Column Description: DynaMed Plus is an evidence-based clinical reference, which is updated daily through systematic surveillance and critical appraisal of the research literature. DynaMed editors and reviewers select content of interest for integrative medicine, summarize the current evidence, and describe challenges in evidence analysis and application. Evidence quality is rated level 1 (likely reliable) evidence for studies with clinical outcomes and minimal risk of bias, level 2 (mid-level) evidence for studies with clinical outcomes and significant methodological or statistical limitations, and level 3 (lacking direct) evidence for reports that do not include scientific analysis of clinical outcomes. When applicable, the number of patients needed to be treated to lead to one patient having an improved outcome (NNT for number needed to treat) or a worse outcome (NNH for number needed to harm) is presented. DynaMed Plus is available at http://www.dynamed.com/. For more information, contact Brian S. Alper, MD, MSPH, FAAFP, at [email protected]

Early osteopathic theory and practice, and the work of the medical intuitive Edgar Cayce suggested that the abdominal areas of individuals with epilepsy would manifest “cold spots.” The etiology for this phenomenon was thought to be abdominal adhesions caused by inflammation and viscero-somatic reflexes caused by adhesions or injury to visceral or musculoskeletal system structures. Indeed, until that advent of electroencephalography in the 1930s, medical practice regarding epilepsy focused on abdominal neural and visceral structures. Following two hypotheses were formulated to evaluate any abdominal temperature phenomena: (1) an abdominal quadrant division analysis would find one or more quadrants “colder” in the focal-onset epilepsy group (ICD9-CM 345.4 and 345.5) compared to controls. (2) Total abdominal areas of individuals with focal-onset epilepsy wound be colder than a control group.Overall, 50 patients with the diagnosis of focal-onset epilepsy were recruited from the office of the Epilepsy Foundation of Florida and 50 control subjects with no history of epilepsy were recruited through advertising to the public. Under controlled room conditions all subjects had infrared thermographic images made and recorded by Med-Hot Model MH-731 FLIR equipment.There were no significant demographic difference between experimental patients and control subjects, though the control group tended to be younger and more often male; however, these were controlled for in all analyses. In the quadrant analysis, there were significant differences in that more epileptic patients had colder left upper abdominal quadrant temperatures than the control group (66.8% versus 44.9%; P = .030). In the total abdominal analysis, however, there were no significant differences.The results support the hypothesis that individuals with focal-onset epilepsy have colder abdominal areas. If substantiated in further research, present study results will require further examination of the mechanisms of action for epilepsy, and suggest the need for re-examination of older formulations of abdominal epilepsy, including the place of abdominal injury, inflammation, and adhesions in epileptic pathology. The concept of somato-visceral and viscero-somatic neurological interactions is one of the possible mechanisms underlying the “cold spot” findings and warrants further consideration.

Background: Modern living is awash with low-frequency electromagnetic radiation raising concern over health effects, birth defects, and infant cancers especially leukemias. Medical/scientific opinion is ambivalent, especially regarding possible mechanisms of action despite our bodies' many electric currents.Aims: Are some cancers induced by morphogenetic changes rather than direct mutation? We wished to see if morphogenetic effects of weak, extremely low-frequency electric (ELF) fields in embryonated hen's eggs could induce cancers, knowing that such treatment is usually deleterious. We report a pilot study intended to reveal a promising cell source in which to search for cancer cells by established methods and then to check for DNA damage.Methods: Stored (5 degrees C for 1-36 days) fresh, fertile hens' eggs were incubated (38 degrees C, total five or six days) in presence or absence of a weak ELF oscillating electric field (1-40 V/cm, 1-50 Hz and two to six days). Separated embryos were assessed for development stage.Results: Storage of untreated eggs (>12 days, 5 degrees C) allows a steady loss of normal embryo formation at 38 degrees C (few viable by 25 days, half-life similar to 18 days). Surprisingly, incubation in a weak ELF field during the period of declining viability significantly (P: 0.03-0.0001) improved viability and condition of the embryos (new half-life similar to 21 days), rather than the expected converse. Thus for a few days, the field could keep viable some embryos that would otherwise not have survived.Conclusions: The rescued embryos and their untreated controls seem the most promising place to seek any carcinogenic effects of ELF fields. The nature of the presumed critical component keeping them viable during 5 degrees C storage is at least of equal interest.

This study combined physical data from synchrotron SAXS, FTIR and microscopy with in-silico molecular structure predictions and mathematical modeling to examine inulin adjuvant particle formation and structure. The results show that inulin polymer chains adopt swollen random coil in solution. As precipitation occurs from solution, interactions between the glucose end group of one chain and a fructose group of an adjacent chain help drive organized assembly, initially forming inulin ribbons with helical organization of the chains orthogonal to the long-axis of the ribbon. Subsequent aggregation of the ribbons results in the layered semicrystalline particles previously shown to act as potent vaccine adjuvants. γ-Inulin adjuvant particles consist of crystalline layers 8.5 nm thick comprising helically organized inulin chains orthogonal to the plane of the layer. These crystalline layers alternate with amorphous layers 2.4 nm thick, to give overall particle crystallinity of 78%.

Herbal medicines have received attention as antiabdominal obesity agents. We present a series of 13 cases that demonstrate the positive effect of the herbal complex Hwang-Ryun-Haedok-Tang (HRHT; Tsumura, Tokyo, Japan) on weight and abdominal fat control in patients with abdominal obesity. We treated 13 patients with abdominal obesity treated for 54.46 ± 18.07 days with 5.0 g of HRHT daily. To evaluate the treatment, the morphometric (i.e., waist circumstance, weight, body fat) and biochemical parameters were measured once monthly. After HRHT therapy, the waist circumstance decreased from 91.96 ± 7.99 cm to 87.12 ± 8.09 cm (paired t test, P < .001) and the weight decreased from 78.09 ± 14.35 kg (average ± standard deviation) to 75.72 ± 14.60 kg (paired t test, P < .001). All 13 (100%) patients had low waist circumstances after treatment. Overall, 12 (92.3%) of the 13 patients had a lower weight and body mass index. In the present study, we showed the clinical effects of HRHT on waist circumstance, weight, body mass index, and body fat in patients with abdominal obesity. Further clinical studies investigating the effects of HRHT are needed.

Semi-crystalline microparticles of inulin (MPI) have clinical utility as potent human vaccine adjuvants but their relevant surface structure and crystal assembly remain undefined. We show inulin crystal surfaces to resemble multi-layered, discoid radial spherulites resulting from very rapid formation of complex tertiary structures, implying directed crystal initiation. Physical and in silico molecular modelling of unit cells confirm steric feasibility of initiation by hydrogen-bonded cross-linking of terminal glucose to a fructose of another chain, mimicking bonding in sucrose crystals. A strong, chelate-like dual H-bond is proposed to compel the known antiparallel alignment of inulin chains. Such cross-linking would require one extra fructose per chain in the native inulin crystal, as observed. Completion of five H-bonded internal ring-domains would 'lock in' each new 6-fructose structural unit of each antiparallel helix pair to create a new isoform. All known properties of inulin isoforms follow readily from these concepts.

There is an ongoing need for new adjuvants to facilitate development of vaccines against HIV, tuberculosis, malaria and cancer, amongst many others. Unfortunately, the most potent adjuvants are often associated with toxicity and safety issues. Inulin, a plant-derived polysaccharide, has no immunological activity in its native soluble form but when crystallized into a stable microcrystalline particulate from (delta inulin) acquires potent adjuvant activity. Delta inulin has been shown to enhance humoral and cellular immune responses against a broad range of co-administered viral, bacterial, parasitic and toxin antigens. Inulin normally crystallizes as large heterogeneous particles with a broad size distribution and variable solubility temperatures. To ensure reproducible delta inulin particles with a consistent size distribution and temperature of solubility, a current Good Manufacturing Practice (cGMP) process was designed to produce Advax™ adjuvant. In its cCMP form, Advax™ adjuvant has proved successful in human trials of vaccines against seasonal and pandemic influenza, hepatitis B and insect sting anaphylaxis, enhancing antibody and T-cell responses while being safe and well tolerated. Advax™ adjuvant represents a novel human adjuvant that enhances both humoral and cellular immunity. This review describes the discovery and development of Advax™ adjuvant and research into its unique mechanism of action.

There is a need for additional safe and effective human vaccine adjuvants. Advax (TM) is a novel adjuvant produced from semi-crystalline particles of delta inulin. In animal studies Advax enhanced humoral and cellular immunity to hepatitis B surface antigen (HBsAg) without inducing local or systemic reactogenicity. This first-in-man Phase 1 clinical trial tested the safety and tolerability of three intramuscular doses of HBsAg formulated with Advax in a group of healthy adult subjects. Advax was well tolerated with injection site pain scores not significantly different to subjects receiving HBsAg alone and no adverse events were reported in subjects that received Advax. Seroprotection and HBsAb geometric mean titers (GMT) after three immunizations were higher in the Advax 5 mg (seroprotection 5/6, 83.3%, GMT 40.7, 95% CI 11.9-139.1) and 10 mg (seroprotection 4/5,80%, GMT 51.6,95% CI 10.0-266.2) groups versus HBsAg alone (seroprotection 1/5, 20%, GMT 4.1, 95% CI 1.3-12.8). Similarly the proportion of subjects with positive CD4 T-cell responses to HBsAg was higher in the Advax 5 mg (4/6,67%) and Advax 10 mg (4/5,80%) groups versus HBsAg alone (1/5, 20%). These results confirm the safety, tolerability and immunogenicity of Advax adjuvant observed in preclinical studies. Advax may represent a suitable replacement for alum adjuvants in prophylactic human vaccines subject to confirmation of current results in larger studies. Australia and New Zealand Clinical Trial Registry: ACTRN12607000598482. (C) 2014 Elsevier Ltd. All rights reserved.

We earlier identified a developmental series of seven isoforms/polymorphs of microparticulate inulin by comparing non-covalent bonding strengths. Their pharmaceutical utility lies in the modulation of cellular immunity, exploited as vaccine adjuvants (Advax™) especially for delta inulin (DI). As such particles cannot be sterilized by filtration we explore the effect of (60)Co gamma radiation (GR) on inulin isoforms, particularly DI. Its adjuvant activity and overt physical properties were unaffected by normal GR sterilizing doses (up to 25kGy). Heating irradiated isoform suspensions near their critical dissolution temperature revealed increased solubility deduced to reflect a single lethal event in one component of a multi-component structure. Local oxidative effects of GR on DI were not found. The observed DI loss was almost halved by re-annealing at the critical temperature: surviving inulin chains apparently reassemble into smaller amounts of the original type of structure. Colorimetric tetrazolium assay revealed increases in reducing activity after GR of raw inulin powder, which yielded DI with normal physical properties but only 25% normal recovery yet 4× normal reducing ability, implying final retention of some GR-changed inulin chains. These findings suggest minimal inulin chain cleavage and confirm that GR may be a viable strategy for terminal sterilization of microparticulate inulin adjuvants.

Inulin isoforms, especially delta inulin, are important biologically as immune activators and clinically as vaccine adjuvants. In exploring action mechanisms, we previously found regular increments in thermal properties of the seven-member inulin isoform series that suggested regular additions of some energetic structural unit. Because the previous isolates carried additional longer chains that masked defining ranges, these were contrasted with new isoform isolates comprising only inulin chain lengths defining that isoform. The new series began with 19 fructose units per chain (alpha-1 inulin), increasing regularly by 6 fructose units per isoform. Thus the 'energetic unit' equates to 6 fructose residues per chain. All isoforms showed indistinguishable X-ray diffraction patterns that were also identical with known inulin crystals. We conclude that an 'energetic unit' equates to one helix turn of 6 fructose units per chain as found in one unit cell of the inulin crystal. Each isoform chain comprised progressively more helix turns plus one additional fructose and glucose residues per chain.

In studying the molecular basis for the potent immune activity of previously described gamma and delta inulin particles and to assist in production of inulin adjuvants under Good Manufacturing Practice, we identified five new inulin isoforms, bringing the total to seven plus the amorphous form. These isoforms comprise the step-wise inulin developmental series amorphous → alpha-1 (AI-1) → alpha-2 (AI-2) → gamma (GI) → delta (DI) → zeta (ZI) → epsilon (EI) → omega (OI) in which each higher isoform can be made either by precipitating dissolved inulin or by direct conversion from its precursor, both cases using regularly increasing temperatures. At higher temperatures, the shorter inulin polymer chains are released from the particle and so the key difference between isoforms is that each higher isoform comprises longer polymer chains than its precursor. An increasing trend of degree of polymerization is confirmed by end-group analysis using (1)H nuclear magnetic resonance spectroscopy. Inulin isoforms were characterized by the critical temperatures of abrupt phase-shifts (solubilizations or precipitations) in water suspensions. Such (aqueous) "melting" or "freezing" points are diagnostic and occur in strikingly periodic steps reflecting quantal increases in noncovalent bonding strength and increments in average polymer lengths. The (dry) melting points as measured by modulated differential scanning calorimetry similarly increase in regular steps. We conclude that the isoforms differ in repeated increments of a precisely repeating structural element. Each isoform has a different spectrum of biological activities and we show the higher inulin isoforms to be more potent alternative complement pathway activators.

Fructose is a significant component in unprocessed food and has become one of the most commonly sweeteners used in food manufacturing. Fructose is also a useful pharmaceutical excipient and derivatives of fructose are exploited as renewable chemical building blocks. Fructose based polysaccharides have extensive pharmaceutical and dietary functions. We discuss here the chemistry and physical behaviours of this saccharide and how these factors affect the utility and health implications of fructose.

d-Fructose was analysed by NMR spectroscopy and previously unidentified 1H NMR resonances were assigned to the keto and α-pyranose tautomers. The full assignment of shifts for the various fructose tautomers enabled the use of 1H NMR spectroscopy in studies of the mutarotation (5–25 °C) and tautomeric composition at equilibrium (5–50 °C). The mutarotation of β-pyranose to furanose tautomers in D2O at a concentration of 0.18 M was found to have an activation energy of 62.6 kJ mol−1. At tautomeric equilibrium (20 °C in D2O) the distribution of the β-pyranose, β-furanose, α-furanose, α-pyranose and the keto tautomers was found to be 68.23%, 22.35%, 6.24%, 2.67% and 0.50%, respectively. This tautomeric composition was not significantly affected by varying concentrations between 0.089 and 0.36 M or acidification to pH 3. Upon equilibrating at 6 temperatures between 5 and 50 °C there was a linear relationship between the change in concentration and temperature for all forms.

The hydrolysis of various carbohydrates was investigated under acidic conditions in real time by 1H NMR spectroscopy, with a focus on the polysaccharide inulin. Sucrose was used as a model compound to illustrate the applicability of this technique. The hydrolysis of sucrose was shown to follow pseudo first order kinetics and have an activation energy of 107.0kJmol−1 (SD 1.7kJmol−1). Inulin, pullulan and glycogen also all followed pseudo first order kinetics, but had an initiation phase at least partially generated by the protonation of the glycosidic bonds. It was also demonstrated that polysaccharide chain length has an effect on the hydrolysis of inulin. For short chain inulin (DPn 18, SD 0.70) the activation energy calculated for the hydrolytic cleavage of glucose was similar to sucrose at 108.5kJmol−1 (SD 0.60). For long chain inulin (DPn 30, SD 1.3) the activation energy for the hydrolytic cleavage of glucose was reduced to 80.5kJmol−1 (SD 2.3kJmol−1). This anomaly has been attributed to varied conformations for the two different lengths of inulin chain in solution.

The role for adjuvants in human vaccines has been a matter of vigorous scientific debate, with the field hindered by the fact that for over 80 years, aluminum salts were the only adjuvants approved for human use. To this day, alum-based adjuvants, alone or combined with additional immune activators, remain the only adjuvants approved for use in the USA. This situation has not been helped by the fact that the mechanism of action of most adjuvants has been poorly understood. A relative lack of resources and funding for adjuvant development has only helped to maintain alum's relative monopoly. To seriously challenge alum's supremacy a new adjuvant has many major hurdles to overcome, not least being alum's simplicity, tolerability, safety record and minimal cost. Carbohydrate structures play critical roles in immune system function and carbohydrates also have the virtue of a strong safety and tolerability record. A number of carbohydrate compounds from plant, bacterial, yeast and synthetic sources have emerged as promising vaccine adjuvant candidates. Carbohydrates are readily biodegradable and therefore unlikely to cause problems of long-term tissue deposits seen with alum adjuvants. Above all, the Holy Grail of human adjuvant development is to identify a compound that combines potent vaccine enhancement with maximum tolerability and safety. This has proved to be a tough challenge for many adjuvant contenders. Nevertheless, carbohydrate-based compounds have many favorable properties that could place them in a unique position to challenge alum's monopoly over human vaccine usage.

We report a novel isoform of β-D-[2 → 1] poly(fructo-furanosyl) α-D-glucose termed delta inulin (DI), comparing it with previously described alpha (AI), beta (BI) and gamma (GI) isoforms. In vitro, DI is the most immunologically active weight/weight in human complement activation and in binding to monocytes and regulating their chemokine production and cell surface protein expression. In vivo, this translates into potent immune adjuvant activity, enhancing humoral and cellular responses against co-administered antigens. As a biocompatible polysaccharide particle, DI is safe and well tolerated by subcutaneous or intramuscular injection. Physico-chemically, DI forms as an insoluble precipitate from an aqueous solution of suitable AI, BI or GI held at 37-48°C, whereas the precipitate from the same solution at lower temperatures has the properties of AI or GI. DI can also be produced by heat conversion of GI suspensions at 56°C, whereas GI is converted from AI at 45°C. DI is distinguished from GI by its higher temperature of solution in dilute aqueous suspension and by its lower solubility in dimethyl sulfoxide, both consistent with greater hydrogen bonding in DI's polymer packing structure. DI suspensions can be dissolved by heat, re-precipitated by cooling as AI and finally re-converted back to DI by repeated heat treatment. Thus, DI, like the previously described inulin isoforms, reflects the formation of a distinct polymer aggregate packing structure via reversible noncovalent bonding. DI forms the basis for a potent new human vaccine adjuvant and further swells the growing family of carbohydrate structures with immunological activity.

alpha-D-glucopyranosyl-[beta-D-fructofuranosyl](n-1)-D-fructofuranoside, commonly referred to as inulin, is a natural plant-derived polysaccharide with a diverse range of food and pharmaceutical applications. It is used by the food industry as a soluble dietary fibre and fat or sugar replacement, and in the pharmaceutical industry as a stabiliser and excipient. It can also be used as a precursor in the synthesis of a wide range of compounds. New uses for inulin are constantly being discovered, with recent research into its use for slow-release drug delivery. Inulin, when in a particulate form, possesses anti-cancer and immune enhancing properties. Given its increasing importance to industry, this review explains how inulin's unique physico-chemical properties bestow it with many useful pharmaceutical applications.

Advax is a polysaccharide-based adjuvant that potently stimulates vaccine immunogenicity without the increased reactogenicity seen with other adjuvants. This study investigated the immunogenicity of a novel Advax-adjuvanted Vero cell culture candidate vaccine against Japanese encephalitis virus (JEV) in mice and horses. The results showed that, in mice, a two-immunization, low-dose (50 ng JEV antigen) regimen with adjuvanted vaccine produced solid neutralizing immunity comparable to that elicited with live ChimeriVax-JE immunization and superior to that elicited with tenfold higher doses of a traditional non-adjuvanted JEV vaccine (JE-VAX; Biken Institute) or a newly approved alum-adjuvanted vaccine (Jespect; Novartis). Mice vaccinated with the Advax-adjuvanted, but not the unadjuvanted vaccine, were protected against live JEV challenge. Equine immunizations against JEV with Advax-formulated vaccine similarly showed enhanced vaccine immunogenicity, confirming that the adjuvant effects of Advax are not restricted to rodent models. Advax-adjuvanted JEV vaccine elicited a balanced T-helper 1 (Th1)/Th2 immune response against JEV with protective levels of cross-neutralizing antibody against other viruses belonging to the JEV serocomplex, including Murray Valley encephalitis virus (MVEV). The adjuvanted JEV vaccine was well tolerated with minimal reactogenicity and no systemic toxicity in immunized animals. The cessation of manufacture of traditional mouse brain-derived unadjuvanted JEV vaccine in Japan has resulted in a JEV vaccine shortage internationally. There is also an ongoing lack of human vaccines against other JEV serocomplex flaviviruses, such as MVEV, making this adjuvanted, cell culture-grown JEV vaccine a promising candidate to address both needs with one vaccine.