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Thursday, September 27, 2018

A Promising Start to A New Crohn's Treatment?

Bacteroides thetaiotaomicron Ameliorates Colon Inflammation in Preclinical Models of
Crohn’s Disease.
Recent discoveries in Crohn’s Disease research may give insight into developing future treatments
for people that are affected by the disease.1 Crohn’s disease is an autoimmune disease which is
characterized by inflammation along any part of the gastrointestinal (GI) tract which can lead to
fistulas, or abnormal passages that connect different hollow parts of organs to each other.
Although the exact causes of Crohn’s are not known, it is classified as an autoimmune disease because of
the overactivation and infiltration of immune cells to various areas of the GI tract
causing inflammation along the entire thickness.2 It is also known that there are genetic risk
factors, immunological risk factors, and microbiotic risk factors associated with the development
of the disease. Crohn’s disease affects approximately 700,000 people in the United States and can
range in severity from mild flare-ups causing discomfort to severe inflammation and fistulas in the
GI tract that can require surgical procedures.3
It is “widely” believed that Crohn’s is likely triggered by an improperly mounted response to a
shift in the microbiome of the intestinal mucosa.2 The microbiome consists of the various
microscopic organisms, both good and bad, that reside in the mucosa, the protective lining, of the
intestines. In this new preclinical model, Bacteroides thetaiotaomicron (BT) is shown to be a
helpful microorganism in reducing the inflammatory response of the immune system to flare-ups
of Crohn’s. Two different models of Crohn’s diseases were created in germ-free, or isolated, mice in order
to test the effectiveness of BT on alleviating symptoms of Crohn’s flare-ups. Mice were first dosed for 8
days with BT or culture medium (for DSS mice) and then both groups were exposed for 6 days to 3% concentration of dextran sodium sulphate (DSS), which has been established to mimic Crohn’s disease in mice.3 (One group of mice were pure controls and were not exposed to anything.) The researchers then evaluated the weight change, physical changes, and regulation of genes associated with inflammation. They found that mice dosed with BT had less weight loss and less enlargement of GI tissue,4 suggesting less disruption to their diet and lower levels of inflammation. Lower levels of inflammation were also confirmed by observing the decreased activation of pro-inflammatory genes.


Figure 1: Graphical representation of weight loss in DSS Crohn’s model of mice.  In DSS exposed
mice, BT significantly decreased weight loss as compared with mice that were not administered any form
of treatment. Control = mice not exposed to DSS or BT. DSS = mice that were exposed to dextran sodiu
sulphate to induce Crohn's like symptoms. DSS/BT = mice exposed to DSS and treated with BT as a
treatment of the gastrointestinal inflammation.

The researchers went on to recreate this experiment in an additional mouse model of Crohn’s
disease. The researchers knocked out an anti-inflammatory molecule interleukin-10 (IL-10) in mice before
birth which causes them to spontaneously develop inflammation in their intestines around 2-4 months of
age.5,6 These mice were also treated with BT 3 times a week for 13-14 weeks. Although this is a slightly
different treatment plan, there were still significant results in the same categories as described above.
Additionally, freeze-dried BT was used in a different cohort of DSS mice to assess the effectiveness of the
organism in its less active form. The freeze-dried version gave nearly identical amelioratory effects as the
regular BT. These variations of administering BT demonstrate multiple prospective treatment options that
would be equally effective in ameliorating Crohn’s symptoms.
Figure 2: Colons of IL10KO mice. The mice treated with BT have similar colon structure to the
wild-type mice which represent people without Crohn’s. The IL10KO mouse has significant levels of
inflammation and enlargement which are relieved with the BT treatment. WT=wildtype/control, IL10KO= IL-10 knockout, untreated, IL10KO/BT= IL-10 knockout treated with BT.

Finally, the researchers synthesized a protein called pirin-like protein BT_0187, which is one of 43
proteins highly expressed by BT in epithelial cell cultures. Although this protein was able to alleviate
some inflammation in rat models of Crohn’s, it was nowhere near as effective as the BT or freeze-dried
BT. It is important to note that they performed this last part of the experiment in rats rather than mice.
Perhaps there would have been a greater effectiveness of the treatment in mice. Or perhaps both mice and
rats are too different than humans for any of these results to be clinically relevant, although hopefully not.
Although the pirin-like protein was ineffective in ameliorating the DSS induced pathology in rats,
it is still important to recognize the accomplishments made in the rest of the article. Bacteroides
thetaiotaomicron would be an easy supplement to treat patients with Crohn’s disease as bacteria
proliferate at exponentially fast levels. Further studies must be conducted in animal models using BT
before starting experimental treatment or supplements in human patients with Crohn’s. The next step
would be to increase the levels of BT in mice that are not “germ-free” in order to evaluate the effects of
the bacteria in conjunction with other microorganisms. Additionally, it would be interesting if research is
done with the other 42 upregulated genes produced by BT that the researchers mentioned but did not name
or evaluate specifically. Perhaps a different protein would have greater effectiveness in humans than it
does in rodent models and be used as an additional treatment. All-in-all, if future trials with BT provide
good results, it could potentially be used as to replace or reduce doses of immunosuppressive drugs which
many Crohn’s patients currently use to treat their disease.3 Immunosuppressants are drugs that cause an
overall decrease in activation of immune cells; this global decrease can leave Crohn’s patients more
susceptible to getting other illnesses. It is important to continue research of BT and other microorganisms
that may ameliorate Crohn’s inflammation because they would be inexpensive, mass producible, and
natural alternatives to medicating patients for any type of relief and comfort. BT could also be used in
addition to common treatments in order to hasten relief or shorten hospital time. This paper effectively
convinces the reader that Bacteroides thetaiotaomicron just may become a treatment of Crohn's disease in the future, so keep your eye out for more!
If you, or someone you know, is struggling with Crohn’s disease, try visiting these websites to get
more information.


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1Delday, Margaret, Imke Mulder, Elizabeth T. Logan, and George Grant. "Bacteroides Thetaiotaomicron
Ameliorates Colon Inflammation in Preclinical Models of Crohn’s Disease." Inflammatory Bowel
Diseases 24, no. 9 (September 12, 2018). doi:10.1093/ibd/izy281.


2Boyapati, R., Satsangi, J., & Ho, G.-T. (2015). Pathogenesis of Crohn’s disease. F1000Prime Reports, 7,
44. http://doi.org/10.12703/P7-44


3"Understanding Crohn's Disease." Crohn's and Colitis. Accessed September 27, 2018.
https://www.crohnsandcolitis.com/crohns/disease-treatment.


4Kiesler, P., Fuss, I. J., & Strober, W. (2015). Experimental Models of Inflammatory Bowel Diseases.
Cellular and Molecular Gastroenterology and Hepatology, 1(2), 154–170.


5Berg, D. J., Davidson, N., Kühn, R., Müller, W., Menon, S., Holland, G., … Rennick, D. (1996).
Enterocolitis and colon cancer in interleukin-10-deficient mice are associated with aberrant cytokine
production and CD4(+) TH1-like responses. Journal of Clinical Investigation, 98(4), 1010–1020.

6Wang, Honggang, Peiliang Shi, Lugen Zuo, Jianning Dong, Jie Zhao, Qinghong Liu, and Weiming Zhu.
"Dietary Non-digestible Polysaccharides Ameliorate Intestinal Epithelial Barrier Dysfunction in IL-10
Knockout Mice." Journal of Crohns and Colitis 10, no. 9 (2016): 1076-086. doi:10.1093/ecco-jcc/jjw065.

Tuesday, September 25, 2018

Vascular Repair after mTBI: Regulated by the Immune System

A recent global study has highlighted the growing impact of Traumatic Brain Injury (TBI) on the population. This so called “silent epidemic” has grown substantially in recent years, and approximately 70 million people suffer TBI each year.1 While TBI can be catastrophic and receives more attention, mild Traumatic Brain Injury (mTBI), commonly referred to as “concussion”, may be far more prevalent and insidious than TBI. While research is still ongoing, mTBI has already clearly been shown to cause physical, mental and emotional changes. mTBI is also suspected as a cause of several neurodegenerative and deadly diseases including Chronic Traumatic Encephalopathy (CTE), Alzheimer's, Dementia and Parkinson's.  These diseases cost the United States billions of dollars every year in treatment and health care spending, in addition to other immeasurable monetary, health and lifestyle costs for patients and their families.2



Because not all people react to and heal from mTBIs the same way, numerous studies have explored the mechanisms through which the brain repairs itself after concussion and mTBI.3 4 5 In April, 2018, a group of scientists working at the National Institutes of Health published a paper in Nature Immunology examining how immune cells promote meningeal vascular repair and remove dead cells after mTBI. Russo et al. (2018) used a mouse model of mTBI and a variety of imaging techniques to view how immune cells interact with the lesions made by mTBI. They found that these immune cells have two major functions: promoting angiogenesis, or the formation of new blood vessels, around the periphery of the lesion, and clearing dead cells from the center of the lesion. Experiment after experiment showed that the combination of these two complementary actions shrunk the size of the lesion to where it almost disappeared in about a week, and replaced the lesion with healthy, functional vasculature. Specifically, within 24 hours of the injury there was a great increase in pro-inflammatory genes in and around the lesion, recruiting peripheral immune cells called neutrophils and monocytes to the area; these inflammatory signals usually faded within a week, when the lesion was normally repaired, suggesting that the immune response is temporally regulated to coincide with the healing process.


At 4 days after mTBI, Russo et al. (2018)6 found large numbers of a certain type of macrophages, Lyve-1+CD206+, that are derived from the non-classical monocytes that migrated to the lesion after the
release of the pro-inflammatory molecules. These Lyve-1+CD206+ macrophages traveled to the edge
of the lesion, where they released an enzyme called Matrix Metalloproteinase MMP-2, which signaled
to nearby endothelial cells to make blood vessels and upregulated Vascular Endothelial Growth Factor,
VEGF, which further promoted angiogenesis.

Around the same time, angiogenesis occurred in the periphery of the lesion, and neutrophils and classical monocytes traveled to the center of the lesion, where they released further pro-inflammatory signals to recruit other immune cells, and participated in the so called “wound-healing” response (removal of dead cells from the core of the lesion and angiogenesis in the periphery). Before new cells and vasculature could replace those killed by the mTBI, the dead cells had to first be removed. The neutrophils and classical monocytes broke down and removed these dead cells, clearing the path for recovery and new growth.


The most interesting finding of the researchers was the effect of a secondary mTBI before complete recovery had occurred. They found that the week of healing could be divided in two stages: a period of rapid influx of immune cells that occurred  24-48 hours after injury, followed by a time of differentiation and proliferation of these cells, along with “wound-healing”. Interestingly, when another mTBI occurred in the first 24-48 hours post-injury (during the recruitment of immune cells phase), the lesion size was increased and peripheral angiogenesis was severely hindered. However, when the second mTBI occurred 4 or more days after the initial trauma, there was no noticeable effect on lesion repair or vascular remodeling. As well, when the second mTBI occurred during the initial inflammatory state, there was an influx of neutrophils in the lesion within 30 minutes, instead of the usual 2-3 hours for neutrophils to invade the the primary mTBI lesion or the lesion if it was re-injured at 4 days. mTBI lesions therefore are clearly temporally sensitive to secondary injuries, and respond with great diversity in terms of how they heal in part based on further injury, and the timing of those injuries.

This research is important public health information, and highlights the dangers of  experiencing a secondary head injury
soon after the first, with likely complications and prolonged recoveries. As there are an estimated 1.6-3.8
million sports-related concussions in America alone7, the data Russo and colleagues discovered can
be very influential in creating changes to policy and the so called “return to play” protocols that
either allow or prohibit an athlete from re-entering a match in which they sustained a possible
head injury or concussion. As well, by understanding the molecular mechanisms that occur when
mTBI lesions heal, doctors can better treat concussions and hope to prevent Post-Concussion
Syndrome8, where symptoms linger for months to years after the initial mTBI. Because an
estimated 13% of Americans who sustain an mTBI develop Post-Concussion Syndrome, and a
recent study found that in some cases this syndrome can result in permanent symptoms9, there
is a pressing need for the medical community to further research these mTBIs and what can
be done to promote and accelerate healing.


Although this article was extremely informative and shows how lesions repair after mTBI in mice,
there are still important questions to be answered. One of the most important questions is if
environmental factors affect recovery. Until very recently, “return to play” guidelines included rest,
avoiding sensory-stimulating environments (bright lights and loud noises) and not exercising until
symptoms subside. However, some doctors have recently started advising brief specific types of aerobic
exercise (like indoor stationary biking) while still symptomatic, which new research shows may in fact
be more beneficial and promote repair. Researchers could perform a similar experiment, after the
primary mTBI, by dividing the mice and placing them in different environments, some of which involved
controlled aerobic exercise, some of which contained bright lights and loud noises, and some of which
would have a combination of both. They could again examine the lesions and see if environmental
factors can play a role in recovery, and if so, which are most beneficial. This would be extremely
informative, and could change mTBI recovery protocol drastically.






________________________________________

1. Dewan, M., Rattani, A., Gupta, S., Baticulon, R., Hung, Y., Punchak, M., Agrawal, A., Adeleye, A.,
Shrime, M., Rubiano, A., Rosenfeld, J., Park, K. (2018). “Estimating the Global Incidence of Traumatic
Brain Injury”. Journal of Neurosurgery, (2018).
2. Mayo Clinic description of symptoms and diseases that can result from TBI and mTBI:  
https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557
3. Heidi Losoi, Noah D. Silverberg, Minna Wäljas, Senni Turunen, Eija Rosti-Otajärvi, Mika Helminen,
Teemu M. Luoto, Juhani Julkunen, Juha Öhman, and Grant L. Iverson.Journal of Neurotrauma.
Apr 2016.
4. Hellstrøm T, Kaufmann T, Andelic N, Soberg HL, Sigurdardottir S, Helseth E, Andreassen OA and
Westlye LT (2017) Predicting Outcome 12 Months after Mild Traumatic Brain Injury in Patients Admitted
to a Neurosurgery Service. Front. Neurol. 8:125.
5. Dikmen, Sureyya, Joan Machamer, and Nancy Temkin. “Mild Traumatic Brain Injury: Longitudinal
Study of Cognition, Functional Status, and Post-Traumatic Symptoms.” Journal of Neurotrauma 34.8
(2017): 1524–1530. PMC. Web. 25 Sept. 2018.
6. Russo, M., Latour, L., McGavern, D. “Distinct Myeloid Cell Subsets Promote Meningeal Remodeling
and Vascular Repair after Mild Traumatic Brain Injury”. Nature Immunology (2018).
7. Statistics about sports-related concussions/mTBI:  http://www.protectthebrain.org/Brain-Injury-
Research/What-is-a-Concussion-.aspx
8. Statistics about the percentage of people who experience Post-Concussion Syndrome:  
https://www.statista.com/statistics/705230/rate-of-post-concussion-syndrome-by-year-in-us/
9. Hiploylee, Carmen et al. “Longitudinal Study of Postconcussion Syndrome: Not Everyone Recovers.”
Journal of Neurotrauma 34.8 (2017): 1511–1523. PMC. Web. 25 Sept. 2018.