COMBINATION PRODUCT FOR PROPHYLAXIS AND TREATMENT OF IRRITABLE BOWEL SYNDROME

Abstract

A combination product comprising a strain of Bifidobacterium NCIMB 41676 and a strain of Bifidobacterium NCIMB 41003 is used in the prophylaxis or treatment of irritable bowel syndrome (IBS). The combination product leads to a surprising, sustained positive effects, even after feeding has stopped.

Claims

1. A formulation comprising an isolated strain of Bifidobacterium NCIMB 41676 and an isolated strain of Bifidobacterium NCIMB 41003.

2. A formulation as claimed in claim 1 wherein at least one of the Bifidobacterium strains is in the form of viable cells.

3. A formulation as claimed in claim 1 or 2 wherein at least one of the Bifidobacterium strains is in the form of non-viable cells.

4. A formulation as claimed in any of claims 1 to 3 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of more than 10.sup.6 cfu.

5. A formulation as claimed in any of claims 1 to 4 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of from 10.sup.7 to 10.sup.10 cfu.

6. A formulation as claimed in any of claims 1 to 5 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of from 10.sup.8 to 10.sup.9 cfu.

7. A formulation as claimed in any of claims 1 to 6 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of about 510.sup.8 cfu.

8. A formulation as claimed in any of claims 1 to 7 wherein the Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of more than 10.sup.6 cfu.

9. A formulation as claimed in any of claims 1 to 8 wherein Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of from 10.sup.7 to 10.sup.10 cfu.

10. A formulation as claimed in any of claims 5 to 9 wherein Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of from 10.sup.8 to 10.sup.9 cfu.

11. A formulation as claimed in any of claims 1 to 10 wherein the Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of about 510.sup.8 cfu.

12. A formulation as claimed in any of claims 1 to 11 in the form of a bacterial broth.

13. A formulation as claimed in any of claims 1 to 11 in the form of a freeze-dried powder.

14. A formulation as claimed in any of claims 1 to 13 which further comprises a prebiotic material.

15. A formulation as claimed in any one of claims 1 to 14 further comprising an ingestible carrier.

16. A formulation as claimed in claim 15 wherein the ingestible carrier is a pharmaceutically acceptable carrier such as a capsule, tablet or powder.

17. A formulation as claimed in claim 15 wherein the ingestible carrier is a food product such as an acidified milk, a yoghurt, a frozen food such as frozen yoghurt or ice cream, a gum, a candy, a milk powder, a milk concentrate, a cheese spread, a nutritional composition, a nutritional supplement, a cereal bar, a dressing or a beverage.

18. A formulation as claimed in claim 15 wherein the formulation is an infant food.

19. A formulation as claimed in any of claims 1 to 18 in the form of a fermented food product.

20. A formulation as claimed in any of claims 1 to 19 in the form of a fermented milk product.

21. A formulation as claimed in any of claims 15 to 20 wherein the carrier does not occur in nature.

22. A formulation as claimed in any one of claims 1 to 21 which further comprises a protein and/or peptide, in particular proteins and/or peptides that are rich in glutamine/glutamate, a lipid, a carbohydrate, a vitamin, mineral and/or trace element.

23. A formulation as claimed in any one of claims 1 to 22 which further comprises an adjuvant.

24. A formulation as claimed in any one of claims 1 to 23 which further comprises a bacterial component.

25. A formulation as claimed in any one of claims 1 to 24 which further comprises a drug entity.

26. A formulation as claimed in any one of claims 1 to 25 which further comprises a biological compound.

27. A foodstuff comprising a formulation as claimed in any of claims 1 to 26.

28. A medicament comprising a formulation as claimed in any of claims 1 to 26.

29. A product comprising an isolated strain of Bifidobacterium NCIMB 41676 and an isolated strain of Bifidobacterium NCIMB 41003 for use in the prophylaxis or treatment of irritable bowel syndrome (IBS).

30. A product for use as claimed in claim 29 for altering bowel symptoms associated with IBS.

31. A product for use as claimed in claim 29 or 30 for improving mood associated with IBS.

32. A product for use as claimed in any of claims 29 to 31 for reducing stress associated with IBS.

33. A product for use as claimed in any of claims 29 to 32 for reducing anxiety associated with IBS.

34. A product for use as claimed in any of claims 29 to 33 for improving sleep quality associated with IBS.

35. A product for use as claimed in any of claims 29 to 34 for treating depression associated with IBS.

36. A product for use as claimed in any of claims 29 to 35 for normalising dysregulated cortisol awakening response associated with IBS.

37. A product for use as claimed in any of claims 29 to 36 comprising administering a formulation as claimed in any of claims 1 to 26.

38. A combination product comprising an isolated strain of Bifidobacterium NCIMB 41676 and an isolated strain of Bifidobacterium NCIMB 41003 for use in the prophylaxis or treatment of irritable bowel syndrome (IBS).

39. A product for use as claimed in any of claims 29 to 38 wherein at least one of the Bifidobacterium strains is in the form of viable cells.

40. A product for use as claimed in any of claims 29 to 39 wherein at least one of the Bifidobacterium strains is in the form of non-viable cells.

41. A product for use as claimed in any of claims 29 to 40 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of more than 10.sup.6 cfu.

42. A product for use as claimed in any of claims 29 to 41 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of from 10.sup.7 to 10.sup.10 cfu.

43. A product for use as claimed in any of claims 29 to 42 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of from 10.sup.8 to 10.sup.9 cfu.

44. A product for use as claimed in any of claims 29 to 43 wherein the Bifidobacterium strain NCIMB 41676 is present in the formulation in an amount of about 510.sup.8 cfu.

45. A product for use as claimed in any of claims 29 to 44 wherein the Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of more than 10.sup.6 cfu.

46. A product for use as claimed in any of claims 29 to 45 wherein Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of from 10.sup.7 to 10.sup.10 cfu.

47. A product for use as claimed in any of claims 29 to 46 wherein Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of from 10.sup.8 to 10.sup.9 cfu.

48. A product for use as claimed in any of claims 29 to 47 wherein the Bifidobacterium strain NCIMB 41003 is present in the formulation in an amount of about 510.sup.8 cfu.

49. A product for use as claimed in any of claims 29 to 48 wherein the product is in the form of a bacterial broth.

50. A product for use as claimed in any of claims 29 to 49 wherein the product is in the form of a freeze-dried powder.

51. A product for use as claimed in any one of claims 29 to 50 wherein the product further comprises an ingestible carrier.

52. A product for use as claimed in claim 51 wherein the ingestible carrier is a pharmaceutically acceptable carrier such as a capsule, tablet or powder.

53. A product for use as claimed in claim 51 wherein the ingestible carrier is a food product such as an acidified milk, a yoghurt, a frozen food such as frozen yoghurt or ice cream, a gum, a candy, a milk powder, a milk concentrate, a cheese spread, a nutritional composition, a nutritional supplement, a cereal bar, a dressing or a beverage.

54. A product for use as claimed in claim 51 wherein the ingestable carrier is an infant food.

55. A product for use as claimed in any of claims 29 to 51 wherein the product comprises a fermented food product such as a fermented milk.

Description

BRIEF DESCRIPTION OF THE FIGURES

[0064] The invention will be more clearly understood from the following description thereof, given by way of example only, with reference to the accompanying figures in which:

[0065] FIG. 1 is a schematic diagram of an open label combo IBS study schematic;

[0066] FIG. 2 is a graph of IBS symptom severity scale (IBS-SSS) for the IBS patients before and after combo treatment;

[0067] FIGS. 3(a) to (e) are a set of graphs of IBS-SSS individual symptoms (Abdominal pain (a) discomfort and (b) frequency, (c) abdominal distension, (d) bowel satisfaction and (e) IBS quality of life) for the IBS patients before and after combo treatment;

[0068] FIGS. 4(a) to (c) are a set of graphs of IBS symptom severity scale (IBS-SSS) for the IBS patients (constipation (a), mixed (b) and diarrhoea (c)) before and after combo treatment;

[0069] FIGS. 5(a) to (c) are a set of graphs of IBS symptom severity scale (IBS-SSS) for the IBS patients (a) moderate to severe, (b) moderate and (c) severe) before and after combo treatment;

[0070] FIG. 6(a) and (b) are graphs of (a) HADS depression and (b) HADS anxiety scores for the IBS patients before and after combo treatment;

[0071] FIGS. 7(a) and (b) are plots of the correlation between (a) IBS symptom severity scale vs HADS depression and (b) IBS symptom severity scale vs HADS anxiety;

[0072] FIGS. 8(a) and (b) are bar charts of % decrease in HADS depression for the IBS patients before and after Bif35624 alone compared to before and after the combo treatment;

[0073] FIGS. 9(a) and (b) are bar charts of percent decrease in HADS anxiety and depression scores for the IBS patients before and after Bif35624 alone compared to before and after the combo treatment;

[0074] FIGS. 10(a) and (b) are plots of plasma TNF levels for the Healthy vs. IBS patients and IBS patients before and after combo treatment;

[0075] FIG. 11 is a plot of plasma TNF levels for the IBS patients before and after Bif35624 treatment;

[0076] FIG. 12 is a plot of global PSQI score for the IBS patients (a) and IBS patients (PSQI over 5) (b) before and after combo treatment;

[0077] FIG. 13 is a plot of subjective sleep latency for the IBS patients (a) and IBS patients (PSQI over 5) (b) before and after combo treatment;

[0078] FIG. 14 is a plot (a) and table (b) of subjective sleep quality for the IBS patients before and after combo treatment;

[0079] FIG. 15 is a plot (a) and table (b) of subjective sleep quality for the IBS patients (PSQI over 5) before and after combo treatment;

[0080] FIG. 16 is a bar graph of salivary cortisol (AUC.sub.i) for the Healthy Controls vs. IBS patients

[0081] FIG. 17 is a plot of salivary cortisol (AUC.sub.i) for the IBS patients (moderate to severe) before and after combo treatment;

[0082] FIGS. 18(a) and (b) are charts of overnight cultures of 35624 either alone or in combination with 1714, or DPC6315;

[0083] FIG. 19 is a plot of IL-10/IL-12 ratios from PBMC stimulated with Bif35624, AH1714 and DPC6315 in vitro;

[0084] FIG. 20 is a bar chart of IL-10 levels from PBMC stimulated with Bif35624, or DPC6315 or a combination of both in vitro;

[0085] FIGS. 21(a) and (b) are graphs of Clinical Arthritis Score -All paws (Score 0-5) after feeding with Bif35624, DPC6315 or a combination of both; and

[0086] FIG. 22 is a plot of percent incidence over time after feeding with Bif35624, DPC6315 or a combination of both.

DETAILED DESCRIPTION

[0087] A deposit of Bifidobacterium longum strain UCC35624 was made at the National Collections of Industrial and Marine Bacteria Limited (NCIMB) Ferguson Building, Craibstone Estate, Bucksburn, Aberdeen, AB21 9YA, Scotland, UK on January 13, 1999 and accorded the accession number NCIMB 41003.

[0088] Bifidobacterium longum strain UCC35624 was isolated from resected and washed human gastrointestinal tract. The strain is described in W000/42168A, the entire contents of which are incorporated herein by reference.

[0089] B. longum 35624 strain has been extensively studied and shown to regulate inflammatory responses (Groeger et al., 2013, Konieczna et al., 2012) and reduce abdominal pain, bloating, gas and unpredictable bowel habits in IBS subjects in two well-controlled clinical studies (O'Mahony et al., 2005, Whorwell et al., 2006).

[0090] A deposit of Bifidobacterium longum strain AH1714 was made at the National Collections of Industrial and Marine Bacteria Limited (NCIMB) Ferguson Building, Craibstone Estate, Bucksburn, Aberdeen, AB21 9YA, Scotland, UK on November 5, 2009 and accorded the accession number NCIMB 41676.

[0091] Bifidobacterium longum strain AH1714 was isolated from colonic biopsy tissue from healthy human subjects. The strain is described in WO2011/058535A, the entire contents of which are incorporated herein by reference.

[0092] B. longum 1714 strain has been shown to attenuate the anxiety and stress and improve cognition in preclinical and clinical studies (Allen et al., 2016, Savignac et al., 2014, Savignac et al., 2015).

EXAMPLES

[0093] The following examples further describe and demonstrate embodiments within the scope of the invention. The examples are given solely for illustration and are not to be construed as limitations of the present invention, as many variations thereof are possible without departing from the spirit and scope of the invention.

[0094] Formulation

[0095] The strains may be administered in a single formulation which is preferred to ensure patient compliance. However, in some cases the strains may be administered at the same or different times and using the same or different routes for administration.

[0096] The strains may be administered in any suitable amount to achieve the desired result. In some cases, the same quantities of the strain are administered.

[0097] Preferably the strains are each administered at a dose of at least 10.sup.6cfu per day per strain, preferably at a target dose of 510.sup.8 cfu to 110.sup.9 cfu per day per strain.

[0098] The strains are in the form of freeze dried powder which is blended with food grade excipient and filled into a format such as a sachet or capsule.

[0099] A freeze-dried powder comprising 510.sup.8 CFU B. longum 35624 and 110.sup.9 CFU B. longum 1714 was prepared. Strains were fermented in de Man, Rogosa and Sharpe medium (from first principles). The particulate collected after centrifugation of each strain was washed and subsequently freeze-dried.

Example 1

An Open Label Irritable Bowel Syndrome (IBS) Study: A Combination B. longum Product Shows Reduction in Symptoms of IBS in Adults (Combo)

[0100] A human trial was performed as follows to investigate the effect of a combination of B. longum 35624 and B. longum 1714 on bowel symptoms in adults with irritable bowel syndrome (IBS). The work consisted of an open label study. Bowel symptoms were measured using self-reported measures such as the IBS symptom severity scale (IBS-SSS) which incorporates pain, distension, bowel dysfunction and quality of life (global well-being). The IBS-SSS is recognised for its ability to reliably score patients previously classified as mild, moderate or severe. The maximum achievable score was 500. Recruitment of more homogeneous groups of patients (mild, moderate and severe cases) were indicated by scores of 75 to 175, 175 to 300 and over 300 respectively. Controls scored below 75 and patients scoring in this range can also be in remission. IBS-SSS of 50 has been defined as a clinically significant change in symptom severity (Francis et al., 1997). This scale provides a valuable instrument in helping to meet the many challenges offered by IBS.

[0101] The clinical protocol for this trial was as follows:

[0102] Forty female subjects aged 18-55 years were recruited with IBS, diagnosed by Rome III criteria, and mild to moderate anxiety and/or depression as determined by the Hospital Anxiety and Depression scale (HADs). Subjects who had a psychiatric diagnosis other than anxiety or depression, a major inflammatory disorder or were on anti-depressants, anxiolytics or antipsychotics in the last 6 months were excluded.

[0103] Results of Combo Trial on IBS Symptoms as Measured by the IBS-SSS Scale

[0104] IBS symptoms were assessed by the IBS-Symptom Severity Scale (IBS-SSS). This was an open labelled study with a freeze-dried powder comprising 510.sup.8 CFU B. longum 35624 and 110.sup.9 CFU B. longum 1714 (combo) for 8-weeks, followed by an 8-week washout (FIG. 1) The IBS-SSS was measured at 0, 4, 8, 12 and 16 weeks.

[0105] The IBS-SSS scores improved significantly from baseline to the end of the intervention (8 weeks) by a meanSD of 100112.5 in the combo group. However once feeding stopped the IBS-SSS dis-improved again and by week 16 (8 weeks post feeding) with only an improvement of 3597 from baseline. A clinically important difference has been described as a change in IBS-SSS of >50 (FIG. 2). When we analysed all the individual symptoms that make up the IBS-SSS score the combo treatment improved all symptoms including of these including abdominal pain discomfort, abdominal pain frequency, abdominal distension, bowel satisfaction and IBS quality of life, a result which is not the same for all probiotics (FIGS. 3(a)-(e)). The combo product benefits all subtypes of IBS patients including those with constipation, diarrhoea and mixed patients (FIGS. 4(a)-(c)). The combo product impacts even the most severe patients while feeding but symptoms start to return once the combination is not being consumed anymore (FIGS. 5(a)-(c)).

[0106] Normally randomised double-blind placebo-controlled studies are state of the art in clinical medicine but using the open label study we were able to provide valuable information on estimating the carryover effect, determine the washout period, provide reliable data on the subject characteristics and variation in the parameters measured as well as showing the therapeutic potential of this combination product.

[0107] Results of Combo Trial on IBS Symptoms as Measured by the HADs Scale

[0108] In the Combo trial we measured anxiety and depression using a validated questionnaire called the Hospital Anxiety and Depression scale (HADs) at 0, 4, 8, 12 and 16 weeks. We found that B. longum 35624 in combination with B. longum 1714 was very effective in IBS in reducing depression and anxiety symptoms in IBS subjects. The HADs depression score improved significantly from baseline to the end of the intervention (8 weeks) by a meanSD of 1.63.122 in the combo group. Surprisingly once feeding stopped the HADs depression score improved further at week 12 (2.02.63; meanSD) and maintained this improvement by week 16 (1.753.386; meanSD) (8 weeks post feeding) (FIG. 6(a)). The HADs anxiety score improved significantly from baseline to the end of the intervention (8 weeks) by a meanSD of 1.3753.012 in the combo group. Surprisingly once feeding stopped the HADs anxiety score also improved further at week 12 (2.2753.637; meanSD) and maintained this improvement at week 16 (2.32.98; meanSD) which was 8 weeks post participants stopped taking the combo product. (FIG. 6(b)). A clinically important difference has been described as an HADs improvement of 2.

[0109] No correlation at Baseline Between HADS Scores and Symptom Severity Score in IBS Patients in the Combo Study

[0110] IBS is a GutBrain Disorder. It well recognized that anxiety and depression are commonly encountered co-morbidities among sufferers with IBS. However, little is known of the precise 20 nature of these co-morbidities and their association in IBS. The objective was to characterize the relationship between IBS and these psychiatric co-morbidities in the IBS group with elevated anxiety and depression to see if these were dependent or independent cofactors. This was assessed utilising the baseline results of the combination study, as described in example 1.

[0111] The median IBS-SSS score was 250 (IQR:190-315) while HADs anxiety score and HADs depression score were 10.432.3 and 5.483.69 respectively. Of the 40 subjects, 95% and 45% had a HADs anxiety or HAD depression score of >8 respectively, while 38% had both a HADs anxiety and HADs depression score of >8. Correlation analysis of the IBS-SSS to the HADs depression and HADs anxiety scores showed a weak correlation for HADs depression score (R2=0.3246; P=0.001) but no correlation for HADs anxiety score (R2=0.3647; P=0.2378) (FIGS. 7(a)-(b)). For the group of IBS subjects with mild to moderate levels of anxiety and depression, a weak or no correlation was observed between the severity of IBS and the levels of anxiety and depression. These results suggest that IBS and co-morbid anxiety/depression are independent factors and may require separate management approaches as used in the combination 35624/1714 product. To further interrogate this hypothesis the results of the combination trial were assessed by reference to data gathered using 35624 strain alone.

[0112] Comparison of the Effect of the Combo or 35624 Alone has on the HADS Scores of IBS Patients

[0113] The Combo product had a clinically significant effect in improving mood (reducing anxiety and depression) and surprisingly, the effects on anxiety and depression were sustained during the 8-week period where participants did not take the combo product. Therefore, it was of interest to compare our results to a previous study performed in IBS patients who were treated with B. longum 35624 alone (Whorwell et al 2006). This study was a randomised double-blind placebo controlled multicentre trial where all types of IBS patients, whether they had co-morbid anxiety/depression, were accepted into the trial. There was no effect on HADs scores over the placebo effect with the single strain B. longum 35624. The subjects had a transient decrease in severity of HADS scores which disappeared once feeding stopped (FIGS. 8(a) and 9(a)). This differs from the combo product where the significant effect on HADs scores were seen after feeding was potentiated and the effects maintained 8 weeks post cessation of feeding (FIGS. 8(b) and 9(b)).

Example 2

The Effect of Feeding of 35624 Strain Alone or in Combination with 1714 Strain on the Plasma TNF-a Levels in IBS Patients

[0114] After feeding the combo product to IBS patients we found there was a reduction in anxiety and depression with IBS and these effects sustained post cessation of feeding. To determine if there was also a change in inflammatory tone of the study participants the plasma biomarker tumor necrosis factor (TNF)- was measured. In a recent study, TNF- serum levels were correlated with discomfort and severity of symptoms in IBS patients (Choghakhori et al 2017). Several other studies have established that IBS patients had higher levels of TNF- in serum compared to healthy controls (Rana et al 2012; Seyedmirzaee et al 2016; Schmulson et al 2012). Furthermore, in a case-control trial, the authors demonstrated that abnormal levels of cytokines including tumor necrosis factor-, were significantly correlated with the symptoms of IBS, and 30 with the severity of depressive and anxiety mood symptoms (Zhen et al 2018).

[0115] We investigated the effect of the combination of B. longum 35624 and B. longum 1714 on the inflammatory marker TNF- in adults with IBS at 0, 4, 8, 12 and 16 weeks.

[0116] The results were compared to another clinical trial undertaken to study the effect of B. longum 35624 alone on patients with IBS who were comorbid with anxiety and depression and who had similarly consumed the product for 8 weeks. For this study, there was a 4-week washout period. The test groups were: Placebo (n=31) and Bifidobacterium longum 35624 (110.sup.10 cfu) (n=39).

[0117] Plasma samples were collected from peripheral blood and stored at 80 C. until analysis. TNF- in the plasma were assayed using a 96-well assay kit from Meso Scale Discovery (Gaithersburg, Md.; catalog K15008B-1), and was quantitated and reported as change from baseline in picograms per millilitre. Each sample was assayed in duplicate.

[0118] In agreement with previous reports we also found a significant increase in plasma TNF- in our IBS patients compared to healthy controls (FIG. 10(a)). The combo product decreased plasma TNF- significantly over time in the IBS cohort. Again, similar to what we saw with the HADs scores there was a prolonged (8 weeks) improvement post feeding i.e. a decrease in TNF- even after feeding had stopped (FIG. 10(b)). In a previous study where IBS patients were fed B. longum 35624 alone there was a significant decrease in plasma TNF- compared to placebo during the feeding period of 8 weeks but 4 weeks after end of feeding the plasma TNF- levels were increasing and returning to baseline levels (FIG. 11). This again highlights a synergy between the combination of B. longum 35624 and B. longum 1714 where we get a prolonged improvement after feeding has stopped. In comparison B. longum 35624 loses its anti-inflammatory effect once feeding stops.

Example 3

Results of Trial on Sleep Quality as Measured by the Pittsburgh Sleep Quality Index

[0119] Sleep quality of IBS patients were assessed by the Pittsburgh Sleep Quality Index (PSQI). This was an open labelled study with the COMBO (510.sup.8 CFU/day B. longum 35624 +110.sup.9 CFU/day B. longum 1714), sachet format with maltodextrin and a flowability agent such as silicon dioxide was taken for 8-weeks, followed by an 8 week washout (FIG. 1). The PSQI was measured at 0, 4, 8, 12 and 16 weeks. Sleep quality was assessed through a modified PSQI 30 designed to measure sleep quality and disturbance over the past month in clinical populations as it has acceptable reliability and validity (Buysse et al., 1989). The PSQI is a 19-item self-report measure assessing sleep quality across seven domains: 1) sleep duration, (2) sleep disturbance, (3) sleep latency, (4) daytime dysfunction due to sleepiness, (5) sleep efficiency, (6) overall sleep quality, and (7) sleep medication use. Each of the sleep components yields a score ranging from 0 to 3, with 3 indicating the greatest dysfunction. The sleep component scores are summed to yield a total score ranging from 0 to 21 with the higher total score (referred to as global score) indicating worse sleep quality. In distinguishing good and poor sleepers, a global PSQI score >5 yields a sensitivity of 89.6% and a specificity of 86.5%.1 (Buysse et al., 1991; Herman et al., 2002; Fillingim et al.; 2011, Porto et al., 2011). We used this >5 global PSQI cut off to look at a subpopulation of our IBS patients who have poor sleep quality. Subjective sleep quality is scored as follows very good (0,) fairly good (1), fairly bad (2) very bad (3).

[0120] The daily ingestion of the Combo product significantly decreased PSQI global scores at week 4 and week 8 (FIG. 12(a)). A decrease in PSQI global score indicates an improvement in sleep quality. When looking at a sub-group of IBS patients who had poor sleep quality (>5 global PSQI) the Combo significantly decreased PSQI global scores at all time points even those post feeding (FIG. 12(b)). The global PSQI score is the sum of seven component scores (sleep disturbance, overall sleep quality, sleep latency (time to fall asleep), duration of sleep, daytime dysfunction due to sleepiness, sleep efficiency, and need for medicines to sleep). Among them, the combo significantly decreased the PSQI-sleep latency score at week 4 and week 8 and 8 weeks post feeding (FIG. 13(a)). Again, when we looked at a sub population of bad sleepers we saw a decrease in PSQI-sleep latency at 8 weeks post feeding (FIG. 13(b)). Another notable result was that when subjects were asked the question during the past month, how would you rate your sleep quality overall?), the results showed that administration of the Combo product significantly improved sleep quality in agreement with the PSQI global score. Subjective sleep quality scores improved from baseline to the end of the intervention (8 weeks), in the combo group and maintained their effect after feeding had stopped (16 weeks) (FIG. 14(a)). When looking at percentage of the different categories of sleepers the combo treatment increased the number of patients describing their sleep as good and decreasing the number of subjects who had fairly bad sleep and this is maintained even after the feeding has stopped (FIG. 14(b)). We also analysed a sub group of IBS patients who had reported that they had bad sleep at baseline, and this was reflected in a global score of PSQI of greater than 5. Subjective sleep quality scores improved from baseline to the end of the intervention (8 weeks) in the this group (global PSQI score of over 5) and maintained their effect after feeding had stopped (16 weeks) (FIG. 15(a)). When looking at percentage of the different categories of sleepers the combo treatment increased the number of patients describing their sleep as fairly good and decreasing the number of subjects who had fairly bad sleep and this is maintained even after the feeding has stopped (FIG. 15(b)). The beneficial effect of combo product on sleep quality is indicative of the potential benefits of this strain combination for health promotion.

[0121] In this IBS study 33 of the 40 patients had a global PSQI score of 5 and over and have so been characterised as bad sleepers which agrees with the literature which shows that IBS patients have poor sleep quality. After combo administration there was a significant reduction in the bad sleep quality as measured by the PSQI in these IBS patients and this effect is maintained 8 weeks after the combo administration. These results agree with what we have seen with the HADs scores where the effects maintained 8 weeks post cessation of feeding as there is an interaction between IBS symptoms and poor sleep quality.

Example 4

The Effect of Feeding of 35624 Strain in Combination with 1714 Strain on Salivary Cortisol in IBS Patients

[0122] As part of the open label trial (as described in example 1), we investigated the effect of a combination of B. longum 35624 and 1714 strains on the stress hormone cortisol in adults with IBS at 0, 4, 8, 12 and 16 weeks. Saliva cortisol and the cortisol awakening response is non-invasive, easy to perform and a well-validated method to assess HPA axis functioning. As salivary cortisol is circadian, we measure waking cortisol at 4 different time points (15 minutes, 30 minutes, 45 minutes, 60 minutes). The dynamic rise in morning cortisol usually occurs within 30-45 minutes after awakening before progressively dropping over the remainder of the day. This is known as the Cortisol Awakening Response (CAR). A normal CAR response is characterised by a short-lived peak at 30 minutes. In IBS patients this dynamic response is blunted with little or no change in cortisol levels on awakening. It is hypothesised that this is due to chronic stressors, associated with the IBS condition, inducing an exhaustion or negative feedback loop in the CAR response. A normalisation of the CAR response could indicate a beneficial reduction in the impact of IBS on the normal working of the brain-gut axis of the subject.

[0123] For hygienic collection of saliva samples Salivette swabs are used, then samples are kept frozen at 80 C. until assay. The Salivette sampling device consists of cotton swabs which the patients chew for 2 minutes and then they are transferred to the plastic tube of the device. The patient is instructed to refrain from eating, smoking, drinking tea or coffee, or brushing teeth 15 min prior to sampling and no dental work is allowed in the 24 hours preceding sample collection. Saliva samples can be stored at room temperature or in the participants' home refrigerator or freezer until they are delivered to the lab. Cortisol concentrations were determined using the Cortisol Enzyme Immunoassay Kit according to the manufacturer's instruction (Enzo Life Sciences, UK). The assay detection limit was 0.16 nmol/1. Inter- and intra-assay coefficients of variation (CVs) were 11.24% and 8.2% respectively.

[0124] From the literature subjects with IBS exhibit high cortisol levels at awakening and a blunted CAR i.e. minimal or no increase in cortisol at 30 minutes after awakening and therefore no subsequent decrease at 60 minutes. To best visualise the effect of an intervention on the CAR, the increase in the area under the curve (AUCi) is graphed and calculated. The AUCi is the area that can be measured underneath the response curve from time zero to time 60 minutes. It is calculated with reference to the first value thereby emphasizing the changes over time.

[0125] IBS patents have a blunted increase in cortisol production upon waking in the morning which results in a lower AUCi for basal morning salivary cortisol levels in IBS subjects in comparison to healthy controls (FIG. 16). This graph was recreated from data provided in the publication Suarez-Hitz et al. 2012.

[0126] The use of the combination of B. longum 35624 and B. longum 1714 (Combo) had a normalising effect on the production of awakening cortisol, leading to a temporary increase at 30mins post wakening in adults with moderate and severe symptoms of IBS. When the AUCi (n=33) was measured at week 0, week 4, week 8, week 12, and week 16 the AUCi increased, indicating a reversal of the blunting of the CAR response in IBS subjects during feeding. This effect was lost over the following 8 weeks post-feeding (week 9-16) (FIG. 17). Therefore, the feeding of the Combo normalises the dysregulated cortisol awakening response. This effect unlike the effect on sleep quality, anxiety and depression, was not sustained after feeding. To our knowledge no probiotic or probiotic combination has been seen to alter the CAR in IBS subjects in this beneficial fashion.

Example 5

Demonstration of Strain Compatibility In Vitro: Overnight Cultures of 35624 Either Alone or in Combination with 1714 Strain, or DPC6315 Strain

[0127] Prior to carrying out the human trial two co-culture experiments were done to investigate the effect of a combination of B. longum 35624 with another B. longum DPC6315 or 1714 strain in growth experiments. All past experience growing the 35624 strain has indicated that it is a sensitive strain that requires careful management. B. longum DPC6315, was chosen for its anti-inflammatory tone in in vitro experiments (example 6).

[0128] AH1714/35624, and DPC6315/35624 were co-cultured at 100 ml scale, using the exact same cell numbers to inoculate all 100m1 cultures. OD-Standardized inoculums were added to 100 ml Allergen Free Medium, 4.5% Sucrose, 0.05% Cysteine which was used for all strains. The incubation of strains only vs. strains in combination was done at 37 C. for 24 hours. The results of this experiment gave us a better indication of the co-culturing capabilities of these strains. Rifampicin resistant variants of 35624 were used to allow detection of the strain on harvest. This variation consists of a point mutation in the rifampicin antibiotic resistance gene. 35624 was cultivated and viable counting on rifampicin-containing agar medium was performed to get an accurate cell count of 35624 in the culture experiments.

TABLE-US-00001 Individual strain Individual strain Combination Control Control AH1714/35624-Rif (2% 35624-Rif) (2% AH1714) (2% each) Control Control DPC6315/35624-Rif (2% 35624-Rif) (2% DPC6315) (2% each)

[0129] AH1714/35624 co-culturing experiment: there was no major inhibition of either strain and the CFU/ml or growth for each was similar to the growth in the co-culture to both strains together (7.9e8 CFU/ml 35624 rif and 7.2e8 CFU/ml AH1714) (FIG. 12(a)).

[0130] DPC6315/35624 co-culturing experiment: there was no major inhibition of either strain and the CFU/ml for each was similar as in the co-culture of both strains together (9.4e8 CFU/ml 35624 rif and 8.5e8 CFU/ml AH1714) (FIG. 12(b)).

[0131] This result showed that there was no detrimental interaction between 35624 and 1714.

Example 6

Anti-Inflammatory (IL-10/IL-12 ratios) PBMC Profiles of 35624, AH1714 and DPC6315

[0132] We had previously demonstrated that B. longum 35624 has an anti-inflammatory profile in vitro and that this type of profile may have relevance in IBS. Therefore, the aim of this study was to determine if we could find similar anti-inflammatory Bifidobacteria longum strains which we could partner with B. longum 35624 to make an enhanced anti-inflammatory combination. We screened 15 different B. longum including both B. longum DPC6315 and B. longum 1714 for their anti-inflammatory strain profile. To determine this, we measure both IL-10 and IL-12 from PBMCs stimulated in vitro with these bacterial strains.

[0133] Interleukin-10 (IL-10) is an anti-inflammatory cytokine which is produced by many cell types 10 including monocytes, macrophages, dendritic cells, mast cells and lymphocytes (T regulatory cells). IL-10 down-regulates the expression of pro-inflammatory Thl cytokines, MHC class II antigens, and co-stimulatory molecules on antigen presenting cells. It also enhances B cell survival, proliferation, and antibody production. This cytokine can block NF-KB activity and is involved in the regulation of the JAK-STAT signalling pathway. Murine knock-out studies have demonstrated the essential role for IL-10 in immunoregulation as IL-10KO mice develop severe colitis. In addition, bacteria which are potent inducers of IL-10 have been shown to promote T regulatory cell differentiation in vivo thus contributing to immunological homeostasis (O'Mahony et al., AJP 2006; O'Mahony et al., 2008).

[0134] Interleukin-12 (IL-12) is a pro-inflammatory cytokine associated with polarisation of Th1 effector T cell responses and stimulates the production of other pro-inflammatory Th1 cytokines, such as interferon-gamma (IFN-) and tumour necrosis factor-alpha (TNF-), from T and natural killer (NK) cells. High levels of IL-12 expression is associated with autoimmunity. Administration of IL-12 to people suffering from autoimmune diseases was shown to worsen disease symptoms. In contrast, IL-12 knock-out mice or treatment of mice with IL-12 neutralising antibodies ameliorated the disease.

[0135] Cytokine cascades and networks control the inflammatory response, rather than the action of a cytokine on a cell type. The relative levels of expression, or balance, of two cytokines (such as IL-10 and IL-12) is more informative than the expression of a single cytokine. In these studies, we stimulated human PBMCs with a range of different bacterial strains. All strains induced IL-10 and all strains induced IL-12. However, examination of the ratio between IL-10 and IL-12 induction revealed that some bacterial strains induced a higher ratio (i.e. more IL-10 with less IL-12) compared to other strains. This is a meaningful observation as it is the balance between each of these opposing signals that ultimately determines the immunological outcome. It is anticipated that a high IL-10:IL-12 ratio would promote an anti-inflammatory response associated with appropriate immunoregulatory activity while a low IL-10:IL-12 ratio would contribute to Thl polarisation of the immune response. Thus, the PBMC IL-10:IL-12 ratio is an important selection criterion for identification of bacterial strains with immunoregulatory properties.

[0136] The assay was performed as described below:

[0137] Peripheral blood mononuclear cells (PBMCs) were isolated from fresh healthy human peripheral blood using BD Vacutainer CPT tubes (BD catalog 362761), as per the manufacturer's instructions. PBMCs were washed and resuspended in Dulbecco's Modified Eagle Medium-Glutamax (Glutamax (Glutamine substitute) +pyruvate +4.5 g/1 glucose (Gibco catalog 10569-010) 10% fetal bovine serum (Sigma catalog F4135), and 1% penicillin/streptomycin (Sigma catalog P0781). Add 200 L of PBMC at a concentration of 1106 cells/mL (i.e. 2105 cells) to a flat-bottomed 96-well plate and add 20 L of bacteria (at a concentration of 1107 CFU/mL) to the required wells i.e. 20 L stimulant/200mL cells. Incubate the plates as required at 37 C./5% CO2 in an incubator.

[0138] The bacteria were generated as follows: For fresh broths bacteria were grown in Difco MRS media and harvested just after entering stationary phase. All cells were grown under anaerobic conditions at 37 C. For freeze dried products bacteria were grown in Difco MRS Media and harvested just after entering stationary phase. Cells were grown under anaerobic conditions at 37 C. The freeze-dried powders were then generated for each of these bacteria and stored by us at 80 C in pre-aliquoted 100mg vials until just before use. Once they were removed from the freezer, a single vial was thawed to room temperature and washed 3 times in 10 ml ringers followed by centrifugation. A fresh vial was used on each occasion. Total bacterial counts were formed as described below. The lyophilised bacterial aliquoted into sterile tubes should be diluted in 10 ml of culture media (RPMI or DMEM). Take 1 ml from this tube and add to 4.5 ml of culture media (RPMI or DMEM) this will be the top dose at a concentration of 1.0E+09 then this will be diluted either 1:1 (medium dose) or 1:9 for the (lower dose). Add either 20 l of the bacterial solution to 200 l of PBMC suspensions (2>105 cells) or 50 l of the bacterial solution to 500 l PBMC suspensions (5105 cells) or 100 l. The usual dilution selected was 1.0E+08, corresponding to 100:1 (bacteria:PBMC). The negative control is just the cryoprotectant which should be added to the unstimulated cells, but it should be diluted the same way as the bacterial aliquots. All assays were done in triplicate. After a 1-day incubation at 37 C., the plates were spun at 300g, and the supernatants were removed and stored frozen at 80 C. until analysis. Cytokines in the culture supernatants were assayed using a 96-well assay kit from Meso Scale Discovery (Gaithersburg, Md.; catalog K15008B-1), Interleukin 10 (II-10), and Interleukin 12p70 (II12p70), and were quantitated and reported as picograms per millilitre. Each sample was assayed in duplicate. Figs show the results of a representative experiment.

[0139] Of the 15 strains tested, three Bifidobacterial longum strains assayed, B. longum 35624 and B. longum 1714 induce a very similar and desired IL-10/ IL-12 ratio. B. longum DPC6315 gave a higher ratio than either 35624 or 1714 which was similarly a desirable trait (FIG. 19).

[0140] In addition, and to try to determine if there were negative effects of combining the strains we assessed IL-10 production of PBMCs stimulated with 35624 and DPC6315 and as a combination of the 2 strains. No negative effects of using both strains in combination in vitro were observed and similar IL-10 production were achieved as the strains used singly (FIG. 20). A similar result is obtained when 35624 is used in combination with 1714. Therefore, it was our hypothesis from all the available information in the literature and from these results that B. longum DPC6315 combined with B. longum 35624 should also be a great combinatory anti-inflammatory product.

Example 7

Strain Comparison in an Anti-Inflammatory Collagen-Induced Arthritis (CIA) Model

[0141] To further test the 35624/DPC6315 combination the strains were combined in a mouse model of inflammation. We have previously demonstrated that consumption of specific probiotic bacterial strains can modulate mucosal inflammatory disease. The aim of this study was to determine the effect of oral administration of probiotic Bifidobacteria longum strains in a murine arthritis model either used singly or in combination in a well-established anti-inflammatory strain screening model. IBS is associated with higher levels of inflammation. Mouse models for IBS that assess anti-inflammatory effects are not well established therefore a well validated anti-inflammatory model was used. These novel bifidobacteria strains were identified to have anti-inflammatory profiles in vitro.

[0142] From our PBMC screen (example 5) we choose B. longum DPC6315, to determine if the known probiotic B. longum 35624 therapeutic effect was able to be enhanced when used in together with the anti-inflammatory B. longum DPC6315. These strains did not inhibit the growth of each other in co-culture experiments.

[0143] Mice were orally fed B. longum 35624, B. longum DPC6315 or a combination of both. Arthritis onset and disease severity in the CIA model of arthritis were the main parameters measured using the endpoints such as clinical signs of disease and paw swelling.

[0144] Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting 1-2% of the Caucasian population. RA is characterized by inflammation of the joint synovial membrane, cartilage 10 degradation and bone erosion. Joint damage occurs early during RA and once present is largely irreversible. Dysregulated expression of pro-inflammatory cytokines TNF, IL-6 and IFN- and anti-inflammatory IL-10 have been reported (Fieldman et al., 1996, Annu Rev Immunol 14;397-440) as have high levels of IL-15 (McInnes IB et al., 1996,) and IL-17 (McInnes I B et al., 2000,). The relevance of TNF- and IL-1 to disease pathogenesis has been highlighted by the clinical success of therapeutic strategies neutralizing TNF- or IL-1 (Elliott M J et al., 1994,. Moreland L W et al., 1997,. Feldmann M: 2002,). Collagen-induced arthritis is a well-known Murine model of human RA and has many characteristics of both humoral and cellular immune mechanisms like those found in RA (Durie F H et al., 1994). The inflammatory infiltrate in mice and rats with type II collagen arthritis consists of neutrophils and macrophages with smaller numbers of lymphocytes when the lesions are in the acute to subacute phase. Tissue edema and neutrophil exudates within the joint space are common in the acute to subacute phase. As the inflammation progresses to chronic, mononuclear inflammatory cells (monocytes, lymphocytes) predominate and fibroblast proliferation, often with deposition of metachromatic matrix, occurs in synovium and periarticular tissue. Exudate is less common in the joint space.

[0145] Unless indicated in the comments area, the inflammation type is acute to subacute.

[0146] The assay was performed as described below.

[0147] Experimental Design

[0148] Animals (15 DBA/1 mice/group for arthritis) were anaesthetized with Isoflurane, shaved at the base of the tail, and injected intradermally with 150 l of Freund's Complete Adjuvant (Difco) containing bovine type II collagen (Bolder BioPATH, Batch #5) (1 mg/ml) at the base of the tail on day 0 and again on day 21. On study day 14, mice were randomized by body weight into treatment groups. Treatment was initiated after enrolment and continued daily (QD at 24 h intervals) as indicated through study day 34 (treatment with positive control Dexamethasone was initiated on d18). On study days 24-35, onset of arthritis occurred. Mice were terminated on study day 35. Clinical scores were given for each of the paws (right front, left front, right rear, left rear) on days 18-35.

[0149] Observations, Measurements, and Specimens

[0150] Once disease is induced mice are observed for clinical signs of disease. Daily clinical scores were given for each of the paws (right front, left front, right rear, left rear) on study days 18-35 using the following criteria: [0151] 0=Normal. [0152] 1=One hind or fore paw joint affected or minimal diffuse erythema and swelling. [0153] 2=Two hind or fore paw joints affected or mild diffuse erythema and swelling. [0154] 3=Three hind or fore paw joints affected or moderate diffuse erythema and swelling. [0155] 4=Four hind or fore paw joints affected or marked diffuse erythema and swelling. [0156] 5=Entire paw affected, severe diffuse erythema and severe swelling, unable to flex Inflammation Scoring [0157] 0=Normal. [0158] 0.5=Very minimal, affects only 1 joint or minimal multifocal periarticular infiltration of inflammatory cells. [0159] 1=Minimal infiltration of inflammatory cells in synovium and periarticular tissue of affected joints. [0160] 2=Mild infiltration of inflammatory cells. If referring to paws, generally restricted to affected joints (1-3 affected). [0161] 3=Moderate infiltration with moderate edema. If referring to paws, restricted to affected [0162] joints, generally 3-4 joints and the wrist or ankle. [0163] 4=Marked infiltration affecting most areas with marked edema, 1 or 2 unaffected joints may be present. [0164] 5=Severe diffuse infiltration with severe edema affecting all joints (to some extent) and periarticular tissues.

[0165] Clinical data for paw scores (means for animal) were analysed by determining the area under the dosing curve (AUC) for days 18-35. For calculation of AUC, the daily mean scores for each mouse was entered Microsoft Excel and the area between the treatment days and the final day was computed. Means for each group were determined and % inhibition from arthritis controls were calculated by comparing values for treated and normal animals. Data were analysed using a one-way analysis of variance (1-way ANOVA) or Kruskal-Wallis test (non-parametric), along with the appropriate multiple comparison post-test. The model was validated by comparing normal controls to disease controls using a Student's two-tailed t-test. Statistical tests make certain assumptions regarding the data's normality and homogeneity of variance, and further analysis may be required if testing resulted in violations of these assumptions. Significance for all tests was set at p<0.05.

[0166] B. longum 35624 feeding resulted in reduced inflammation and clinical signs of disease compared to the disease control group (*p<0. 05) (FIG. 21(a)) or the combination of DPC6315 and 35624 feeding group (FIG. 21(b)). In agreement with this, B. longum 35624 consumption delayed disease onset and severity as measured by percent incidence of disease while the combination of the two Bifidobacteria longum or DPC6315 alone did not, although DPC 6315 displayed a similar trend to 35624 (FIG. 22). In conclusion an oral administration of the probiotic B. longum 35624 was demonstrably better than the combined product for reduced inflammation via joint scores, and incidence and resulted in significant improvement in the visual assessment of arthritis in the collagen-induced arthritis model. This was an unexpected result as these were the best two candidate strains from the in-vitro PBMC tests and where there was no inhibition of growth in the co-culturing experiments. B. longum DPC6315 inhibited the anti-inflammatory effect of 35624 in a mouse model of arthritis (CIA) when combined and the combination was worse than either strain alone. This study demonstrates that the effect of combinations of Bifidobacterium longum strains can be unpredictable in vivo.

[0167] The strains of the invention may be administered to animals (including humans) in an orally ingestible form in a conventional preparation such as capsules, microcapsules, tablets, granules, powder, troches, pills, suppositories, suspensions and syrups. Suitable formulations may be prepared by methods commonly employed using conventional organic and inorganic additives. The amount of active ingredient in the medical composition may be at a level that will exercise the desired therapeutic effect.

[0168] The formulation may also include a bacterial component, a drug entity or a biological compound. In addition, a vaccine comprising the strains of the invention may be prepared using any suitable known method and may include a pharmaceutically acceptable carrier or adjuvant.

[0169] The introduction of probiotic organisms is accomplished by the ingestion of the micro-organism in a suitable carrier. It would be advantageous to provide a medium that would promote the growth of these probiotic strains in the large bowel. The addition of one or more oligosaccharides, polysaccharides, or other prebiotics enhances the growth of lactic acid bacteria in the gastrointestinal tract. Prebiotics refers to any non-viable food component that is specifically fermented in the colon by indigenous bacteria thought to be of positive value, e.g. Bifidobacteria, lactobacilli. Types of prebiotics may include those that contain fructose, xylose, soya, galactose, glucose and mannose. The combined administration of a probiotic strain with one or more prebiotic compounds may enhance the growth of the administered probiotic in vivo resulting in a more pronounced health benefit and is termed synbiotic.

[0170] It will be appreciated that the probiotic strains may be administered prophylactically or as a method of treatment either on their own or with other probiotic and/or prebiotic materials as described above. In addition, the bacteria may be used as part of a prophylactic or treatment regime using other active materials such as those used for treating inflammation or other disorders especially those with an immunological involvement. Such combinations may be administered in a single formulation or as separate formulations administered at the same or different times and using the same or different routes of administration.

[0171] The strains of the invention may be formulated to facilitate controlled release such as a delayed release of the strain. For example, the formulation may be adapted to release the strain at a particular location in the gastrointestinal tract such as the small intestine or in the colon. To achieve such a controlled release the strain may be formulated in a capsule which has a coating which is adapted to release the strain at a particular location. A range of coatings are available to facilitate such controlled release. One such family of coatings are those available under the Trade Mark Eudragit.

[0172] The invention is not limited to the embodiments hereinbefore described, which may be varied in detail.

REFERENCES

[0173] ALLEN, A. P., HUTCH, W., BORRE, Y. E., KENNEDY, P. J., TEMKO, A., BOYLAN, G., MURPHY, E., CRYAN, J. F., DINAN, T. G. & CLARKE, G. 2016. Bifidobacterium longum 1714 as a translational psychobiotic: modulation of stress, electrophysiology and neurocognition in healthy volunteers. Transl Psychiatry, 6, e939.

[0174] ANDERSSON, H., TULLBERG, C., AHRNE, S., HAMBERG, K., LAZOU AHREN, I., MOLIN, G., SONESSON, M. & HAKANSSON, A. 2016. Oral Administration of Lactobacillus plantarum 299v Reduces Cortisol Levels in Human Saliva during Examination Induced Stress: A Randomized, Double-Blind Controlled Trial. Int J Microbiol, 2016, 8469018.

[0175] BLANCHARD, E. B., LACKNER, J. M., JACCARD, J., ROWELL, D., CAROSELLA, A. M., POWELL, C., SANDERS, K., KRASNER, S. & KUHN, E. 2008. The role of stress in symptom exacerbation among IBS patients. J Psychosom Res, 64, 119-28.

[0176] BUYSSE DJ, REYNOLDS CF, MONK TH, BERMAN SR, KUPFER DJ 1989 The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. May; 28(2): 193-213.

[0177] BUYSSE DJ, REYNOLDS C F 3RD, MONK T H, HOCH C C, YEAGER A L, KUPFER D J. 1991 Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI) Sleep. August; 14(4):331-8.

[0178] CHITKARA, D. K., VAN TILBURG, M. A., BLOIS-MARTIN, N. & WHITEHEAD, W. E. 2008. Early life risk factors that contribute to irritable bowel syndrome in adults: a systematic review. Am J Gastroenterol, 103, 765-74; quiz 775.

[0179] CHOGHAKHORI CHOGHAKHORI R, ABBASNEZHAD A, HASANVAND A, AMANI R. 2017 Inflammatory cytokines and oxidative stress biomarkers in irritable bowel syndrome: association with digestive symptoms and quality of life. Cytokine;93:34-43.

[0180] DINAN, T. G. & CRYAN, J. F. 2017. The Microbiome-Gut-Brain Axis in Health and Disease. Gastroenterol Clin North Am, 46, 77-89.

[0181] DROSSMAN, D. A. & HASLER, W. L. 2016. Rome IV-Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology, 150, 1257-61.

[0182] EFSA BIOHAZ PANEL (EFSA PANEL ON BIOLOGICAL HAZARDS. 2013. Scientific Opinion on the maintenance of the list of QPS biological agents intentionally added to food and feed (2013 update). EFSA Journal, 11 3449.

[0183] ELLIOTT M J, MAINI R N, FELDMANN M, KALDEN J R, ANTONI C, SMOLEN J S, LEEB B, BREEDVELD F C, MACFARLANE J D, BIJL H, et al. Randomised double-blind comparison of chimeric monoclonal antibody to tumour necrosis factor alpha (cA2) versus placebo in rheumatoid arthritis. Lancet. 1994 Oct. 22; 344(8930):1105-10.

[0184] ENCK P, AZIZ Q, BARBARA G, FARMER AD, FUKUDO S, MAYER EA, NIESLER B, QUIGLEY EM, RAJILI-STOJANOVI, SCHEMANN M, SCHWILLE-KIUNTKE J, SIMREN M, ZIPFEL S, SPILLER RC. Irritable bowel syndrome. Nat Rev Dis Primers. 2016 Mar. 24; 2:16014.

[0185] FELDMANN M, BRENNAN FM, MAINI RN. Role of cytokines in rheumatoid arthritis. Annu Rev Immunol. 1996; 14:397-440.

[0186] FELDMANN M.Development of anti-TNF therapy for rheumatoid arthritis. Nat Rev Immunol. 2002 May; 2(5):364-71.

[0187] FILLINGIM R B, OHRBACH R, GREENSPAN J D, KNOTT C, DUBNER R, BAIR E, BARAIAN C, SLADE G D, MAIXNER W. 2011 Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA patient-control study. J Pain.;12:T46-T60.

[0188] FORD, A. C., QUIGLEY, E. M., LACY, B. E., LEMBO, A. J., SAITO, Y. A. & SCHILLER, L. R. 2014. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: Systematic review and meta-analysis. Am J Gastroenterol, 109.

[0189] FRANCIS C. Y., MORRIS J. , WHORWELL P. J. 1997 The irritable bowel severity scoring system: a simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther. Apr;il 11(2):395-402.

[0190] GROEGER, D., O'MAHONY, L., MURPHY, E. F., BOURKE, J. F., DINAN, T. G., KIELY, B., SHANAHAN, F. & QUIGLEY, E. M. 2013. Bifidobacterium infantis 35624 modulates host inflammatory processes beyond the gut. Gut Microbes, 4, 325-39.

[0191] HERMAN C R, SCHIFFMAN E L, LOOK J O, RINDAL D B 2002 The effectiveness of adding pharmacologic treatment with clonazepam or cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J Orofac Pain.;16:64-70.

[0192] HUNGIN, A. P., WHORWELL, P. J., TACK, J. & MEARIN, F. 2003. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther, 17, 643-50.

[0193] JEFFERY, I. B., O'TOOLE, P. W., OHMAN, L., CLAESSON, M. J., DEANE, J., QUIGLEY, E. M. & SIMREN, M. 2012. An irritable bowel syndrome subtype defined by species-specific alterations in faecal microbiota. Gut, 61, 997-1006.

[0194] KELL, D. B., KAPRELYANTS A. S., WEICHART D. H., HARWOOD C. R., BARER M. R. 1998 Viability and activity in readily culturable bacteria: a review and discussion of the practical issues. Antonie Van Leeuwenhoek Feb;73(2):169-87.

[0195] KENNEDY, P. J., CLARKE, G., O'NEILL, A., GROEGER, J. A., QUIGLEY, E. M., SHANAHAN, F., CRYAN, J. F. & DINAN, T. G. 2014. Cognitive performance in irritable bowel syndrome: evidence of a stress-related impairment in visuospatial memory. Psychol Med, 44, 1553-66.

[0196] KONIECZNA, P., GROEGER, D., ZIEGLER, M., FREI, R., FERSTL, R., SHANAHAN, F., QUIGLEY, E. M., KIELY, B., AKDIS, C. A. & O'MAHONY, L. 2012. Bifidobacterium infantis 35624 administration induces Foxp3 T regulatory cells in human peripheral blood: potential role for myeloid and plasmacytoid dendritic cells. Gut, 61, 354-66.

[0197] LI, T., YU, T., HAWKINS, B. S. & DICKERSIN, K. 2015. Design, Analysis, and Reporting of Crossover Trials for Inclusion in a Meta-Analysis. PLoS ONE, 10, e0133023.

[0198] MESSAOUDI, M., LALONDE, R., VIOLLE, N., JAVELOT, H., DESOR, D., NEJDI, A., BISSON, J. F., ROUGEOT, C., PICHELIN, M., CAZAUBIEL, M. & CAZAUBIEL, J. M. 2011a. Assessment of psychotropic-like properties of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in rats and human subjects. Br J Nutr, 105, 755-64.

[0199] MESSAOUDI, M., VIOLLE, N., BISSON, J. F., DESOR, D., JAVELOT, H. & ROUGEOT, C. 2011B. Beneficial psychological effects of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in healthy human volunteers. Gut Microbes, 2, 256-61.

[0200] MIYAZAKI, K., ITOH, N., YAMAMOTO, S., HIGO-YAMAMOTO, S., NAKAKITA, Y., KANEDA, H., OISHI, K. (2014). Dietary heat-killed Lactobacillus brevis SBC8803 promotes voluntary wheel-running and affects sleep rhythms in mice. Life Sci, 111(1-2), 47-52.

[0201] MCINNES I. B ., AL-MUGHALES J, FIELD M, LEUNG B P, HUANG F P, DIXON R, STURROCK R D, WILKINSON P C, LIEW F Y. Nat Med. 1996 Februart; 2(2):175-82. The role of interleukin-15 in T-cell migration and activation in rheumatoid arthritis.

[0202] MCINNES, I. B., LEUNG, B. P. and LIEW, F. Y. 2000. Cellcell interactions in synovitis. Interactions between T lymphocytes and synovial cells, Arthritis Res. 2, 374-378.

[0203] MORELAND L W, BAUMGARTNER S W, SCHIFF M H, TINDALL E A, FLEISCHMANN, R M, WEAVER A L, ETTLINGER R E, COHEN S, KOOPMAN W J, MOHLER K, WIDMER M B, BLOSCH C M. Treatment of rheumatoid arthritis with a recombinant human tumor necrosis 30 factor receptor (p75)-Fc fusion protein. N Engl J Med. 1997 Ju. 17; 337(3):141-7.9

[0204] O'MAHONY, L., MCCARTHY, J., KELLY, P., HURLEY, G., LUO, F., CHEN, K., O'SULLIVAN, G. C., KIELY, B., COLLINS, J. K., SHANAHAN, F. & QUIGLEY, E. M. 2005. Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles. Gastroenterology, 128, 541-51.

[0205] O'MALLEY, D. 2015. Immunomodulation of enteric neural function in irritable bowel syndrome. World J Gastroenterol, 21, 7362-6.

[0206] O'MAHONY L., O'CALLAGHAN L., MCCARTHY J., SHILLING D., SCULLY P., SIBARTIE S., KAVANAGH E., KIRWAN W. 0., REDMOND H. P., COLLINS J. K., SHANAHAN F.. Differential cytokine response from dendritic cells to commensal and pathogenic bacteria in different lymphoid compartments in humans. Am J Physiol Gastrointest Liver Physiol. 2006 Apr;290(4):G839-45. Epub 2005 Nov 17

[0207] O'MAHONY C., SCULLY P., O'MAHONY D., MURPHY S., O'BRIEN F., LYONS A., SHERLOCK G., MACSHARRY J., KIELY B., SHANAHAN F., O'MAHONY L. 2008 Commensal-induced regulatory T cells mediate protection against pathogen-stimulated NF-kappaB activation. PLoS Pathog. Aug 1;4(8):e1000112.

[0208] FOOD AND AGRICULTURAL ORGANIZATION OF THE UNITED NATIONS AND WORLD HEALTH ORGANIZATION. 2001. Health and nutritional properties of probiotics in food including powder milk with live lactic acid bacteria. World Health Organization [online]. http://www.who.int/foodsafety/publications/fs_management/en/probiotics.pdf

[0209] PINTO-SANCHEZ, M. I., HALL, G. B., GHAJAR, K., NARDELLI, A., BOLINO, C., LAU, J. T., MARTIN, F. P., COMINETTI, 0., WELSH, C., RIEDER, A., TRAYNOR, J., GREGORY, C., DE PALMA, G., PIGRAU, M., FORD, A. C., MACRI, J., BERNER, B., BERGONZELLI, G., SURETTE, M. G., COLLINS, S. M., MOAYYEDI, P. & BERCIK, P. 2017. Probiotic Bifidobacterium longum NCC3001 Reduces Depression Scores and Alters Brain Activity: a Pilot Study in Patients With Irritable Bowel Syndrome. Gastroenterology.

[0210] PORTO F, DE LEEUW R, EVANS D R, CARLSON C R, YEPES J F, BRANSCUM A, OKESON J P. 2011 Differences in psychosocial functioning and sleep quality between idiopathic continuous orofacial neuropathic pain patients and chronic masticatory muscle pain patients. J Orofac Pain.;25:117-124

[0211] RANA S V, SHARMA S, SINHA S K, PARSAD K K, MALIK A, SINGH K. Pro-inflammatory and anti-inflammatory cytokine response in diarrhoea-predominant irritable bowel syndrome patients. Trop Gastroenterol 2012;33:251-256.

[0212] SAVIGNAC, H. M., KIELY, B., DINAN, T. G. & CRYAN, J. F. 2014. Bifidobacteria exert strain-specific effects on stress-related behavior and physiology in BALB/c mice. Neurogastroenterol Motil, 26, 1615-27.

[0213] SAVIGNAC, H. M., TRAMULLAS, M., KIELY, B., DINAN, T. G. & CRYAN, J. F. 2015. Bifidobacteria modulate cognitive processes in an anxious mouse strain. Behav Brain Res, 287, 59-72.

[0214] SEYEDMIRZAEE S, HAYATBAKHSH MM, AHMADI B, ET AL. Serum immune biomarkers in irritable bowel syndrome. Clin Res Hepatol Gastroenterol 2016;40:631-637117

[0215] SCHMULSON M, PULIDO-LONDON D, RODRIGUEZ O, ET AL. Lower serum IL-10 is an independent predictor of IBS among volunteers in Mexico. Am J Gastroenterol 2012;107:747-753)

[0216] SUREZ-HITZ K. A., OTTO B., BIDLINGMAIER M., SCHWIZER W., FRIED M., EHLERT U. 2012 Altered psychobiological responsiveness in women with irritable bowel syndrome. Psychosom Med. February-March; 74(2):221-31. 2012 Jan. 27.

[0217] TAP, J., DERRIEN, M., TORNBLOM, H., BRAZEILLES, R., COOLS-PORTIER, S., DORE, J., STORSRUD, S., LE NEVE, B., OHMAN, L. & SIMREN, M. 2017. Identification of an Intestinal Microbiota Signature Associated With Severity of Irritable Bowel Syndrome. Gastroenterology, 152, 111-123.e8.

[0218] TURRONI, F., PEANO, C., PASS, D. A., FORONI, E., SEVERGNINI, M., CLAESSON, M. J., KERR, C., HOURIHANE, J., MURRAY, D., FULIGNI, F., GUEIMONDE, M., MARGOLLES, A., DE BELLIS, G., O'TOOLE, P. W., VAN SINDEREN, D., MARCHESI, J. R. & VENTURA, M. 2012. Diversity of bifidobacteria within the infant gut microbiota. PLoS One, 7, e36957.

[0219] WHORWELL, P. J., ALTRINGER, L., MOREL, J., BOND, Y., CHARBONNEAU, D., O'MAHONY, L., KIELY, B., SHANAHAN, F. & QUIGLEY, E. M. 2006. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. Am J Gastroenterol, 101, 1581-90.

[0220] YAMAMURA, S., MORISHIMA, H., KUMANO-GO, T., SUGANUMA, N., MATSUMOTO, H., ADACHI, H., TAKEDA, M. (2007). The effect of Lactobacillus helveticus fermented milk on sleep and health perception in elderly subjects. Eur J Clin Nutr, 63(1), 100-105.

[0221] ZHEN Y, CHU C, ZHOU S, ET AL. Imbalance of tumor necrosis factor-alpha, interleukin-8 and interleukin-10 production evokes barrier dysfunction, severe abdominal symptoms and psychological disorders in patients with irritable bowel syndrome-associated diarrhoea. Mol Med Rep 2015; 12:5239-5245).