Synbiotic modulation of gut flora improves minimal hepatic encephalopathy in cirrhotic patients
Signs of liver disease also improve in conjunction with alterations to gut flora.
Some cirrhotic patients develop brain dysfunction, called hepatic encephalopathy, which causes deficits in behavior, intelligence, consciousness and neuromuscular function. When the dysfunction is minor, it is called minimal hepatic encephalopathy (MHE). Since ammonia has been shown to play a key role in overt hepatic encephalopathy, treatment options for MHE have also focused on reducing ammonia levels in the body.
A new study published in the May 2004 issue of Hepatology has shown that treating cirrhotic patients with synbiotics or fermentable fiber can alter the flora in the gut, lowering its pH levels as well as the ammonia levels in the blood. Both treatments improved clinical signs of brain and liver dysfunction. They may be useful alternatives to lactulose for the management of MHE.
Hepatology, the official journal of the American Association for the Study of Liver Diseases (AASLD), published by John Wiley & Sons, Inc., is available online via Wiley InterScience at http://www.interscience.wiley.com/journal/hepatology.
To consider the effect of synbiotics and fermentable fiber on gut flora and MHE, a collaborative research team from Beijing Youan Hospital and Capital University of Medical Sciences, China, University College London, England and the Prince of Wales Hospital, Sydney, Australia conducted a pilot, placebo-controlled study of 55 individuals with MHE. Twenty of the patients were treated for 30 days with a daily symbiotic preparation. Twenty took fermentable fibers for 30 days, and fifteen received a placebo treatment for 30 days. At 30 days, all patients were re-screened for MHE. The researchers also assessed gut flora in fecal samples at day 1, day 30, and day 44. They compared their findings with the gut flora of 20 normal healthy volunteers.
After 30 days of treatment, 50 percent of patients treated with either the synbiotic preparation or fermentable fiber showed a reversal of MHE, compared to a 13 percent reversal rate in the placebo group. Furthermore, patients in both treatment groups had a lower fecal pH at day 30, along with significantly reduced levels of ammonia in their veins, and significantly reduced serum endotoxin levels.
Both treatments appeared to have significantly altered the cirrhotic patients' gut flora. At the outset of the study, the cirrhotic patients with MHE were found to have significant fecal overgrowths of E. Coli and Staphylococcus. Treatment with the synbiotic preparation reduced these levels to those of the healthy controls, while counts of non-urease producing Lactobacillus were significantly increased. Treatment with fermentable fiber alone increased non-urease producing Bifidobacterium spp and significantly reduced overgrowths of E. Coli and Fusobacterium spp. Treatment with the placebo did not alter the counts of any of the gut flora assessed.
"Our study is the first to examine the impact of synbiotics and fermentable fiber alone on MHE and other aspects of hepatic function in patients with cirrhosis," the authors report. "We conclude that treatment with synbiotics or fermentable fiber alone is an alternative to use of non-absorbable disaccharides, such as lactulose, for the management of MHE in patients with cirrhosis. Significant reductions in viable counts of potentially pathogenic gut flora occur with both treatments."
In an accompanying editorial in the same issue of Hepatology, Drs. Steven F. Solga and Anna Mae Diehl of Johns Hopkins University discuss the "impressive and exciting improvements in HE with both synbiotic therapy and fiber alone." They note that it is even more exciting that altering the gut flora may improve not only HE but also liver disease.
The researchers "have made a major contribution to the application to gut flora therapy to humans with liver disease," they write. "We expect this research to stimulate further interest in the study of gut flora therapy and the 'gut-liver' axis, because the liver does, indeed, care about the gut."
Article: "Synbiotic Modulation of Gut Flora: Effect on Minimal Hepatic Encephalopathy in Patients With Cirrhosis." Qing Liu, Zhong Ping Duan, Da Kang Ha, Stig Bengmark, Jelica Kurtovic, and Stephen M. Riordan, Hepatology; May 2004; 39:5.
Editorial: "Gut Flora-Based Therapy in Liver Disease? The Liver Cares About the Gut." Steven F. Solga, M.D., and Anna Mae Diehl, M.D., Hepatology; May 2004; 39:5.
Contact: David Greenberg
dgreenbe@wiley.com
201-748-6484
John Wiley & Sons, Inc.
Medical Condition Causes Boys, Men To Grow Breasts
Who would think an invitation to a beach, lake, or pool party could strike terror in a boy's -- or man's -- heart? Yet these summer pastimes can seem a fate worse than death for a boy or man with gynecomastia, the development of breast tissue that leads many males to hide in shame and humiliation.
In his new book, Demystifying Gynecomastia: Men With Breasts, psychotherapist Merle Yost reports that up to one-third of males may have to deal with problem gynecomastia at some time. Although adolescent onset is most common, adult-onset gynecomastia is on the rise with men's increased use of prescription drugs -- including anti-depressants -- and this country's obesity epidemic.
Yost himself has been affected since age 11. "I was a skinny little boy who grew noticeable A-cup breasts," says Yost. "They called me 'tits' in junior high. Girls offered bras; boys twisted and taunted." He suffered through school, hiding his body as best he could.
After breast reduction surgery at age 34, Yost posted a gynecomastia page on his therapy practice website. It got so much traffic that he launched a dedicated site, http://www.gynecomastia.org/, a free information and discussion service that now gets 1.2 million hits per year.
Gynecomastia can be a normal part of adolescence, with a mild form affecting up to 70 percent of boys. Their livers can't keep up with the testosterone raging through their bodies, Yost explains, and what the liver can't process converts to estrogen, causing painful nipples, puffy breasts or both. This usually disappears once the liver adjusts. But for some, breast growth is obvious and permanent, causing emotional harm and life-long body self-consciousness.
Yost says many doctors know little about gynecomastia and assure boys they'll grow out of it. Millions don't, however, instead growing up humiliated and ashamed.
Yost's book is sprinkled with heart-wrenching quotes:
-- "I haven't taken my shirt off in public since I was 8."
-- "I have back pain because I slump over to try to reduce the effect."
-- "I pretend to be a strong, carefree individual, when in fact I hate myself sometimes."
"Gynecomastia itself is benign -- it's simply development of a secondary female characteristic," says Yost. "It signals underlying issues that may need treatment, from a pituitary gland tumor or liver dysfunction to weight gain."
Recent increases in the use of steroids, certain anti-depressants, acid reflux, blood pressure and prostate drugs are causing a wave of adult-onset gynecomastia.
Demystifying Gynecomastia explains the condition, causes and potential solutions. The book is available online at http://www.gynecomastia.org/.
Merle Yost, Licensed Marriage & Family Therapist
http://www.gynecomastia.org/
Hepatitis C and health-related quality of life
Patients with Hepatitis C virus (HCV) have a significant decrease in their health-related quality-of-life (HRQOL), although treatment success can mitigate this negative effect. These are among the findings of a systematic review of relevant literature published in the April 2005 issue of Hepatology, the official journal of the American Association for the Study of Liver Diseases (AASLD). Published by John Wiley & Sons, Inc., the journal is available online via Wiley InterScience at interscience.wiley.com/journal/hepatology.
The authors also found that traditional outcomes measured in patients, including liver histology and ALT levels, do not necessarily correspond with HRQOL differences. A panel of experts convened to consider all the data focused on patient-reported vitality as most relevant to HCV-related quality-of-life effects. They established a minimally clinically important HRQOL difference (also called the "MCID") of 4.2 points on the vitality scale.
About 4 million Americans are infected with HCV. While approximately 20 percent of these people eventually develop cirrhosis, the vast majority of people never exhibit clinically significant liver disease. Still evolving data suggests that HCV can diminish quality-of-life even without causing liver disease, perhaps due to HCV symptoms that do not involve the liver, HCV-related cognitive dysfunction, or an association between HCV and comorbid psychosocial disorders.
To better understand how HCV influences health-related quality-of-life, researchers led by Brennan M.R. Spiegel, M.D., M.S.H.S. and Fasiha Kanwal, M.D., M.S.H.S. of the VA Greater Los Angeles Healthcare System and UCLA, performed the first-ever systematic review of relevant literature. They hoped to establish the minimally clinically important health-related quality-of-life difference in HCV patients so researchers and physicians can better monitor patient outcomes, and better inform patients choosing a management strategy.
The authors examined 32 studies published between January 1990 and June 2004. Fifteen compared HRQOL in HCV patients with that of healthy patients. They showed that HCV patients had a diminished HRQOL, most dramatically in social and physical function, general health, and vitality. Nine studies stratified HRQOL by response to treatment measures. They indicated that HRQOL is consistently worse in patients who fail to achieve sustained viral response. Six studies examined HRQOL by neuropsychosocial effects, such as cognitive dysfunction, depression, emotional distress and stigmatization. These studies revealed large HCV-related HRQOL differences. Finally, five studies stratified HRQOL by traditional markers of liver disease. These showed that subtle histological or biochemical changes were not perceived as clinically important by patients, though large differences in HRQOL were found in patients with cirrhosis.
The expert panel concluded that the vitality scale best captured the HRQOL effects relevant to HCV patients. They generated a mean MCID of 4.2 points on the vitality scale. "This value can be used in everyday clinical practice and in clinical trials," the authors suggest. "For example, physicians can measure patient outcomes by administering the 6-item SF vitality scale during office visits. If a patient fails to achieve an increase of 4.2 points over time, then it implies that the ongoing care has failed to perceptively improve the patient's HRQOL. In clinical trials, the MCID can be used as a yardstick to determine whether patients have benefited from the study intervention."
Since the analysis was limited by estimations of MCID based on existing data, the authors suggest that future research directly measure the MCID. Further, they caution, the vitality scale alone may not capture all the key aspects of HRQOL in HCV.
Still, their findings offer a number of important revelations about health-related quality of life in patients with HCV. "In conclusion," the authors report, "chronic HCV diminishes HRQOL across a wide range of clinical anchors. The impact on HRQOL is highly clinically significant and affects physical, social and mental health domains."
Article: "Impact of Hepatitis C on Health Related Quality of Life: A Systematic Review and Quantitative Assessment," Brennan M.R. Spiegel, Zobair M. Younossi, Ron D. Hays, Dennis Revicki, Sean Robbins, and Fasiha Kanwal, Hepatology; April 2005; Volume 41, Issue 4 (Published Online: March 24, 2005).
John Wiley & Sons, Inc.
http://www.interscience.wiley.com
|
|
