits for both species involved, parasitism
implies benefits only for the micoorganisms obtaining nutrients
from the host and commensalism defines a relationship with benefits for the microorganism without harming the host.(1)
Inside the microbiota organisms form complex network of
microb-microb relationships.(8)
Recent studies support the evidence that human are not born as sterile as thought before, amniotic fluid, placenta,
meconium and umbilical cord being populated with microbes
probably implicated in immune-tolerance towards commensal bacteria.(8,9,10,11)
Bacterial colonization acquierd at birth depends on
various factors: genetic factors, maternal inflammatory
conditions (11), type of birth, gestational age, infant’s type of food, use of antibiotics.(7) Vaginally delivered infants are
colonized with bacterial species similar to mother’s vaginal and
faecal microbiota such as Lactobacillus spp., Prevotella spp. and
Sneathia spp. For caesarean-section born infants the first contact is with bacterial species found on the skin Staphylococcus spp.,
Corynebacterium spp. and Propioni bacterium.(7,8)
Preterm infants have a dominant colonization with
Clostridium difficile (7), breast-milk fed infants have microbiota preferentially colonized by Bifidobacterium while formula-fed
infants have gut colonization with Staphylococcus, E.coli,
Bacteroides, Lactobacilli.(1,7)
Both diversity and stability of the microbiota acquired at birth are low, manifests high instability and suffers
modifications during the first year of life, becoming stable in
several years (5,8,12,13) and gains an incredible resistance in
front of aggression, phenomenon known as “colonization resistance”.(1,8)
The composition of gut microbiota has interpersonal
variations and can be modified by a number of factors such as:
dietary factors, vaccination, hygiene practices, use of antibiotics and xenobiotics.(7,8,11)
Gut microbiota is a major palyer in immune
homeostasis, having a profound impact on host both innate and
adaptative, local and systemic immunity.(1,7,8,12) The relationship between the host’s immunity and microbiota is
bidirectional – the immune system controls the microbiota and
the microbiota has the capacity to calbrate and modulate the immune system.(1,14)
INTERACTIONS BETWEEN THE IMMUNE SYSTEM
AND MICROBIOTA
Digestive tract is a lymphoid organ, the lymphoid structures are reunited in GALT (gut-associated lymphoid
tissue) and MALT (mucosal-associated lymphoid tissue) and
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have tree major locations: Peyer’s patch, lamina propria and
intraepitelial follicules.
All levels of innate immunity are implicated in a relationship with microbiota, on both level of development and
function. The influence of microbiota over the immunity can be
demonstrated by using germ-free models where animals are
reared in a sterile enviroment, without being exposed to microbes.(7,15)
The development of lymphoid structures is orchestrated by
the gut microbiota.(15)
- Antigen presenting cells of the Peyer’s patches and microbiota are interconnected, so antigen presenting cells
manifest immune tolerance to normal gut microbiota, and
microbiota has regulatory effects on these cells
development Under the same conditions of stimulation these cells produce higher levels of IL-10, compared to
antigen presenting cells from the spleen.(7)
- Macrophages from the microbiota proximity have a
modified phenotype, responsable of „inflammation anergy”.(7)
- M cells are intestinal epitelial cell, specialized for the
phagocytosis and transcytosis with the ability to induce
specific immune responses in the Peyer’s patches.(16) - A particular class of natural killer cells (IL-22+
, NKp46+) is
selected over the influence of microbiota. (7)
- Intestinal Epitelial Cells production of antimicrobial factors
are regulated by microbiota.(7) Microbiota and acquired immunity:
- All subtypes of T CD4 cells (Th1, Th2, Th17, T reg) have
development and activities regulated by microbiota which
has an important role in the development of T cells, certain bacterial species induce development of a certain T cell
subtype. IL-17 and IL-22 produced by Th 17 are the main
effectors that contribute to the maintenance of the
intestinal homeostasis.(1,7) - The number and cytotoxicity of T CD8+ of the intestine are
adjusted permanently by interaction to microbiota.(7)
- B cells located in Peyer’s patches need permanent stimulation
from the gut microbiota in order to maintain a normal number
and IgA production. In germ-free models was demonstrated the
reduction of the number, cellularity and IgA production in the
studied animals. Studying the same models it has been showed
that plasma levels of Ig A and Ig G are low, plasmatic Ig M levels are normal, while Ig E levels are high both in the intestine
and in plasma.(1,7) A relationship between the microbiota
composition and the cells producing Ig A was discovered, so a
reduction of the nmber of Ig A producing cells was noted when the animal was appendectomized and colonized, demonstating
the liaison between the microbiota and the development of the
immune system. (3)
IMPLICATIONS OF GUT MICROBIOTA IN IMMUNE
DISEASES
Because of the influences of gut microbiota over both
local and systemic immune responses, it has been linked to a number of immune and autoimmune, gastro-intestinal and
extraintestinal diseases.(7,15) The mechanisms involved are
complex and not fully understood.
The most studied entities are Crohn disease and ulcerative colitis, reffered to as inflamatory bowel disease and
linked to the microbiota. Etiology of inflamatory bowel disease
is very complex and reunites genetic factors, immunological
factors concerning the host, environmental factors, infections, stress and microbiota.(1,3,17,18,19) Hygiene hypothesis appears
to be implicated - recent studies show that improved health
measures determine intestinal immunological distrurbances
inducing autoimmunity.(5)
More and more evidence suggest that dysbiosis is not
only present but specific to this disease. Some studies show that normal microbiota contributes to the inflammation present in
inflamatory bowel disese, while other studies indicate
inflammation itself as the cause of dysbiosis.(1,7)
Another attractive idea is that commensal bacteria with high inflammatory abilities can contribute to the disease by
stimulatind both the innate and aquired immune responses to
different antigens and even commensal bacteria, which can be
demonstrated by the high levels of antibody against antigens from the microbiota sources.(1,20,21,22, 23)
Based on of the Crohn disease phenotypes it was
possible to classify the microbiota, recent studies showing that
in ileal and colonic forms of the disease the microbiota is distinct.(14,24) This ascertainment permitted the conclusion that
different mechanisms are involved for different clinical
manifestations.(14,25)
Dysbiosis was recently related to rheumatoid arthritis, especialy in patients with an under six months duration of the
disease. The liason between gut microbiome and arthritis in
reffered as the „gut-joint axis’ hypothesis”.(14) In this disorder
microbiota can play a both inhibitory and augmentatory role based on the imunological target: Th 17 lymphocites or T reg.(7)
In a murine model it was demostrated that the reduction of Th
17 response associates with a reduction of disease activity. (1)
Ankylosing spondylitis has, also been linked to the gut microbiota, based on the observation that one tenth of the people
with ankylosin spondylitis develop in time one form or another
of inflamatory bowel disease, up tu 70% of of the persons
diagnosed with spondylitis have gut inflamation. Dysbiosis in the cecal microbiome could be demonstrated in these cases, and
even more, a association with HLA-B27 and a increasead Th17
population in the mucosa.(7,26)
Dysbiosis appears to be involved as a causative factor in systemic lupus eritematosus, as shown in recent studies using
murine models.(14)
Psoriasis and the psoriatic arthritis were associated
with modifications of gut microbiome similar to those observed
in Intestinal bowel disease and with high levels of secretory
IgA.(14,27)
Type 1 diabetes was linked to the reduction of Tregs
in the intestine.(7) Incidence of type 1 diabetes is higher for nonobese diabetic mouse in germ-free models, while
colonization with SFB (segmented filamentous bacteria) offers
protection to the disease.(1)
CANCER AND THE LINK TO MICROBIOTA The International Agency for Cancer Research
(IACR) has indicated that 10 microorganisms are carcinogenic
to humans, the mechanisms involved concerning either the host
or the microorganism. They are responsible for almost one fifth of the malignancies that appear in humans.(28)
Intestinal cancer and colo-rectal cancer are the result
of gastrointestinal inflammation due to the immune stimulatory effect of commensals and the infiltation of intestinal tumors with
immune cells.(1,5,29,30,31,32,33)
Liver cancer was linked to microbiota by more
mechanisms: microbiota can induce DNA damage by specific bile acids (1, 34), the breakdown of intestinal barrier can induce
hepato-carconima (35), and endotoxemia can promote it’s
progression.(36)
OTHER ASSOCIATIONS WITH MICROBIOME Other associations between microbiota and
pathological states could be established. Obesity and metabolic
syndrome (5,37), circulatory disease (5,38), drug metabolism
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and toxicity (L- DOPA, sulfasalazine, digoxin, simvastatin)
(5,39,40), post surgical recovery and autism (5,41) were related
to the gut microbiome.
CONCLUSIONS
All the implications of gut microbiota in the complex
aspects of immune system are, most certain far from being completely discovered. More and more connections and
interconnections appear permanently due to the new and
advanced technologies used in studying them. It seems logical
that an ecosystem millennia old offers surprising connections. The immune system is still under a continuous process of
discovery, so new liaisons, implications and revelations are
possible at any time.
Microbiota is implicated in different aspects of the immune system and the immune system controls and
orchestrates the microbiota.
Dysbiosis has been linked to many pathological states,
immune and autoimmune disorders, allergy, cancerogenesis, metabolic syndrome, multiple sclerosis and rheumatological
diseases.
Acknowledgement:
Part of this work has been conducted in the Pediatric Clinical Hospital Sibiu, within the Research and Telemedicine
Center in Neurological Diseases in Children - CEFORATEN
project (ID 928 SMIS-CSNR 13605) financed by ANCSI with the
grant number 432 / 21. 12. 2012 thru the Sectoral Operational Programme “Increase of Economic Competitiveness”.
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AMT, vol. 22, no. 3, 2017, p. 32
RISK FACTORS FOR BRONCHIOLITIS IN INFANTS AND THE
ROLE OF FECAL MICROBIOTA PROFILES
OLGA CÎRSTEA
1, OXANA TURCU
2, NINEL REVENCO
3
1,2,3„Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Republic of Moldova
Keywords: infant,
bronchiolitis,
microbiota, lung health
Abstract: The significant burden of lower respiratory tract disease in infancy determines emerging
studies aimed to find new therapeutic and preventive measures. One of the most frequent and potentially
severe lower respiratory tract diseases is bronchiolitis that affect mainly infants under six months of age,
but leading also to long-lived structural alterations of airways and immune cells mediated susceptibility toward allergic sensitization and asthma. Experimental models showed promising results in
demonstrating the important role of the host microbiota in influencing the function and development of
the child immune system. Another authors showed interesting correlations between maternal diet during
pregnancy and immune system function in infant, including protective factors against severe bronchiolitis. In conclusion, revealing risk factors and protective immune mechanisms at an early age
may lead to new opportunities for targeted interventions in children and decrease the morbidity from
lower respiratory tract diseases in early years.
1Corresponding author: Olga Cîrstea, Str. Grenoble, Nr. 149, MD-2060, Chișinău, Republic of Moldova, E-mail: olga.cirstea@usmf.md, Phone:
+37369038523
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):32-34
INTRODUCTION
Globally, acute lower respiratory infection is the
leading cause of childhood mortality and the highest
hospitalization rates among infants, especially between 30 days
and 60 days of age, is due to bronchiolitis.(1,2) Bronchiolitis is a
frequent lower respiratory tract disease of infancy, being mainly
a viral disorder. Clinical manifestations are determined by
morphological changes in the airways, specifically by inflammatory changes and swelling of the mucosa, and mucus
hypersecretion in bronchioles. Evolution of the diseases may
vary from moderate severity symptoms to progressive
respiratory distress caused by obstruction of lower airways. Factors associated with an increased risk of progression to
severe disease or mortality include congenital heart disease,
bronchopulmonary dysplasia, congenital anomalies of the
airways, maternal smoking, immunocompromised host.(3) Viruses that cause bronchiolitis include human rhinovirus,
influenza, parainfluenza viruses, adenovirus, human
metapneumovirus, but the most common is respiratory syncytial
virus (RSV).(4) The vast majority of children (about 90%) gets infected with RSV in the first years of life, and amongst them up
to 40% will develop lower respiratory tract infection.(5)
Respiratory syncytial virus is also found to be one of the most
important risk factors for childhood asthma onset. Therefore, one the most intriguing research area nowadays is to find
underlying immunoregulatory and antiviral pathways that may
have a protective role and potentially may decrease the
susceptibility to both RSV-bronchiolitis and asthma.(6,7,8) A new area of interest is the gut–lung axis, in which
the fecal microbiota participates regulatory in the immunologic
responses to environmental challenges in the lungs, including infectious agents, allergens or endogenous antigens. Until
recently, in the absence of an active infectious process such as
pneumonia or bronchiolitis, much of the respiratory tract was
assumed to be sterile. New emerging data from research tend to demonstrate different physiologic and immune cross-linked
mechanisms between different organs and fecal microbiota.(9)
Hasegawa et al. (10) in a recently published study have revealed
specific changes in the nasopharyngeal microbiota in infants
with RSV-bronchiolitis. However, it is not clear yet whether
changes in the composition of the gut and/or lung microbiota
predisposes to RSV-bronchiolitis or is simply a consequence of
disease.
Immediately after birth, the newborn is colonized by a diversity of environmentally associated microbiota such as
microbes derived from the mother’s vagina and feces during
vaginal delivery. In the first hours of life the breast milk further
diversifies the neonatal microbiota by providing milk oligosaccharides and other microbial metabolites such as short-
chain fatty acids (SCFAs).(11,12) Interestingly, in infants born
by Cesarean section, the gut microbiota profile correlates mostly
with bacterial populations of the mother’s skin, this finding seen also in formula-fed infants.(11,12,13,14) Short-chain fatty acids
serve as a significant source of energy in the gastrointestinal
tract for both the local microbiota and intestinal epithelial cells,
and also have a variety of regulatory immune functions.(15) Interestingly, the supplementation of infant formulas with
prebiotics or probiotics does not fully reproduce the effect of
breast milk on the development of the gut microbiota in the
newborn.(16) Nevertheless, there are rapid changes of the gut microbiota in response to environmental factors that may affect
immune homeostasis.(17)
Experimental studies on mice demonstrated the key
role for the host microbiota in influencing the function and development of the immune system.(18,19) Emerging studies
suggest that microbial metabolites such as SCFAs, acetic acid,
butyric acid, and propanoic acid play an important role in regulating host physiology and immunity: by the mechanism of
histone deacetylases inhibition they stimulate the formation of a
tolerogenic, anti-inflammatory cell phenotype; also, peripheral
blood mononuclear cells and/or neutrophils being exposed to acetate, propionate, or butyrate consecutively suppress NF-κB
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AMT, vol. 22, no. 3, 2017, p. 33
and downregulate the production of the pro-inflammatory
cytokine TNF-α.(20,21,22)
Hasegawa et al.(23) studied fecal microbiota profiles in 40 infants with bronchiolitis in a case-control study, who
were compared with 115 healthy children of the same age.
Authors identified four distinct types of bacteria that prevail,
such as Escherichia in 30% of children, Bifidobacterium in 21% of children, Enterobacter associated with Veillonella species
(22%), and in 28% microbiota consisted of Bacteroides species.
Interestingly, Bacteroides species was the type of bacteria
associated with bronchiolitis, as authors concluded based on the results of the multivariate analysis. Moreover, an inverse
correlation was found for Escherichia and Bifidobacterium
species.(23) This is an important insight into the future
therapeutic approaches aimed to modulate gut microbiota in order to decrease the rate of acute respiratory infections in
children.
Conversely, Sjögren et al.(24) reported an association
in early infancy of high quantity of Bacteroides fragilis in the gut with reduced levels of proinflammatory mediators in the
blood.
Another plausible hypothesis is that of the reverse
causation, meaning that viral infection influence the gut microbiota and lead to intensive growth of Bacteroides species
in the intestine.(25) Moreover, other research groups reported an
association of these species of gut bacteria higher morbidity in
early infancy.(26) The underlying mechanism of this correlation remains to be elucidated, but these observations bring more
evidence to support the hypothesis that bronchiolitis in infants is
associated mostly with deficit of gut microbiota rather than
microbial diversity.(27) Consequently, a deeper understanding of the diversity
of factors that determine susceptibility to bronchiolitis at an
early age may lead to new opportunities for targeted
intervention, including primary prevention. Existing up to date evidence highlights the positive influence of the microbiome on
the maturation of the immune system of the child. Accordingly,
clinical and preclinical studies results may indicate alternative
approaches aiming to reduce the risk and severity of viral
bronchiolitis in infants by modifying the infant microbiota.
Nevertheless, it is important to highlight the role of the
breast milk. Besides being a primary source of nutrition for the
child it also contains different immune factors that affect the immune response. Studies showed that in breast-fed infants the
pH of the intestinal contents is acidic (pH=5.0), whereas in
formula-fed infants the pH is neutral (pH=7.1).(28)
Oligosaccharides from the milk represent the major factor that maintains the growth of Bifidobacteria and consequently they
may influence gastrointestinal and circulating SCFAs levels.(29)
This way, milk oligosaccharides presumably have two roles –
one is to act as prebiotics by supporting selectively the growth of commensals that are more competitive comparing with
potentially pathogen bacteria, and secondary milk
oligosaccharides have direct anti-pathogenic and pro-tolerogenic roles in gut mucosa by acting as glycan receptor decoys for
microbial adhesion factors and preventing pathogen
attachment.(29)
Moreover, in several epidemiological studies researchers tried to link the probability of a severe RSV
bronchiolitis in infants who are not breast-fed, although this
finding is not universal.(30,31,32,33) All these studies
demonstrate that breast milk is one of the most important environmental determinants of bacterial colonization and may
significantly influence the immune homeostasis and postnatal
development of gut microbiota and lung health.
In addition to these mechanisms, an important
research area is the composition of the maternal intestinal
microbiota in relationship with the infant intestinal microbiota and lung health.(34) It was studied the association of maternal
transient colonization during gestation and immune responses in
the offspring. For this purpose, pregnant germ-free mice were
inoculated during late gestation with a bioengineered strain of Escherichia coli (HA107) that was cleared from the intestine
within 72 hours.(35) Noticeably, results of the study showed that
colonization with E. coli during last gestational months was
associated with a better intestinal immune system in the child, manifested by increased levels of group 3 innate lymphoid cells
and F4/80+ CD11c+ mononuclear phagocytes, the latter
potentially may inhibit the inflammatory processes in the
intestine, as animal studies showed. Moreover, experimental models showed that maternal gut microbiota during the
pregnancy period influence positively the child’s systemic
immune response. This hypothesis was confirmed by the
improved immune response within the child spleen following intraperitoneal administration of lipopolysaccharide.(36)
However, other studies failed to find an association
between SCFAs and the numbers of mononuclear cells and the
group 3 innate lymphoid cells in the offspring’s intestine.(37) Interestingly, Ferolla et al.(38) found an interesting correlation
between maternal dietary preferences and child lung health in a
prospective birth cohort study that included more the fifty
thousand children. The highest number of children amongst those who had a respiratory infection (1293 patients) were
diagnosed with RSV infection (>60%); human RV was found in
22% of cases and influenza in 4% of children. One intriguing
result of the study was that the a more severe form of bronchiolitis developed children with RSV who were born from
mothers whose diet was rich in carbohydrates and poor in fruits
and vegetables. The causative relation is not known but one
plausible hypothesis is that this diet may alter maternal gut microbiota and consequently influence negatively fetal systemic
immune response.(38)
CONCLUSIONS Various studies aimed to reveal the role of gut
microbiota on lung health and protection against bronchiolitis in
children. However, this pathogenetic mechanism continues to be
a subject of ongoing and future research because molecular pathways and networks between the gut microbiota and lung
mucosal immunity may become a potential therapeutic target in
the complex treatment of bronchiolitis in early life.
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AMT, vol. 22, no. 3, 2017, p. 35
GUT MICROBIOTA AND IRRITABLE BOWEL SYNDROME
CORINA CAZAN
1
1“Lucian Blaga” University of Sibiu, Pediatric Clinic, Research and Telemedicine Center of Neurological Diseases in Children
Keywords: gut
microbiota, dysbiosis,
irritable bowel
syndrome
Abstract: Irritable bowel syndrome is defined as chronic or recurrent abdominal pain in the absence of
a demonstrable pathology. The mechanisms that explain the role of microbiota in the development of IBS
include altered composition of the microbiota, mucosal immune activation, gut inflammation, small
intestinal bacterial overgrowth, dysbiosis, increased intestinal permeability and impaired mucosal barrier function. Modulation of the intestinal microbiota through dietary changes and use of probiotics,
prebiotics and antibiotics has been proposed for IBS treatment strategy.
1Corresponding author: Corina Cazan, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Romania, E-mail: corinacazan2000@yahoo.com, Phone: +40745
998833
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):35-37
Chronic abdominal pain has an increased prevalence affecting up to 25 % of schoolchildren and teenagers. Using
conventional diagnostic methods, the majority of children with
chronic abdominal pain are diagnosed as abdominal pain-related
functional gastrointestinal disorder classified as functional dyspepsia, functional abdominal pain and irritable bowel
syndrome (IBS) and that is the most prevalent, affecting
approximately 60 % of children. IBS is phenotypically
subtyped, using the Rome III criteria, into IBS with constipation
(IBS-C), IBS with diarrhea (IBS-D), IBS mixed (IBS-M) and
IBS un-subtyped (IBS-U). In irritable bowel syndrome are
several factors that play an essential role in the symptom
expression including: visceral hyperalgesia, intestinal hyperpermeability, dysmotility, altered barrier function, gut
microbiome composition, low-grade immune activation, food
intolerance, colonic bacterial fermentation, gut inflammation,
genetics, environmental factors and psychosocial distress.(1,2) In the last decade, advances registered and reported in the
pathophysiology of irritable gut syndrome have revealed that the
alterations in intestinal microbiota are significantly implicated in
pathogenesis.(3) Dysbiosis as an alteration of the gut microbial balance
occurs as a cause in functional disorders and thus in irritable
bowel symptoms. Quantitative imbalance in the composition of
small gut microbiota defines intestinal bacterial overgrowth (SIBO). Quantitative changes cause diarrhea, abdominal pain,
bloating, excessive gas, malabsorption and severe motor
dysfunction.(5) Changes and alteration at the colonic microbiota
cause excessive gas production and excessive short chain fatty acids. Methane gas, carbon dioxide and hydrogen gas have as
clinical expression symptoms like abdominal pain and
abdominal distension. The increase of acetate butyrate and
propionate short chain fatty acids has as a consequence alteration electrolyte and water transport through the process of
acidification and deconjugation of bile acids. The carbohydrate
diet causes excessive hydrogen gas predictive for IBS-D and excess of methane gas production predictive for IBS-C.(4,5) The
gastrointestinal tract is first colonized in the intrauterine period
through the placental barrier transfer. Beneficial factors that
influence gut colonization are maternal microbiota, genetics and environmental factors, geographical origin, diet before and
during pregnancy and breast feeding. At birth, the infant intestinal tract is colonized by aerobic species and gradually
becomes anaerobic over a period of days. Recent data report that
microbiota composition has over 35,000 species and 70%
colonized the colon. The small intestine is colonized mainly by aerobic bacteria, and the large intestine is colonized by Gram-
negative and strictly by anaerobic bacteria.(4)
Dysbiosis as an alteration of the gut microbial balance
occurs as a cause in functional disorders and thus in irritable
bowel symptoms. Quantitative imbalance in the composition of
small gut microbiota defines intestinal bacterial overgrowth
(SIBO). Quantitative changes cause diarrhea, abdominal pain,
bloating, excessive gas, malabsorption and severe motor dysfunction.(5) Changes and alteration at the colonic microbiota
cause excessive gas production and excessive short chain fatty
acids. Methane gas, carbon dioxide and hydrogen gas have as
clinical expression symptoms like abdominal pain and abdominal distension. The increase of acetate butyrate and
propionate short chain fatty acids has as a consequence
alteration electrolyte and water transport through the process of
acidification and deconjugation of bile acids. The carbohydrate diet causes excessive hydrogen gas predictive for IBS-D and
excess of methane gas production predictive for IBS-C.(4,5)
Pathophysiology.
1. Dysbiosis. Current research suggests that gut microbiota ecosystem changes or dysbiosis have potentially
significant effect in the pathogenesis of gastrointestinal tract
disfunction and also in irritable bowel syndrome.(6,7) Alteration
in gut microbiota facilitates the attachment of pathogenic bacteria to the wall of the enteric tract, as a concept supported
by recent studies in IBS. The normal composition of the
microbiota includes Firmicutes, Bacteroidetes and especially
Bifidobacteria. Recent survey reports significant alteration of the normal intestinal microbiota composition in patients
diagnosed with irritable bowel syndrome.(4) Another study
reported significant changes in the ratio between the main species of intestinal microbiota composition in these patients.
The data reported maintain that the ratio of Firmicutes to
Bacteroidetes increases twice while Bifidobacterium decreases
quantitatively.(8) The level of inflammatory cytokines IL6 and IL8 increases significantly in relation to an excess of
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Enterobacteriaceae in irritable syndrome.(9) In several studies
culture, based analysis the composition of microbiota suggests
an important imbalance for Lactobacillus and excess in lumen versus enteral mucosa.(9)
2. Postinfectious IBS (PI-IBS).
Postinfectious IBS occurs following an acute episode
of enteral infection sustained by abdominal pain, abdominal discomfort fever, vomiting and then persistent diarrhea
concerning psychological factors including anxiety and
depression. Recent studies estimate prevalence in PI-IBS at 3-
30% of subjects with persistent diarrhea after an acute gastroenteritic episode. The most common infectious agents
involved in the development of PI-IBS are Salmonella, Shigella,
Campylobacter, Staphylococcus, Clostridium difficile and
perfringens or viruses.(4) Several reports are indicating that patients diagnosed
with traveller's diarrhea develop over time post infectious
irritable bowel syndrome with a prevalence of 7-14%.The
current concept regarding the pathogenic mechanisms for postinfectious irritable gut syndrome suggests that this entity is
correlated with a lot of factors such as: 1.alteration of gut
motility, 2.increased intestinal permeability, 3.dysbiosis after the
use of antibiotics, 4. an increased numbers of enterochromaffin cells, 5.genetic predisposition, 6. determinant psychological
factors, 7. persistent of the inflammatory process , 8. continuous
activation of the immune system.(4,9) Increased gut
permeability and persistent of inflammatory process induce activation of the immune system characterized by an increasing
number of T lymphocytes, macrophages, mast cells and an
increased expression of inflammatory mediators and cytokines
such as IL2, IL6 and IL10. The results suggest an exposure to pathogenic agents that disrupt the barrier function, alter the
neuromuscular integrity and support the inflammatory process
by releasing inflammatory cytokines and mediators such as
IL1α, IL1β, IFNγ which sustains irritable bowel syndrome symptoms. Dysbiosis or alteration of the echogenic microbiota
occurs in post infectious irritable intestinal syndrome after using
antibiotics and resulting in suppression of antimicrobial
peptides.(4,9) Bacterial fermentation of undigested nutrients
induces a bacteriostatic effect by releasing short chain fatty
acids which decrease intraluminal pH.(4,9)
3. Excessive bacterial growth in the small intestine.
The composition of microbiota and quantitative representation differ significantly in the duodenum, jejunum,
proximal or terminal ileum and in the cecum compared to the
colon.(10) Intestinal microbiota colony counts balance is
maintained through mechanisms that include the presence of stomach acid, normal gastrointestinal motility, enzymes,
mucosal immunity and the integrity of the ileocecal valve.
Characteristic for small intestinal bacterial overgrowth (SIBO) is
the presence of more than 105 colony forming units/ml in the jejunum with symptoms and signs included bloating, diarrhea,
flatulence and malabsorption of nutrients. Symptoms and
nutrient deficiencies are induced by excess intraluminal small intestinal bacteria results from the fermentation of nutrients
producing gas, alteration of intestinal motility, alteration of the
immune response, hypochlorhydria, bile salt deconjugation
resulting in the suppression of the bacteriostatic effect of pancreatic enzymes and bile acids.(4,10) Excess intestinal
bacteria determine fat malabsorption causing steatorrhea or
secretory diarrhea. SIBO is associated with malabsorption and
irritable bowel syndrome. Lactulose and glucose breath tests are noninvasive diagnostic tests. Use of lactulose causes excess gas
hydrogen and methane in the proximal intestine which is
eliminated by the respiratory tract and detected by the breath
test. The bacteriological examination, the culture of the jejunal
aspirated sample is accepted and recognized as a standard
diagnosis in dysbiosis.(4,10) 4. Altered Immune Response. The current data support the
hypothesis that irritable bowel syndrome may be a condition of
low-grade inflammation and abnormal immune response.
Microbiota has a crucial role in the modulation of the immune response. Commensal bacteria including Bacteroidetes and
Firmicutes interact with intestinal epithelial cells and modulate
immune responses. Several studies demonstrate that Th1 and
Th2 have a different role in the mediation of immune response and confirm that Th1 and Th2 cells function interact to maintain
a balanced immune response. The available data suggest
increased levels of pro-inflammatory cytokines including IL-1β,
TNF-α, IL-6 and IL-8 in patients with IBS.(4)
Therapeutic strategies in IBS.
Probiotics are living micro bacteria with beneficial
effects on gut microbiota if given in appropriate quantity.
Recent studies reported that probiotics use is associated with better outcomes in irritable bowel syndrome. The benefits and
directions of action, in the context of dysbiosis and
inflammatory changes, include suppression of pathogens and
their adhesion effect, improvement of epithelial barrier function, colonic motility and immune response. Bifidobacterium infantis
an intensively studied strain in IBS, reduces the level of pro-
inflammatory mediators such as TNF-alpha, IL-6 and IL-12.
Lactobacillus has a similar effect on the IL-12 and IL-10 cytokine balance.(4,11) The essential characteristics of
probiotics are: stability in gastrointestinal tract without side
effects and genetic stability.(4,12) Other studies, which use the
probiotics added to milk for eight weeks, report a significant improvement in abdominal pain, discomfort, distension and
bowel movement.(4,12)
Prebiotics are undigested carbohydrates which are
designed to stimulate the growth and activity of beneficial bacteria, mostly Bifidobacterium and Lactobacillus. The
fermentation of prebiotics released short chain fatty acids as a
nutritional support for enterocytes.(13) Prebiotics include in
composition galactooligosaccharides, fructooligosaccharides
and inulin.(4,14)
Antibiotics. Rifaximin, derived from rifamycin, with
minimal systemic absorption and intraluminal high level, is
recommended in dysbiosis and small intestinal bacterial overgrowth.(4,15) The probiotic administered in combination
potentiates the effect of the antibiotic to improve the
symptoms.(4,16,17)
CONCLUSIONS In the last decade, advances in gastrointestinal
pathophysiology indicate the role of gut microbiota and
dysbiosis as relevant factors in IBS symptoms. Improved understanding of the microbiota especially in IBS leads to future
therapeutic strategies targeting the modulation of gut microbiota
composition. Acknowledgement:
Part of this work has been conducted in the Pediatric
Clinical Hospital Sibiu, within the Research and Telemedicine
Center in Neurological Diseases in Children - CEFORATEN project (ID 928 SMIS-CSNR 13605) financed by ANCSI with the
grant number 432 / 21. 12. 2012 thru the Sectorial Operational
Program “Increase of Economic Competitiveness”
REFERENCES 1. Chumpitazi Bruno P, Shulman Robert J., Underlying
molecular and cellular mechanisms in childhood irritable
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bowel syndrome, Molecular and Cellular Pediatrics 2016.
2. Rajilić-Stojanović M, Jonkers DM, Salonen A, Hanevik
K, Intestinal Microbiota And Diet in IBS: Causes, Consequences, or Epiphenomena?, Am J Gastroenterol
2015.
3. Bhattarai Y, Pedrogo DAM, Kashyap PC, Irritable bowel
syndrome: a gut microbiota-related disorder?, American Journal of Physiology - Gastrointestinal and Liver
Physiology, Vol. 312 no. 1, 2017, G52-G62.
4. Ghoshal UC, Shukla R, Ghoshal U,
Gwee KA,
Siew C.
Ng, Quigley EM, The Gut Microbiota and Irritable Bowel Syndrome: Friend or Foe?, International Journal of
Inflammation, Article ID 151085, 2012.
5. Bures J, Cyrany J, Kohoutova D. et al., Small intestinal
bacterial overgrowth syndrome, World Journal of Gastroenterology, vol. 16, no. 24, 2010, pp. 2978–2990.
6. Bennet SMP, Öhman L, Simrén M, Gut Microbiota as
Potential Orchestrators of Irritable Bowel Syndrome, Gut
and Liver, Vol. 9, No. 3, 2015, pp. 318-331. 7. Shankar V, Reo NV, Paliy O, Simultaneous fecal microbial
and metabolite profiling enables accurate classification of
pediatric irritable bowel syndrome, Microbiome, 2015.
8. Ponnusamy K, Choi JN, Kim J, Lee SY, Lee CH, Microbial community and metabolomic comparison of irritable bowel
syndrome faeces, Journal of Medical Microbiology, vol.
60, no. 6, 2011, pp. 817–827.
9. Saulnier DM, Riehle K, Mistretta TA et al., Gastrointestinal microbiome signatures of pediatric patients
with irritable bowel syndrome, Gastroenterology, vol. 141,
no. 5, pp. 2011, 1782–1791.
10. Chandra S, Dutta U, Noor MT et al., Endoscopic jejunal biopsy culture: a simple and effective method to study
jejunal microflora, Indian Journal of Gastroenterology,
2011, pp. 1–5.
11. Lee BJ, Bak YT, Irritable bowel syndrome, gut microbiota and probiotics, Journal of Neurogastroenterology and
Motility, vol. 17, no. 3, 2011, pp. 252–266.
12. O’Mahony L, Mccarthy J, Kelly P et al., Lactobacillus and
Bifidobacterium in irritable bowel syndrome: symptom
responses and relationship to cytokine profiles,
Gastroenterology, vol. 128, no. 3, 2005, pp. 541–551.
13. Preidis GA and Versalovic J, Targeting the human
microbiome with antibiotics, probiotics, and prebiotics: gastroenterology enters the metagenomics era,
Gastroenterology, vol. 136, no. 6, 2009, pp. 2015–2031.
14. Silk DBA, Davis A, Vulevic J, Tzortzis G, Gibson GR, The
effects of a trans-galactooligosaccharide prebiotic on faecal microbiota and symptoms in irritable bowel syndrome,
Alimentary Pharmacology and Therapeutics, vol. 29, no. 5,
2009, pp. 508–518.
15. Pimentel M, Lembo A, Chey WD et al., Rifaximin therapy for patients with irritable bowel syndrome without
constipation, New England Journal of Medicine, vol. 364,
no. 1, 2011, pp. 22–32. 16. Prakash S, Rodes L, Coussa-Charley M et al., Gut
microbiota: next frontier in understanding human health
and development of biotherapeutics, Biologics, vol. 5,
2011, pp. 71–86. 17. Distrutti E, Monaldi L, Ricci P, Fiorucci S, Gut microbiota
role in irritable bowel syndrome, World J Gastroenterol.
Feb 21; 22(7): 2016, 2219–2241.
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THE IMPACT OF ANTIBIOTICOTHERAPY ON GUT
MICROBIOTA IN CHILDREN
OXANA TURCU
1, OLGA CIRSTEA
2, ALA HOLBAN
3, NINEL REVENCO
4
1,2,3,4„Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Republic of Moldova
Keywords: antibioticotherapy,
microbiota, antibiotic
resistance, children
Abstract: Development of the intestinal microbiota in young age children is characterized by important
changes in microbial abundance, composition, and diversity (2). Most drug-based therapies interfere
with infants’ gut microbiota, but the most significant changes result after administration of antimicrobial
agents. The changes induced by antibiotherapy in gut microbiota may persist long periods of time, months and even years after the end of treatment (15, 16). The role of microbiota in host’s metabolism
and disease susceptibility it is well recognized. Repeated courses of antibiotics may have a significant
role in the pathogenesis of allergic, autoimmune and metabolic disorders later in life.
1Corresponding author: Oxana Turcu, Str. Ştefan cel Mare, Nr. 165, Chișinău, Republic of Moldova, E-mail: oxana.turcu@usmf.md, Phone:
+37369358765
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):38-40
INTRODUCTION
The human microbiota is a selection of cells, genes, and
bacteria metabolites, eukaryotes, viruses that can inhabit in
humans, and is defined as a key element of our body function. It has a major role in nutrition, metabolic reactions, the host’s
innate and adaptive immune responses and body
development.(1)
Development of the intestinal microbiota in young age
children is characterized by important changes in microbial
abundance, composition, and diversity. These modifications are
influenced by a multitude of factors, such as mode of delivery,
family diet, diseases, and therapies used. Over the humans grows up, the microbiota is modified in such of structured,
means sequences of foreseeable species, similar across human
populations.(2) The link between microbiome and eukaryotes,
also viruses, is understandable as an ecosystem partnership, although less is known about their function.(3,4)
Although is generally recognized that the first contact of
newborns with microbes occurs after birth delivery, in the
presence of an abnormal amniotic liquid, recently it was found that the placenta and the meconium also contain microbes.(5)
These findings show that the first contact with microbes occurs
during intrauterine life of children, although the effects of this
interaction are still studied. In the light of these findings, it’s increasing the importance of any early external influence on
microbiota development such as antenatal chemoprophylaxis
with penicillin in pregnant women carrying group B
Streptococcus. The mode of delivery is another important determinant
of gut microbiota composition in infants. Lactobacillus,
Prevotella, and Sneathia species from vaginal microflora will
colonize infants’ digestive tract during vaginal delivery, while the intestine of the infants delivered by C-section is generally
colonized by Staphylococcus, Corynebacterium, and
Propionibacterium species from mother’s skin.(6) Pre- and postnatal administration of antibiotics during C-sections
delivery also can irreversibly disrupt the microbiome natural
process of maturation. Infants delivered by C-section present an
instable homeostasis of their gut microbiome resulting in an increased susceptibility to methicillin-resistant Staphylococcus
aureus.(7) Several studies confirmed that C-section delivery can
be associated with long-term health problems in late childhood
or adulthood, especially immunological disorders such as
asthma and type 1 diabetes.(8,9) Important changes of the gut microbiota composition
with increased concentration of Proteobacteria are noted in
premature infants, especially in those treated with broad-
spectrum antibacterial agents form the first days of life.(10)
Latest studies showed that extended courses of antibiotic
therapy in premature newborns increase the risk of late-onset
sepsis and necrotizing enterocolitis with high rate of mortality.
That is why the latest researches are focused on the relationship between modified composition of the intestinal ecosystem and
these illnesses in infants.(11)
Most drug-based therapies interfere with infants’ gut
microbiota, but the most significant changes result after administration of antimicrobial agents. Antibiotic therapy affects
both the target pathogen and commensal inhabitants of the
intestine, resulting in marked reduction of bifidobacteria
populations and multiplication of enterobacteria and enterococci with selection of drug-resistant microbes.(12,13) This is one of
the major causes of the changes in the normal evolution of
intestinal microbiota with reduced microbial fecal diversity and
its composition. The way and degree of severity of microbiota alteration depends on several factors as the spectrum of the
antibacterial agent, the route of administration, the dosage and
the length of treatment, number of the courses, and the
pharmacokinetic and pharmacodynamic properties of the drug. Broad-spectrum antibiotics are active against anaerobic
bacteria that dominate intestinal microbiota and can have
substantial negative consequences on the functional stability of
the microbiota.(14) Microbiota may return to a similar composition of the
original one after the end of treatment, but initial condition is
often not fully recovered and the changes induced by antibiotherapy may persist long periods of time, months and
even years. Extended terms of intestine ecosystem recovery can
be explained by important shift of bacterial population and by
short intervals between repeated courses of antibacterial drugs.(15,16)
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Previous assumptions that fever previous to antibiotic
treatment may alter the composition of gut microbiota in
children, have not been confirmed. Both fever and infections cannot explain all those changes in the intestinal flora which
persist long after treatment with antibiotics, although previously
it was thought that antibiotics have a short term impact on the
human microbiome.(17) Low gut bacterial diversity with important low
concentration of Bifidobacterium has been identified previously
to necrotizing enterocolitis onset. Preterm newborns exposed to
broad-spectrum antibiotics and infants whose mothers received antibiotic treatment before delivery presented high risk for
necrotizing enterocolitis development due to C. difficile
overgrowth.(18)
Chron’s disease was one of the first autoimmune disease for which was established a strong correlation between
repeated antibiotic courses in children younger than 5 and an
increase of Gram-negative bacteria like Porfiromonadaceae in
gut microbiota.(19,20) There are evidences to support that antibiotics may play a significant role in the pathogenesis of
irritable bowel syndrome, especially by reduction in gut
microbiota diversity.(21)
Numerous researchers have found a correlation between allergic disorders and Bifidobacteria
deficiency with Escherichia coli abundance in gut microbiota
after antibiotic intake during early childhood.(22,23,24) The
most recent studies confirmed the link of autoimmune and atopic diseases to gut microbiota dysbiosis, caused by the intake
of antibiotics during early life, which is a critical period for
development of the immune system and immunological
tolerance. Is sustained that intestinal microbiota contain activation factors for innate immunity, similar to
inflammation.(24)
Increased frequency of atopic diseases by maternal
intake of antibiotics during pregnancy was a topic of several discussions being linked to the broad-spectrum and the dosage
but this connection couldn’t be sustained in other two large
prospective case-control studies.(23,24)
Gut microbiota is an important factor in the control of
human body metabolism, particularly of energy homeostasis and
adiposity. Several metabolic disorders have been linked with gut
microbiota dysbiosis.(25,26) Antibiotic use it was recognized as
an aggravating factor in obese child and associated metabolic syndrome.(26) Latest studies confirmed a strong association
between macrolide antibiotics use in early life and increased
BMI, obesity or metabolic diseases in children or adults due to
abundance of Bifidobacterium and Bacteroides in the intestine, which normalized within 24 months.
The response of gut microbiota to amoxicillin use is
mild to moderate being characterized by short-term decrease in
aerobic Gram-positive cocci but the main disadvantage is the enrichment of gut microbiota with resistant enterobacteria.
Recently, human gut microbiota has been established as a
significant reservoir of antibiotic resistances not only in adults, but infants and children too.(27,28,29,30)
Antibiotic resistance lately it became a major public
health threats, mostly because of unnecessary overuse of
antibiotics. The development of resistance to harmful environment factors is a normal evolutionary process for
bacteria, but this process can go faster due to incorrect use of
antibacterial drugs. New researches found resistant strains of
bacteria not only in adults and children who received several courses of antibiotics, but in isolated human populations who
have never used antibiotics.(31,32)
Children with nutritional disorders present different
way of gut microbiota maturation and in result the response to
the influence of environmental factors is altered.
Undernutrition is characterized by a delay in the evolution of the microbiome. This immature microbiome is
associated with susceptibility to digestive infections, has
negative impact on nutritional correction measures and can
prolong the malnourished state. Curiously, Trehan I. et al. in their study showed that a short course of broad-spectrum
antibiotic (amoxicillin or cefdinir) can improve nutritional
treatment results and can reduce mortality rate between children
with acute malnutrition. These results are sustained by an important meta-analysis focused on the antibiotics impact on
children’s growth in low and middle income countries that
increased their weight after antibiotic therapy. On the other
hand, in developed countries obesity has become an important public health problem. A high-calorie diet and early antibiotic
exposure change gut ecosystem to abundance of Bacteroidetes
that have a higher capacity of energy harvesting and increase the
risk of obesity in older children.(32) Intestinal microbiota develops and evolves quickly
during infancy, on a predictable way, until it achieves a
physiological homeostasis and bacteria should remain stable for
life. The role of microbiota in host’s metabolism and disease susceptibility it is well recognized. Latest studies are focused on
the link between intestinal microbiota changes in early infancy
and metabolic or other diseases later in life.
Lately are discussed several opportunities of restoring gut microbiota, like toxin inhibitors for C.difficile and E.coli,
use of probiotics, phage therapy or transplant of fecal
microbiota. Probiotics are the most used strategy to maintain
and improve the microbiota components after antibiotic treatment. Probiotics are living microorganisms with health
consequences in humans, only if are properly used. (33) Some
opinions suggest that probiotics could have the capability of
antibiotic resistances transfer to intestine bacteria. Bacteria that normally inhabit human intestine can share resistance genes
among themselves. This type of transfer turns out to be a vast
problem when these safe commensal bacteria are converted to
pathogen pattern. In result intestine is reside with antibiotic
resistance genes, among both pathogen and commensal bacteria.
Once acquired, resistance genes become a relatively stable part
of gut intestine genome (34).
The beneficial impact of antibiotic drugs is delicate to enhance. Nevertheless, excessively widespread use of antibiotics
has created many threats for the present and future of human
population. The most important challenge is constant increasing
resistance of bacterial pathogens to antibiotics. In light of this facts, and given that bacterial infections
remain an important major public health problem, new studies
are required to develop strategies to abrupt or reduce negative
impact of antibiotics when their administration is needed.
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LEFT INGUINAL HERNIA AND CRYPTORCHIDISM.
PARTICULARITIES OF TREATMENT AND EVOLUTION.
CASE REPORT
CRISTIAN-ŞTEFAN BERGHEA-NEAMŢU1
1“Lucian Blaga” University of Sibiu, Surgical Clinic-Pediatric Clinic Hospital, Sibiu
Keywords: inguinal
hernia in infants,
recurrent dehiscence,
severe anemia and hypoproteinemia
Abstract: Inguinal hernia in children can be associated with anemia and/or hypoproteinemia. These
kind of conditions can cause a bad evolution, with multiple surgical interventions (recurrent dehiscence,
infected surgical wound, dehydration). It is possible to be present a vicious circle: recurrent dehiscence
is explained by hypoproteinemia, but multiple surgical interventions can lead to hypoproteinemia, together with severe anemia.
1Corresponding author: Cristian-Ştefan Berghea-Neamţu, Str. Gh. Baritiu, Nr. 1-3, Sibiu, Romania, E-mail: cristineamtu@hotmail.com Phone:
+40722641331
ACTA MEDICA TRANSILVANICA- SUPPLEMENT September 2017;22(3):41-42
INTRODUCTION
Inguinal hernia in children can be associated with anemia and/or hypoproteinemia, with its complications and
evolution particularities. There are some appropriate therapeutic
solutions, successfully applied in surgical practice.
PURPOSE
The purpose is to highlight the whole mechanisms
implied in evolution particularities of an inguinal hernia in
neonates.
MATERIALS AND METHODS
We present an infant, male, 21 days old, admitted in
Pediatric Surgical Clinic Sibiu at the end of December 2016 for specialty diagnostic and therapeutic advice in the context of the
present of a pseudotumor formation, with an elastic consistence,
and subjacent placed of the left inguinal arcade, which seems to
be contiguous, with the left scrotum swelling. The infants comes from two members family, the
mother, 17 years old, schoolgirl, and the father, 21 years old,
healthy, without family medical history, except paternal
grandmother, with type 1 Diabetes Mellitus. Is the first born in this family, from a physiological pregnancy, 2910 g the weight
at birth, 10 Apgar score, good postnatal evolution and almost
good weight gain, breastfeeding, exclusively; poor educational
and lifestyle conditions, means 6 persons are living in only 2 rooms; mother smoking during the pregnancy. The admittance is
required via Emergency room for a condition with acute onset,
in the same day, by the presence of the pseudotumor formation
in the left inguinal area, and ipsilateral scrotum.
RESULTS
The clinical exam in the first moment of admission
emphasize good general condition, no fever, 3500 g actual weight, subcutaneous cells tissue reduced at the level of thorax
and abdomen, the same left inguinal and ipsilateral scrotum
pseudotumor formation, the left scrotum difficult to examine; no other organs or system pathology. Clinical and anamnestic data
allowed the exclusion of the other conditions of the left inguinal
site, such as hydrocele, spermatocele, femoral hernia, spermatic
cord hernia, with the step diagnostic of Left inguinal and scrotal hernia, and suspicion of cryptorchidism.
The laboratory data were normal, and ultrasound ones
confirm the step diagnostic.
Given the possibility of an evolution towards strangulation, with alteration of intestinal viability, the surgical
treatment was considered to be immediate done, the surgical
intervention was a large one, with a medium anesthetic risk.
Under general anesthesia the surgical hernia cure was decided; also, the mesentery and left orchidopexy.
Was performed a limited transverse incision in the site
of left inguinal fold; was permeate at the left inguinal canal, and
with its wall opens was highlighted an edematous hernia sac, also endured, friable, the scrotum with intestinal content no taxis
reducible. With the sac open, the intestinal content appears
cyanotic and edematous along a 15 cm, with a proximal area of
stenosis, 0.5 cm length and permeable. Was also cured the mesentery, with local warm serum
application; good intestinal evolution after 10 minutes, and than
its content was reapplied in the peritoneal cavity. Was dissected
the edges of the spermatic cord sac; the sac close down and the Barker procedure too. Was performed a transversal incision on
the left scrotum, with the left orchidopexy. After surgery
procedures, the digital rectal examination had revealed a normal
feces. The patient was monitored in intensive care unit about 6 days, with pain management indication; no peritoneal abnormal
signs. Was discharged in good condition, but after a month the
patient had presented fever, bilious vomits, secondary acute
dehydration. The patient laboratory data showed leukocytosis, positive inflammatory markers, anemia, high blood urea, high
blood amylase.
Figure no. 1. The patient abdominal radiography (see,
multiple gases in the superior part of abdomen), with the
permission
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Based on laboratory and radiology data, the final
diagnostic was: Intestinal Occlusion; Secondary Acute
Dehydration; Anemia. After nasogastric aspiration and intravenous
hydration, the patient was operated by exploratory laparotomy
on the upper site of umbilical region, with the median incision;
were highlighted a marked intestinal distension and a complete stenosis, 30 cm from ileocecal valve. Was practicing the stenosis
region resection, with T-T, double layer, anastomosis.
Figure no. 2. The patient at the first surgical reintervention
(with the permission)
After the first surgical intervention, a secretion and
repeated dehiscence of surgical wound are observed. It was
necessary a second surgical reintervention with blood
replacement in the same time (because of severe anemia). The bacteriologic exam of the wound secretion had revealed the
presence of Enterobacter cloacae; the labs exam revealed severe
anemia, severe hypoproteinemia.
Figure no. 3. The patient before the second surgical
reintervention (with the permission)
The second surgical reintervention consists in
resection of the affected area (near anastomosis).
Figure no. 4. The patient after the second surgical
reintervention (with the permission)
The post surgical monitoring has focus to the
treatment of anemia and hypoproteinemia, antibiotics for
infected surgical wound. The evolution was favorable, and the outcome was made in good condition.
Figure no. 5. The patient at the discharged moment (with
permission)
CONCLUSIONS The recurrence of dehiscence surgical wounds was
explained by hypoproteinemia, mainly, also by the surgical reintervention, but it did not associated with the dehiscence of T-T, double layer, anastomosis.