Essential Oils for Improving Quality of Life in Children with Autism Spectrum Disorder - PowerPoint Presentation

1. Essential Oils for Improving Quality of Life in Children with Autism Spectrum DisorderJill Hollway, Ph.D., M.A.L. Eugene Arnold, M.D., M.EdTaylor Wong, B.S.Cheryl Li, B.S.Nisonger Center, UCEDDOhio State UniversityYoung Living Essential Oils

2. Aromatherapy...use of essential oils extracted from plants to treat physical or psychological health...the concept is ancient…used as incense (China), for embalming (Egypt), and for bathing (Rome). …term was coined by Rene-Maurice Gattefosse in the1920’s(Herz, 2009)

3. Review of the Essential Oils Literature Rachel Herz Ph.D., 2009 (Brown University) conducted a systematic review of the essential oils literature using the guidelines provided by the Sense of Smell Institute

4. Herz Review Method/ResultsThe studies reviewed met at least 3 of the 5 eligibility criteria18 studies were chosen as representative of valid experimentation

5. Herz Review Study LimitationsNo reported power analysis to detect effect Subjective measures only (i.e., no objective physiological measures)Natural chemicals or synthetic chemicals used (makes designating effects to specific odors less achievable)Factors that mitigated or modulated response were culture, experience, gender, and personality

6. Autism Spectrum Disorder (ASD)Delayed verbal and nonverbal communication, or if verbal then impaired reciprocal communicationImpairment in reciprocal and social interactions Stereotyped behaviors and restricted interests

7. ASD and Associated Behavioral Problems and Parent StressIncreased irritability (McCracken et al., 2002)Anxiety (Lecavalier et al., 2014)Sleep disturbance (40%-80%) (Hollway & Aman, 2011)Sleep problems cause significant family distress (Hiscock & Wake, 2002)

8. Essential Oils to Improve Quality of Life in children with ASDPrimary Aims: to evaluate the feasibility of conducting a much larger multisite trial to examine preliminary data regarding the benefit and tolerability of Young Living’s Re-Connect essential oils blend for enhancing QOL in children with ASD.

9. HypothesesTwenty seven participants will be enrolled with 85% adherence and 85% retention through both conditions.With Young Living Re-Connect™, participants will show significantly improved QOL, sleep, and anxiety. Participants will show negligible or no increases in adverse events (AEs), including allergic contact dermatitis or immediate contact reactions

10. METHODS:Randomized Double-Blind Crossover Study of Two Oil Blends7-month crossover studyTwo 3-month conditions One month washoutRandomly assigned to treatment orderDouble-blind to conditionAll participants get both oil blends10 study Visits in all

11. Treatment ConditionsYoung Living Re-Connect ™17 Essential oilsCoconut Oil Comparator

12. Dosing Schedule AM and PMTopical application in the morning (2 drops) One drop on back of neck and 1 drop to the feet. Rub in for 30 seconds to one minuteDiffusion method in the evening at bedtime. 20 minutes before bedtime add water and 8-12 drops of oil to the diffuser and begin the aromatherapy

13. Inclusion Criteria(1) Outpatients between 3 and 9 years of age, inclusive (2) Diagnosis of Autism Spectrum Disorder (ASD) by DSM-V (3) Item mean of > 1.5 on Pediatric Quality of Life Inventory(4) Reliable care provider

14. Exclusion Criteria (1) Bipolar disorder or major depression accompanied by family history of bipolar disorder (2) Children with allergies to essential oils, vanilla, or nuts(3) Children with seizure disorder/epilepsy(4) Significant physical illness (e.g., serious cardiovascular, liver or renal pathology)

15. Exclusion Criteria Continued (5) Insomnia medication or a melatonin supplement within 2 weeks before baseline(6) Anticipated changes in medication dose, medical treatments or supplements (7) Weight less than 10 kg(8) Sleep Disordered Breathing (SDB) as defined by a total score of > 3 on the CSHQ SDB subscale and parent report.

16. Outcome Measures:Pediatric Quality of Life Scale Age range – 2-4 ; 5-7; 8-12 yearsFour subscales:Physical FunctioningEmotional FunctioningSocial FunctioningSchool functioningOutcome total item means

17. CHILDRENS SLEEP HABITS QUESTIONNAIRE (CSHQ)Clinically significant sleep disturbanceTotal Sleep Disturbance Score (33 Items = > 41) Subscales: Bedtime Resistance; Sleep Onset Delay; Duration; Sleep Anxiety; Parasomnias; Sleep Disordered Breathing; Daytime Sleepiness; Night Awakenings

18. Parent-Rated Anxiety Scale for Autism Spectrum Disorder (PRAS-ASD) Scahill, Lecavalier, Bearss & Aman, 10/23/15The PRAS-ASD is a valid and reliable measure of anxiety in ASDThe parent-rated scale includes 25 items based on situations that are anxiety provoking in ASD

19. Safety Measures Laboratory Tests:Conducted to assess changes in test values since the Screening Visit Blood and urine were collected at 3 time-points during the study (Screen, Week 12, Week 28)Lab Tests will include:ALT, AST, total and direct bilirubin (liver function tests), and CBC. Standard urinalysis

20. Statistical AnalysesThe data were analyzed using a Linear Mixed Model for repeated measures in order to model changes over time.

21. RESULTSPediatric Quality of Life InventoryCSHQPRAS

22. PedsQL Physical Functioning SubscaleEffect of Active Treatment vs Control, N.S. P-value = .16

23. PedsQL Emotional Functioning SubscaleEffect of Active Treatment vs Control, N.S. p-value = .17

24. PedsQL Social Functioning SubscaleEffect of Active Treatment vs Control, N.S. p- value = .14

25. PedsQL School Functioning SubscaleEffect of Active Treatment vs Control, N.S. p-value =.24

26. Children’s Sleep Habits QuestionnaireEffect of Active Treatment vs Control, N.S. p-value =. 20

27. Parent-Rated Anxiety Scale - ASD Effect of Active Tx vs Control for AC on PRAS-ASD Total S.S. p-value= .004

28. Results Safety ChecksAdverse Events (AEs):Participants are systematically monitored for adverse events by study physicians (at all 10 visits) Vital signs, including resting BP, evaluated at every visit

29. Safety MeasuresResults Laboratory TestsALT, AST, total and direct bilirubin (liver function tests), and CBC. Standard urinalysisNo Clinically Significant Abnormal Laboratory Values

30. Adverse EventsURI (14)Vomiting (10)Sleep disturbance and daytime sleepiness (9)Seasonal Allergies(8)Pharyngitis (6)Cough (6)GI problems (6)Accidental lesions/bruising (6)Repetitive Behavior (5)Irritability (5)Fever (5)Strep throat (3)Anxiety (3)Hypearactivity (3)Eczema (3)Rashes (2) Not Oil sites

31. Discussion We hypothesized that participants using Young Living’s Re-Connect essential oil blend would show significantly improved QOL on the Pediatric Quality of Life InventoryWe found that there was no significant difference between the active treatment and the control on quality of life, in the areas of Physical Functioning, Emotional Functioning, Social Functioning and School Functioning

32. Discussion - ContinuedWe hypothesized that participants would show negligible or no increases in adverse events (AEs), including allergic contact dermatitis or immediate contact reactionsWe found that there were no significant differences in adverse events between the active treatment and the control group on the number and types of adverse events

33. RESULTSCaregiver SatisfactionCaregiver Satisfaction with the study procedures.

34. Parent Satisfaction QuestionnaireQuestion 7: If you had to do it all over again, not knowing how your child would react to the oils, would you join the study again?Table of psq_q7 by trtgrppsq_q7(psq_7)trtgrp(trtgrp)FrequencyCol PctACCATotalYes, definitely685.7110100.0016Maybe, some reservations114.2900.001Total71017

35. Parent Satisfaction QuestionnaireQuestion 6: Would you recommend this study to other parents who have children with similar problems?Table of psq_q6 by trtgrppsq_q6(psq_6)trtgrp(trtgrp)FrequencyCol PctACCATotalYes, definitely7100.00880.0015Maybe, some reservations00.00220.002Total71017

36. Table of psq_q3 by trtgrppsq_q3(psq_q)trtgrp(trtgrp)FrequencyCol PctACCATotalToo few to ensure safety 00.0019.091Necessary part of treatment1090.911090.9120Blood tests not necessary19.0900.001Total111122Parent Satisfaction QuestionnaireQuestion 3: We did some blood tests to check for possible unknown safety problems with the oils. How do you feel about the blood test?

37. Parent Satisfaction QuestionnaireQuestion 5: How do you feel about the side effects assessmentsTable of psq_q5 by trtgrppsq_q5(psq_q)trtgrp(trtgrp)FrequencyCol PctACCATotalVery important981.8212100.021Somewhat important19.0900.001Not important19.0900.001Total111223

38. Parent Satisfaction QuestionnaireQuestion 10: What type of oil application do you prefer?Table of psq_q10 by trtgrppsq_q10(psq_q)trtgrp(trtgrp)FrequencyCol PctACCATotalTopical342.86330.006Diffusion457.14660.0010Neither00.00110.001Total71017

39. Parent Satisfaction QuestionnaireQuestion 8: Were there aspects of the study you did not like?Table of psq_q8 by trtgrppsq_q8(psq_8)trtgrp(trtgrp)FrequencyCol PctACCATotalYes436.36541.679No763.64758.3314Total111223

40. Parent Satisfaction QuestionnaireQuestion 8: Were there aspects of the study you did not like?Length of visits and questionnairesActigraph WatchTravel time to siteBlood testsWishing for more positive response

41. Parent Satisfaction QuestionnaireQuestion 9: Were there aspects of the study you especially liked or thought were particularly valuable?Table of psq_q9 by trtgrppsq_q9(psq_9)trtgrp(trtgrp)FrequencyCol PctACCATotalYes872.731083.3318No327.27216.675Total111223

42. Parent Satisfaction QuestionnaireQuestion 9: Were there aspects of the study you especially liked or thought were particularly valuable?The teamSmell of the oilSleep logs and box-scoresMonthly progress reviews/Child being closely monitored

43. ReferencesHerz R.S. (2009). Aromatherapy Facts and Fictions: A Scientific Analysis of Olfactory Effects on Mood, Physiology and Behavior. International Journal of Neuroscience, 119(263), 263-290.Hiscock, H., & Wake, M. (2002). Randomized Controlled trial of behavioral infant sleep intervention to improve infant sleep and maternal mood. British Medical Journal, 324, 1062-1065.Hollway, J.A., & Aman, M.G. (2011b). Correlates of sleep disturbance in children with pervasive developmental disorders. Research in Developmental Disabilities, 32, 1399-1421.Lecavalier, L., Wood, J.J., Halladay, A., Jones, N. et al. (2014). Measuring anxiety as a treatment endpoint in youth with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44, 1128-1143.Lillehei, A.S. & Halcon, L.L. (2014). A systematic review of the effect of inhaled essential oils on sleep. Journal of Alternative and Complementary Medicine, 20 (6), 441-451.McCracken, J.T., McGough, J., Shah, B., Cronin, P., Hong, D., Aman, M.G., Arnold, L.E., Lindsay, R.L., Nash, P., Hollway, J., McDougle, C.J., Posey, D., Swiezy, N., Kohn A., Scahill, L., Martin, A., Koenig, K., Volkmar, F., Carroll, D., Lancor, A., Tierney, E., Ghuman, J., Gonzalez, N. M., Grados, M., Vitiello, B., Ritz, L., Davies, M., Robinson, J., McMahon, D., (2002). A double-blind, placebo- controlled trial of risperidone in children with autistic disorder. The New England Journal of Medicine, 347, 314-321.

44. Probiotics for Improving Quality of Life in Autism: a placebo-controlled pilot studyL. Eugene Arnold, M.D., M.EdJill Hollway, Ph.D., M.A.Addie Jeffs, B.S.Autism Treatment Network/Autism Intervention Research in Physical Health

45. IntroductionAutism Spectrum Disorder (ASD) is a heterogenous developmental disorder reportedly affecting 1 in 68 children in the United States.Medical and mental health conditions commonly co-occur. Among the more commonly reported co-occurring conditions in children with ASD are GI problems and anxiety symptoms, which in combination with core ASD symptoms can negatively impact health and well-being.The healthy human gut contains beneficial bacteria that protect from pathogenic microbes, assist in metabolism and immune balance, and enable healthy GI functioning. Research in GI disorders has led to increased awareness and understanding of the gut microbiome. Studies have found altered bacterial composition in individuals with inflammatory bowel disorders.

46. Rationale: Microbiome-Gut-Brain AxisProbiotics can be defined as substances that stimulate the growth of microorganisms, especially those with beneficial properties. The most common types are lactic acid bacteria and bifidobacteria.Studies have shown that changing the gut flora by the intervention of probiotics can positively impact GI function. Furthermore, studies have shown that changes in gut microbriota can impact neurobehavioral function through the microbiome-gut-brain axis.Probiotics produce neurotransmitters, such as GABA and Serotonin, which act on the brain-gut axis via the vagus, and have thus been dubbed “Psychobiotics” in this role. Prior research has not only shown that probiotics appear to improve GI function and emotional symptoms such as anxiety and depression in rodent models and in neurotypical humans, but also a slight improvement in autistic symptoms in subjects with ASD.

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48. Literature ThemesThere are 4 encouraging literature themes:probiotics appear to improve GI function and emotional symptoms such as anxiety and depression in rodent models and in neurotypcial humansChildren with ASD have a high rate of GI dysfunction and gut microbiome that differs from healthy controls GI problems are significantly associated with anxiety and sensory over-responsivity in ASDAn open trial of probiotic in ASD suggested mild improvement in autistic symptoms

49. Probiotics to Improve Quality of Life in children with ASD: Primary AimsAim 1: To determine the feasibility of a large multisite randomized clinical trialAim 2: Confirm the safety of Visbiome in children with ASDAim 3:To explore effects of probiotics on quality of life, GI dysfunction, and anxiety in children with ASDAim 4: explore the extent to which Visbiome changes the composition of gut microbiome and stool neurotransmitters in children with ASD

50. Methods: Randomized Double-Blind Crossover Study12 children aged 3-12 years diagnosed with ASD were randomly assigned 1:1 to probiotic or placebo19-week cross over studyTwo 8 week conditions (either probiotic or placebo)3 week washout6 study visits

51. Inclusion CriteriaChild aged 3-12 years, inclusiveDiagnosis of Autism Spectrum Disorder (ASD) by DSM-Vhad >2 mo. abdominal pain, constipation, diarrhea, and/or vomiting, with an item-mean score >2 on at least one scale of the GI module of the PedsQL scale had clinical anxiety symptoms with an item mean of >1.0 (0-3 scale) on Parent-Rated Anxiety Scale (PRAS)English-speaking (both child and at least one caregiver)

52. Exclusion CriteriaAntibiotics in 2 months prior to enrollingPrior bowel surgeryChronic serious medical condition (i.e. diabetes)Weight or height < 3rd %ile for age Chronic anti-inflammatory use within 2 months prior to enrolling history of inflammatory bowel disease, celiac disease, or eosinophilic disordersAlready taking probiotics within the previous 6 months

53. Probiotic Treatment: Visbiome (VSL#3)Made up of 4 strains of lactobacilli (L. casei, L. plantarum, L. acidophilus, and L. delbrueckii subsp. bulgaricus), 3 strains of bifidobacteria (B. longum, B. infantis, and B. breve), 1 strain of Streptococcus thermophiles, and starch Visbiome is available commercially from ExeGi Pharma LLC, Gaithersburg, MD We chose this formulation because of previous experience in treating irritable bowel syndrome (IBS) with it Participants took 2 packets daily (900 billion bacteria) for 8 weeks mixed in a cold food or noncarbonated beverage

54. Treatment Dosing ScheduleProbiotic and matched placebo were supplied by the company in powder packets each containing 900 billion orgnaismsStarting does the first 4 weeks was a half packet to be taken twice daily mixed with food or drinkAfter 4 weeks, there was an option to increase to a full packet twice daily if no effect was noted (determined by physician)Adherence was measured by packet counts of returned probiotic and placebo containers.

55. Primary and Secondary Outcome MeasuresPrimary Outcome MeasureGastrointestinal Module of the Pediatric Quality of Life Inventory (Peds QL GI)Secondary Outcome MeasuresParent-rated Anxiety Scale for ASD (PRAS-ASD)Target Symptom RatingAberrant Behavior Checklist (ABC)Social Responsiveness Scale (SRS)Abbreviated Children’s Sleep Habits Questionnair (CSHQ)Parent Stress Index (PSI)Fecal bacterial DNADiet Logs

56. Primary Outcome Measure: Gastrointestinal Module of the Pediatric Quality of Life Inventory (Peds QL GI)74-item survey with 14 scales (# of items)Stomach pain and hurt, discomfort when eating, food and drink limits, trouble swallowing, heartburn/reflux, nausea/vomiting, gas and bloating, constipation, blood in poop, diarrhea, worry about going poop, worry about stomachaches, medicines, and communicationReponse choices are in Likert-scale format ranging from 0 to 4 (0=Never, 1=Almost Never, 2=Sometimes, 3=Often, 4=Almost Always)Items are reverse-scored and transformed to a 0-100 scale so lower scores reflect worse GI dysfunction4 versions, for ages 2-4 years, 5-7 years, 8-12 years, and 13-18 yearsUsed the age-normed scale for appropriate for each child; once selected, same scale was used throughout the child’s participation

57. Parent-Rated Anxiety Scale for ASD (PRAS-ASD)25-item scale used to assess observable anxiety symptoms in children with ASD within the last two weeksItems rated on a 0-3 scale (0=none and 3=severe)Created based on the FDA’s requirements to include feedback from “the population being served”

58. Target Symptom RatingParents were asked to name the 2 problems of most concern to them at baseline, one relating to GI problems and one relating to anxietyA clinician helped the parent to quantify and describe the problem (frequency, duration, severity, interference with daily life)At subsequent visits, the clinician reminded the parent of the previous description and helped them quantify the current stateA panel of blind clinicians reviewd the descriptions and rated each on a 9-point scale relative to baseline, from remission to disastrously worse (5 being no change)rating were then averagedThe GI symptoms were analyzed separately, as well as being averaged into the overall symptom ratingA rating of 5=no change, so we subtracted 5 from values reported for the Target Symptoms scale, so that a negative number indicates improvement from baseline and a positive number indicates deterioration.

59. Secondary Outcome MeasuresAberrant Behavior Checklist (ABC)58-item parent rating on a 0-3 scales with 5 subscales: irritability, social withdrawal, stereotypies, hyperactivity, inappropriate speechSocial Responsiveness Scale (SRS)65-item rating scale to measure the severity of ASD symptoms as they occur in natural social settingsAbbreviated Children’s Sleep Habits Questionnaire (CSHQ)33-item parent rating with eight subscales to measure sleep habits: bedtime resistance, sleep onset latency, sleep duration, anxiety around sleep, night awakenings, sleep disordered breathing, parasomnias, and morning waking/daytime sleepiness Parent Stress Index (PSI)Used to evaluate the degree of stress in the parent-child relationship36-items rated on a 5 point scale from 1=strongly disagree to 5=strongly agree

60. Fecal Bacterial DNA-Stool SamplesStool samples were collected from each participant at the baseline and end of each condition (4 samples total)Microbiome was characterized by sequencing the 16S rRNA gene and bioinformatics analysis of bacterial composition, diversity, and community structure LC- and GC-mass spectrometry identified metabolites of interest in anxiety, as well as a panel of microbial-produced neurotransmitters (GABA, serotonin, indoles)Complete multi-omic analysis of a subset of children in each order of condition, integrating microbiome, metabolome, and clinical metadata, was done to identify of correlative profiles with anxiety in ASD

61. Diet LogsDiet logs were completed by parents for three days prior to each stool sample collectionThis was done to determine whether the child’s diet changed significantly since the baseline stool sample was collectedThis allowed us to adjust for dietary changes as a potential confounding factor in stool sample variation

62. Results13 patients were randomized to order, but 3 dropped out, leaving 10 who progressed through the studyMedian adherence to study treatment was 96%Only 6 of the 10 guessed the correct treatment order; 2 did not have enough clue to take a guess and 2 guessed incorrectly

63. Results Continued Over the 19 weeks of the trial, each outcome measure showed improvement from baselinePedsQL and PRAS-ASD didn't’t show a significant difference between treatments There was a carryover effect of the first condition through the 3 week washout to week 1111-week improvement from original baseline on the PedsQL GI from probiotic condition is greater than from the placebo conditionOn the first target symptom selected by parent, participants showed more improvement while on supplement than on placebo after 8 weeks of treatmentSecond target symptom effect was not significantAverage of the two target symptoms did not show significance

64. Results ContinuedEffect Sizes: more utility than statistical significance for this pilot studyPedsQL showed an effect size of d=0.49 by the general model and d=0.79 by simple comparison of week 8 changes from respective baselinesPRAS-ASD showed an effect size of d=0.07 Average of target symptoms had an effect size of d=0.52All of these are in the direction of more improvement with probiotic than placebo

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70. Results: Adverse EventsNo serious adverse eventsNo AE’s occurred significantly more often with probiotic than with placebo14 occurred with probiotic17 occurred with placeboOf Ae’s that were probably or possibly attributable to study treatment, 3 participants reported them while on probiotic and 7 reported them while on placebo

71. Microbiome ResultsNo significant shifts in fecal microbiota community structure or diversity associated with probiotic treatment Lactobacillus was positively correlated with improvement in PedsQL GIUnclassified Clostridial species was significantly associated with low PedsQL GI scores in the longitudinal cohort type of bug that may regulate neurotransmitter levels

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74. Discussion: FeasibilityAble to recruit 13 families in 10 months with a 76% retention rate with good adherence, good satisfaction, and acceptable blindingData suggests that a parallel-groups design is necessary for a larger RCT due to the unsuccessful washoutUnsuccessful washout is both good and bad newsSuggest a more enduring effect from 8 weeks of probioticSuggests that a cross-over Outcome MeasurementsPedsQL GI=sensitiveTarget symptoms=moderately sensitivePRAS-ASD=insensitivedifferent measure of anxiety should be considered for the RCT

75. Discussion: SafetyNo serious adverse events, as predictedThe probiotic formulation as not associated with any more AE’s than placeboResults confirm previous data on safety of Visbiome

76. Discussion: Effect SizesPedsQL GI had a medium effect, but not significant at this sample sizeTarget symptom assessment showed a medium to large effect sizeBoth findings are encouraging enough to warrant a large RCTLarge improvement in both groups from baseline to 8 weeks and baseline to 11 weeksLarge part of improvement due to placebo effectCan be dealt with in power calculations

77. Discussion: LimitationsSmall sample size increase sample size by removing restrictionsToo short of a washout period increase length of washoutChoice of a newly created anxiety scale that promised to be specific to ASD but was insensitive for this treatment choose different anxiety scale

78. ConclusionThe probiotic Visbiome is a safe treatment in children with ASD and GI dysfunctionEfficacy for quality of life is unprovenEffect sizes of target symptoms and quality of life suggest that a large Randomized Clinical Trial (RCT) is warranted

79. ReferencesBercik, P, A J Park, D Sinclair, A Khoshdel, J Lu, X Huang, Y Deng, et al. “The Anxiolytic Effect of Bifidobacterium Longum NCC3001 Involves Vagal Pathways for Gut-brain Communication.” Neurogastroenterology and Motility: The Official Journal of the European Gastrointestinal Motility Society 23, no. 12 (December 2011): 1132–1139. Bercik, Premysl, Emmanuel Denou, Josh Collins, Wendy Jackson, Jun Lu, Jennifer Jury, Yikang Deng, et al. “The Intestinal Microbiota Affect Central Levels of Brain-derived Neurotropic Factor and Behavior in Mice.” Gastroenterology 141, no. 2 (August 2011): 599–609, 609.e1–3.Coccorullo, P., Strisciuglio, C., Martinelli, M., Miele, E., Greco, G., Staiano, A. Lactobacillus reuteri (DSM 17938) in Infants with Functional Chronic Constipation: A Double-Blind, Randomized, Placebo- Controlled Study. J Pediatr 2010;157:598-602Dinan TG, Stanton C, Cryan JF. Psychobiotics: a novel class of psychotropic. BIOL PSYCHIATRY 2013;74:720–726. Lozupone, Catherine A., Jesse I. Stombaugh, Jeffrey I. Gordon, Janet K. Jansson, and Rob Knight. “Diversity, Stability and Resilience of the Human Gut Microbiota.” Nature 489, no. 7415 (September 13, 2012): 220–230.Sadeghzadeh, M., Rabieefar, A., Khoshnevisasl, P., Mousavinasab, N., Eftekhari, K. The Effect of Probiotics on Childhood Constipation: A Randomized Controlled Double Blind Clinical Trial. Int. J. of Ped. (2014): 937212. DOI: 10.1155/2014/937212Tiequn B, Guanqun C, Shuo Z (2015). Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis. Intern Med 54:243-249, 2015. DOI: 10.2169/internalmedicine. 54.2710