Two-, Three-, or Four-Corner Arthrodesis for Midcarpal Osteoarthritis: A Systematic Review and Meta-Analysis.

PURPOSE: Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis. METHODS: A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications. RESULTS: Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group. CONCLUSIONS: Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Joint Distraction for Thumb Carpometacarpal Osteoarthritis: 2-Year Follow-up Results of 20 Patients.

Background Joint distraction is a fairly new treatment for patients with symptomatic thumb carpometacarpal osteoarthritis (CMC1 OA). A previous pilot study of five patients showed that CMC1 joint distraction is technically feasible. The current study presents the results of CMC1 joint distraction in 20 patients with a 2-year follow-up period. Purposes The primary study aim was to assess if patients with CMC1 OA have better physical function and less pain 2 years after CMC1 joint distraction. Second, we assessed the number of patients who achieved a minimal clinically important difference (MCID) in patient-reported outcome measures at each follow-up time point. Furthermore, this study sought differences on magnetic resonance imaging (MRI) of the CMC1 joint before and after distraction. Adverse events were noted and reported. Methods Twenty patients (median age of 54 years) with symptomatic CMC1 OA and an established indication for a trapeziectomy were enrolled. An external distractor device was placed over the CMC1 joint and left in situ for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), visual analogue scale (VAS), and grip strength were recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. Results Two years after joint distraction, physical function and pain scores had improved significantly compared with baseline: DASH from 48 to 17, MHQ from 56 to 83, and VAS for pain from 50 to 18 mm. Fourteen of 19 patients (74%) reached an MCID in DASH and MHQ scores. One patient was not satisfied with treatment outcome and chose to proceed with a trapeziectomy 14 months after initial distraction therapy. Conclusions This study demonstrates that CMC1 joint distraction can postpone more invasive surgical interventions (e.g., trapeziectomy) for at least 2 years. Larger comparative studies are needed to assess the value of CMC1 joint distraction in the treatment of CMC1 OA. Level of Evidence This is a Level IV, prospective case series study.

Retrospective Study of a Series of 20 Ivory Prostheses in the Treatment of Trapeziometacarpal Osteoarthritis.

Background Many surgical treatment options for osteoarthritis (OA) of the trapeziometacarpal (TMC) joint exist. However, no procedure has been proven superior. Good results have been described for TMC joint replacement. Purpose To analyze the results of the Ivory prosthesis in the treatment of symptomatic TMC OA. Patients and Methods A retrospective single-center follow-up study was performed. Visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Michigan Hand Outcomes Questionnaire (MHQ), active range of motion, strength, and radiological outcomes were assessed and analyzed. Differences between the operated and nonoperated hand were analyzed using paired t-tests. Twenty patients were included with a mean follow-up duration of 37.0 months. Results Patients experienced minimal pain with a mean VAS pain score of 1.9. DASH and MHQ scores indicated mild to moderate impairments. Eighty-five percent of patients assessed the operation excellent or good. Significant differences were found in measurements of extension and palmar thumb abduction in favor of the contralateral hand. No significant differences in strength between both hands were found. Two patients had a dislocation of the prosthesis; one patient required open reduction and tightening of the joint capsule. The other dislocation was treated with trapeziectomy and interposition of a fascia lata allograft. One patient had a collapse of the trapezium requiring a revision procedure. Conclusion Ivory prosthesis TMC arthroplasty can achieve good results in patients with symptomatic isolated TMC OA. In this series, however, revision surgery was required in 3 of 20 cases.

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review.

BACKGROUND: Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation. METHODS: Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow. RESULTS: Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels. CONCLUSIONS: Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.

Conservative treatment of thumb base osteoarthritis: a systematic review.

PURPOSE: To provide a systematic review of randomized controlled trials regarding the conservative treatment of thumb base osteoarthritis (OA). METHODS: A systematic literature search was conducted in the electronic bibliographic databases Medline (Pubmed) and Embase (both starting year to May 2014) using predetermined criteria for studies on nonoperative treatment of thumb base OA. RESULTS: Twenty-three articles fulfilled our inclusion criteria. Systematic evaluation demonstrated the following: (1) Hand therapy can possibly reduce pain. However, owing to the lack of good-quality (randomized controlled) trials with sufficient follow-up time, no proper conclusions can be drawn. (2) Although both steroid and hyaluronate intra-articular injections can provide pain relief, most authors conclude that injection of hyaluronate is more effective. Follow-up is rather short with a maximum of 12 months in 1 study. Furthermore, study comparison is hampered by heterogeneity of study design and outcome parameters. (3) The use of orthoses reduces pain without effect on function, strength, or dexterity. Included studies used various types of orthoses. Follow-up times varied (2 wk-7 y). (4) There is no justification for the use of transdermal steroid delivery. (5) There is insufficient evidence justifying the use of leech therapy. (6) There are no high-level evidence studies specifically evaluating the effect of analgesics and patient education in joint protection in patients with thumb base OA. CONCLUSIONS: There are only a few high-quality studies addressing the conservative treatment of trapeziometacarpal OA. Available evidence suggests only some effect of orthoses and intra-articular hyaluronate or steroid injections.

Soluble mediators in posttraumatic wrist and primary knee osteoarthritis.

BACKGROUND: New discoveries about the pathophysiology changed the concept that all forms of osteoarthritis are alike; this lead to the delineation of different phenotypes such as age, trauma or obese related forms. We aim to compare soluble mediator profiles in primary knee and posttraumatic wrist osteoarthritis. Based on the general faster progression rate of wrist osteoarthritis, we hypothesize a more inflammatory profile. METHODS: We collected synovial fluid from 20 primary osteoarthritic knee and 20 posttraumatic osteoarthritic wrist joints. 17 mediators were measured by multiplex enzyme-linked immunosorbent assay: chemokine ligand 5, interferon-γ, leukemia inhibitory factor, oncostatin-M, osteoprotegerin, tumor necrosis factor-α, vascular endothelial growth factor, interleukin (IL)-1α, IL-1ß, IL-1 receptor antagonist, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13 and IL-17. RESULTS: TEN MEDIATORS WERE HIGHER IN POSTTRAUMATIC OSTEOARTHRITIC SYNOVIAL FLUID: tumor necrosis factor-α (TNFα), IL-1α, IL-1RA, IL-6, IL-10, IL-17, oncostatin-M, interferon-γ, chemokine ligand 5 and leukemia inhibitory factor (P<0.001). IL-1ß, IL-4, IL-7 were not detected, TNFα was not detected in knee osteoarthritic synovial fluid. IL-8, IL-13, osteoprotegerin and vascular endothelial growth factor levels did not differ between the synovial fluid types. CONCLUSIONS: In general wrist osteoarthritis seems characterized by a stronger inflammatory response than primary knee osteoarthritis. More pronounced inflammatory mediators might offer a paradigm for the faster progression of posttraumatic osteoarthritis. Increase of specific mediators could form a possible target for future mediator modulating therapy in wrist osteoarthritis.

An alternative suspension technique after trapeziectomy for advanced thumb carpometacarpal osteoarthritis.

Osteoarthritis of the first carpometacarpal joint is often treated by (partial) trapeziectomy and tendon interposition or suspension arthroplasty procedures. In this article, an alternative suspension technique, using 2 osseous tunnels (through the first and second metacarpal) and a flexor carpi radialis tendon strip, is described.

Correlation between protection against sepsis by probiotic therapy and stimulation of a novel bacterial phylotype.

Prophylactic probiotic therapy has shown beneficial effects in an experimental rat model for acute pancreatitis on the health status of the animals. Mechanisms by which probiotic therapy interferes with severity of acute pancreatitis and associated sepsis, however, are poorly understood. The aims of this study were to identify the probiotic-induced changes in the gut microbiota and to correlate these changes to disease outcome. Duodenum and ileum samples were obtained from healthy and diseased rats subjected to pancreatitis for 7 days and prophylactically treated with either a multispecies probiotic mixture or a placebo. Intestinal microbiota was characterized by terminal-restriction fragment length polymorphism (T-RFLP) analyses of PCR-amplified 16S rRNA gene fragments. These analyses showed that during acute pancreatitis the host-specific ileal microbiota was replaced by an "acute pancreatitis-associated microbiota." This replacement was not reversed by administration of the probiotic mixture. An increase, however, was observed in the relative abundance of a novel bacterial phylotype most closely related to Clostridium lituseburense and referred to as commensal rat ileum bacterium (CRIB). Specific primers targeting the CRIB 16S rRNA gene sequence were developed to detect this phylotype by quantitative PCR. An ileal abundance of CRIB 16S rRNA genes of more than 7.5% of the total bacterial 16S rRNA gene pool was correlated with reduced duodenal bacterial overgrowth, reduced bacterial translocation to remote organs, improved pancreas pathology, and reduced proinflammatory cytokine levels in plasma. Our current findings and future studies involving this uncharacterized bacterial phylotype will contribute to unraveling one of the potential mechanisms of probiotic therapy.

[Treatment of osteoarthritis of the thumb basal joint]. / Behandeling van artrose van de duimbasis.

Osteoarthritis in the carpometacarpal joint of the thumb (CMC1) is described in three patients who were all restricted in their daily activities by the disease. CMC1 osteoarthritis is a common disease affecting mainly postmenopausal women and individuals who use the joint intensively. Two of our patients, a 52-year-old female teacher and a 45-year-old male dentist, were treated by resection of the articular surfaces and interposition of a tendon or a polycarbon disc into the joint. To achieve a strong, stable thumb a 58-year-old sculptress had arthrodesis of the left CMC1. In her right hand, resection of the trapezium and ligament reconstruction of the CMC1 joint was necessary. There is no evidence-based guideline for treatment of osteoarthritis of the carpometacarpal joint of the thumb. Many non-surgical and surgical treatment options for CMC1 osteoarthrosis have been described. Optimal treatment is chosen depending on radiological staging of the disease and on the wishes and expectations of the patient.

Probiotics prevent intestinal barrier dysfunction in acute pancreatitis in rats via induction of ileal mucosal glutathione biosynthesis.

BACKGROUND: During acute pancreatitis (AP), oxidative stress contributes to intestinal barrier failure. We studied actions of multispecies probiotics on barrier dysfunction and oxidative stress in experimental AP. METHODOLOGY/PRINCIPAL FINDINGS: Fifty-three male Spraque-Dawley rats were randomly allocated into five groups: 1) controls, non-operated, 2) sham-operated, 3) AP, 4) AP and probiotics and 5) AP and placebo. AP was induced by intraductal glycodeoxycholate infusion and intravenous cerulein (6 h). Daily probiotics or placebo were administered intragastrically, starting five days prior to AP. After cerulein infusion, ileal mucosa was collected for measurements of E. coli K12 and (51)Cr-EDTA passage in Ussing chambers. Tight junction proteins were investigated by confocal immunofluorescence imaging. Ileal mucosal apoptosis, lipid peroxidation, and glutathione levels were determined and glutamate-cysteine-ligase activity and expression were quantified. AP-induced barrier dysfunction was characterized by epithelial cell apoptosis and alterations of tight junction proteins (i.e. disruption of occludin and claudin-1 and up-regulation of claudin-2) and correlated with lipid peroxidation (r>0.8). Probiotic pre-treatment diminished the AP-induced increase in E. coli passage (probiotics 57.4+/-33.5 vs. placebo 223.7+/-93.7 a.u.; P<0.001), (51)Cr-EDTA flux (16.7+/-10.1 vs. 32.1+/-10.0 cm/s10(-6); P<0.005), apoptosis, lipid peroxidation (0.42+/-0.13 vs. 1.62+/-0.53 pmol MDA/mg protein; P<0.001), and prevented tight junction protein disruption. AP-induced decline in glutathione was not only prevented (14.33+/-1.47 vs. 8.82+/-1.30 nmol/mg protein, P<0.001), but probiotics even increased mucosal glutathione compared with sham rats (14.33+/-1.47 vs. 10.70+/-1.74 nmol/mg protein, P<0.001). Glutamate-cysteine-ligase activity, which is rate-limiting in glutathione biosynthesis, was enhanced in probiotic pre-treated animals (probiotics 2.88+/-1.21 vs. placebo 1.94+/-0.55 nmol/min/mg protein; P<0.05) coinciding with an increase in mRNA expression of glutamate-cysteine-ligase catalytic (GCLc) and modifier (GCLm) subunits. CONCLUSIONS: Probiotic pre-treatment diminished AP-induced intestinal barrier dysfunction and prevented oxidative stress via mechanisms mainly involving mucosal glutathione biosynthesis.

Pretreatment but not treatment with probiotics abolishes mouse intestinal barrier dysfunction in acute pancreatitis.

BACKGROUND: Intestinal barrier failure during acute pancreatitis (AP) is associated with translocation of luminal bacteria, resulting in infectious complications. We examined the effects of multispecies probiotics on the intestinal barrier impairment in a murine model of AP. METHODS: Mice were injected with cerulein to induce AP and were sacrificed 11 (early AP) or 72 hours (late AP) after start of induction. AP and associated systemic effects were confirmed by histology of pancreas and lung. Animals received daily probiotics starting 2 days prior to AP induction (pretreatment) or at the moment of AP induction (treatment). Mucosal barrier function of the distal ileum was assessed in Ussing chambers by measurement of the epithelial electrical resistance and the permeability to Na-fluorescein. RESULTS: Histological analysis revealed pancreatic injury in both phases of AP, and lung damage in the early phase. Epithelial resistance of the ileum was reduced and permeability increased in both phases of AP, indicating impairment of the intestinal barrier. Pretreatment had no effect on resistance or permeability in the early phase of AP. In the late phase of AP, pretreatment but not treatment abolished the AP induced resistance decrease and permeability increase. Administration of probiotics as such (ie, without induction of AP) had no effect on intestinal barrier function. CONCLUSION: Pretreatment with multispecies probiotics for 2 days abolishes intestinal barrier dysfunction in the late phase of AP, while treatment does not. The effectiveness of probiotics in this model depends on the timing of administration. Clinical trials with probiotics should seek conditions where treatment can be started prior to onset of disease or elective surgical intervention.

Probiotics enhance pancreatic glutathione biosynthesis and reduce oxidative stress in experimental acute pancreatitis.

Factors determining severity of acute pancreatitis (AP) are poorly understood. Oxidative stress causes acinar cell injury and contributes to the severity, whereas prophylactic probiotics ameliorate experimental pancreatitis. Our objective was to study how probiotics affect oxidative stress, inflammation, and acinar cell injury during the early phase of AP. Fifty-three male Sprague-Dawley rats were randomly allocated into groups: 1) control, 2) sham procedure, 3) AP with no treatment, 4) AP with probiotics, and 5) AP with placebo. AP was induced under general anesthesia by intraductal glycodeoxycholate infusion (15 mM) and intravenous cerulein (5 microg.kg(-1).h(-1), for 6 h). Daily probiotics or placebo were administered intragastrically, starting 5 days prior to AP. After cerulein infusion, pancreas samples were collected for analysis including lipid peroxidation, glutathione, glutamate-cysteine-ligase activity, histological grading of pancreatic injury, and NF-kappaB activation. The severity of pancreatic injury correlated to oxidative damage (r = 0.9) and was ameliorated by probiotics (1.5 vs. placebo 5.5; P = 0.014). AP-induced NF-kappaB activation was reduced by probiotics (0.20 vs. placebo 0.53 OD(450nm)/mg nuclear protein; P < 0.001). Probiotics attenuated AP-induced lipid peroxidation (0.25 vs. placebo 0.51 pmol malondialdehyde/mg protein; P < 0.001). Not only was AP-induced glutathione depletion prevented (8.81 vs. placebo 4.1 micromol/mg protein, P < 0.001), probiotic pretreatment even increased glutathione compared with sham rats (8.81 vs. sham 6.18 miccromol/mg protein, P < 0.001). Biosynthesis of glutathione (glutamate-cysteine-ligase activity) was enhanced in probiotic-pretreated animals. Probiotics enhanced the biosynthesis of glutathione, which may have reduced activation of inflammation and acinar cell injury and ameliorated experimental AP, via a reduction in oxidative stress.

Modification of intestinal flora with multispecies probiotics reduces bacterial translocation and improves clinical course in a rat model of acute pancreatitis.

BACKGROUND: Infection of pancreatic necrosis by gut bacteria is a major cause of morbidity and mortality in patients with severe acute pancreatitis. Use of prophylactic antibiotics remains controversial. The aim of this experiment was assess if modification of intestinal flora with specifically designed multispecies probiotics reduces bacterial translocation or improves outcome in a rat model of acute pancreatitis. METHODS: Male Sprague-Dawley rats were allocated into 3 groups: (1) controls (sham-operated, no treatment), (2) pancreatitis and placebo, and (3) pancreatitis and probiotics. Acute pancreatitis was induced by intraductal glycodeoxycholate and intravenous cerulein infusion. Daily probiotics or placebo was administered intragastrically from 5 days prior until 7 days after induction of pancreatitis. Tissue and fluid samples were collected for microbiologic and quantitative real-time PCR analysis of bacterial translocation. RESULTS: Probiotics reduced duodenal bacterial overgrowth of potential pathogens (Log(10) colony-forming units [CFU]/g 5.0 +/- 0.7 [placebo] vs 3.5 +/- 0.3 CFU/g [probiotics], P < .05), resulting in reduced bacterial translocation to extraintestinal sites, including the pancreas (5.38 +/- 1.0 CFU/g [placebo] vs 3.1 +/- 0.5 CFU/g [probiotics], P < .05). Accordingly, health scores were better and late phase mortality was reduced: 27% (4/15, placebo) versus 0% (0/13, probiotics), respectively, P < .05. CONCLUSIONS: This experiment supports the hypothesis that modification of intestinal flora with multispecies probiotics results in reduced bacterial translocation, morbidity, and mortality in the course of experimental acute pancreatitis.

Cholesterol crystals enhance and phospholipids protect against pancreatitis induced by hydrophobic bile salts: a rat model study.

OBJECTIVES: The role of bile composition in the pathogenesis of biliary pancreatitis is unknown. The objective of this experiment was to explore the potential role of bile salts, phospholipids, and cholesterol crystals in the pathogenesis of biliary pancreatitis in a rat model. METHODS: Model systems composed of taurodeoxycholate (TDC), mixed bile salts (MBS), or tauroursodeoxycholate (TUDC) [in 10 mM phosphate-buffered saline (PBS), pH 7.4], with or without cholesterol crystals or phosphatidylcholine, were infused into bile ducts of male Sprague-Dawley rats. Twenty-four hours later, animals were killed for histopathologic scoring of (peri)pancreatic inflammation. RESULTS: : Severity of acute pancreatitis depended on bile salt hydrophobicity (TDC > MBS >> TUDC = PBS; histopathologic scores: 25.6 +/- 0.5, 23.0 +/- 1.5, 14.4 +/- 2.2, 14.8 +/- 1.0, respectively; P < 0.001), with corresponding differences in serum lipase concentration. Phosphatidylcholine protected against detrimental effects of TDC at physiological, but not at low, concentrations (scores: 19.5 +/- 2.3 vs 28.3 +/- 1.9 in case of Phosphatidycholine/(TDC + Phosphatidycholine) ratios 0.25 or 0.05, respectively). Cholesterol crystals increased severity of pancreatitis in model systems containing TDC or MBS, but not TUDC or PBS (33.2 +/- 0.4, 29.6 +/- 1.2, 18.6 +/- 1.5, 18.5 +/- 2.2, respectively; P < 0.001). CONCLUSIONS: In the rat model, hydrophobic bile salts and cholesterol crystals aggravate biliary pancreatitis, whereas phospholipids have a protective effect.

Effects of subtotal colectomy on bacterial translocation during experimental acute pancreatitis.

OBJECTIVES: The colon is considered a major source of bacteria causing infection of pancreatic necrosis in acute pancreatitis (AP). Subtotal colectomy before AP in rats reduces mortality, but its role in affecting small bowel flora, bacterial translocation, and infection of pancreatic necrosis is unknown. Our aim was to study these phenomena in rats with AP. METHODS: Fifty rats, allocated in 4 groups, underwent 2 laparotomies: group 1, sham laparotomy and saline biliopancreatic duct infusion; group 2, subtotal colectomy and saline infusion; group 3, sham laparotomy and AP (ductal infusion of glycodeoxycholic acid and intravenous cerulein); group 4, subtotal colectomy and AP. Seventy-two hours later, samples were collected for microbiological analysis. RESULTS: Subtotal colectomy caused small bowel bacterial overgrowth with gram-positive cocci (group 1 versus group 2, duodenum: P = 0.030, ileum: P = 0.029). Bacterial counts of gram-negative rods/anaerobes in the duodenum and ileum and pancreatic bacterial counts of rats with colectomy and AP were significantly higher than in rats with AP only (group 3 versus group 4, duodenum: P = 0.040, ileum: P = 0.029, pancreas: P = 0.017). Duodenal bacterial overgrowth and pancreatic infection correlate significantly (r = 0.45, P = 0.004). CONCLUSIONS: Subtotal colectomy induces small bowel bacterial overgrowth, which is associated with increased bacterial translocation to the pancreas.

Prevention of infectious complications in surgical patients: potential role of probiotics.

Infectious complications in surgical patients often originate from the intestinal microflora. In the critically ill patient, small bowel motility is disturbed, leading to bacterial overgrowth and subsequent bacterial translocation due to dysfunction of the gut mucosal barrier. The optimal prophylactic strategy should act on all these factors, but such a strategy is not yet available. For several decades, antibiotic prophylaxis to prevent translocation of pathogenic bacteria has been studied with conflicting results. Selective decontamination of the digestive tract has shown good results, but fear for bacterial multiresistance has prevented worldwide implementation. In recent years, probiotics, living bacteria with a potential beneficial effect to their host, have shown promising results in several randomized placebo-controlled trials. Currently, in vitro and experimental research focuses on the effects of probiotics on the microflora responsible for gut-derived infections, structural mucosal barrier function and the immune system.