Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

Critical role of retinoid/rexinoid signaling in mediating transformation and therapeutic response of NUP98-RARG leukemia

While the nucleoporin 98-retinoic acid receptor gamma (NUP98-RARG) is the first RARG fusion protein found in acute leukemia, its roles and the molecular basis in oncogenic transformation are currently unknown. Here, we showed that homodimeric NUP98-RARG not only acquired unique nuclear localization pattern and ability of recruiting both RXRA and wild-type NUP98, but also exhibited similar transcriptional properties as RARA fusions found in acute promyelocytic leukemia (APL). Using murine bone marrow retroviral transduction/transformation assay, we further demonstrated that NUP98-RARG fusion protein had gained transformation ability of primary hematopoietic stem/progenitor cells, which was critically dependent on the C-terminal GLFG domain of NUP98 and the DNA binding domain (DBD) of RARG. In contrast to other NUP98 fusions, cells transformed by the NUP98-RARG fusion were extremely sensitive to all-trans retinoic acid (ATRA) treatment. Interestingly, while pan-RXR agonists, SR11237 and LGD1069 could specifically inhibit NUP98-RARG transformed cells, mutation of the RXR interaction domain in NUP98-RARG had little effect on its transformation, revealing that therapeutic functions of rexinoid can be independent of the direct biochemical interaction between RXR and the fusion. Together, these results indicate that deregulation of the retinoid/rexinoid signaling pathway has a major role and may represent a potential therapeutic target for NUP98-RARG-mediated transformation.

Structural distortion-induced magnetoelastic locking in Sr(2)IrO(4) revealed through nonlinear optical harmonic generation

We report a global structural distortion in Sr_{2}IrO_{4} using spatially resolved optical second and third harmonic generation rotational anisotropy measurements. A symmetry lowering from an I4_{1}/acd to I4_{1}/a space group is observed both above and below the Néel temperature that arises from a staggered tetragonal distortion of the oxygen octahedra. By studying an effective superexchange Hamiltonian that accounts for this lowered symmetry, we find that perfect locking between the octahedral rotation and magnetic moment canting angles can persist even in the presence of large noncubic local distortions. Our results explain the origin of the forbidden Bragg peaks recently observed in neutron diffraction experiments and reconcile the observations of strong tetragonal distortion and perfect magnetoelastic locking in Sr_{2}IrO_{4}.

Association between hypoxia-inducible factor-1a levels in serum and synovial fluid with the radiographic severity of knee osteoarthritis

Osteoarthritis (OA) is primarily characterized by articular cartilage degradation. Hypoxia-inducible factor-1a (HIF-1a), a subunit of the basic helix-loop-helix-containing PER-ARNT-SIM (PAS) domain transcription factors, plays a vital role in the survival of articular chondrocytes to the hostile hypoxic microenvironment and complicates the progression of OA. In this study, we examined whether HIF-1a levels in the serum and synovial fluid (SF) of patients with knee OA were increased and whether the increase was correlated with the radiographic severity of the disease. A total of 278 knee OA patients and 203 healthy controls were enrolled in this study. Knee OA radiographic grading was performed according to Kellgren-Lawrence (KL) grading system by evaluating X-ray changes observed on anteroposterior knee radiography. HIF-1a levels in the serum and SF were determined using an enzyme-linked immunosorbent assay. Serum HIF-1a levels in patients with knee OA were higher than those in healthy controls. Knee OA patients with KL grade 4 showed significantly elevated HIF-1a levels in the serum and SF compared with those with KL grades 2 and 3. Knee OA patients with KL grade 3 showed significantly higher SF levels of HIF-1a than those with KL grade 2. HIF-1a levels in the serum and SF of knee OA patients were significantly correlated with disease severity according to KL grading criteria. HIF-1a levels in the serum and SF were closely related to the radiographic severity of OA and may serve as an alternative biomarker for the progression and prognosis of knee OA.

Population genetic structure of Gasterophilus pecorum in the Kalamaili Nature Reserve, Xinjiang, based on mitochondrial cytochrome oxidase (COI) gene sequence

Gasterophilosis is a significant threat to equids in the desert steppe of Xinjiang, China, where Gasterophilus pecorum (Fabricius) (Diptera: Gasterophilidae) is the dominant botfly species. A population analysis was conducted on 195 individual G. pecorum larvae from three host species, Przewalski's horse, the domestic horse and the Asiatic wild ass. The distribution of haplotypes of the maternally inherited mitochondrial cytochrome oxidase subunit I (COI) gene was analysed to assess the population differentiation of G. pecorum. High haplotype diversity was observed among G. pecorum populations from all host species, indicating that the G. pecorum infecting one host had multiple maternal ancestors. A phylogenetic tree showed six clades, suggesting a high degree of genetic differentiation. A constructed haplotype network described both the origin of the haplotypes and the population structure. The findings indicated that G. pecorum infections within Przewalski's horses were mainly transmitted from Asiatic wild asses. Clade 1 was found to be the most primitive group and to have evolved to be highly adaptable to the desert steppe. Clade 2 originated from Clade 1, potentially as a result of the annual migration of domestic horses. Revealing the differentiation of the G. pecorum population is important for elucidating the aetiology of Gasterophilus infection in Xinjiang and for planning appropriate control measures.

A study of the methodological and clinical validity of the combined lactulose hydrogen breath test with scintigraphic oro-cecal transit test for diagnosing small intestinal bacterial overgrowth in IBS patients

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) may be a cause of irritable bowel syndrome (IBS); however, current investigations have important limitations. We aimed to identify clinically relevant diagnostic criteria for SIBO based on lactulose hydrogen breath test (LHBT) alone and combined with scintigraphic measurement of oro-cecal transit (SOCT).

METHODS

Results of LHBT/SOCT investigation from 89 IBS patients and 13 healthy volunteers were included in a systematic analysis of six published criteria for SIBO diagnosis. Clinical relevance of competing criteria was determined by assessing (i) prevalence of SIBO in IBS patients and healthy volunteers (ii) if SIBO diagnosis predicted improvement in IBS symptoms in a prospective, pilot therapeutic trial of a non-absorbable antibiotic (rifaximin 600 mg b.d.) in IBS patients.

KEY RESULTS

Reproducibility of SIBO diagnosis by combined LHBT/SOCT was near perfect. A ≥5 ppm H2 increase prior to appearance of cecal contrast was detected in more IBS patients than healthy volunteers (35/89 vs 1/13; p = 0.026), but not for other diagnostic criteria. IBS patients with SIBO, compared to those without SIBO, reported significantly greater improvement in abdominal symptoms following rifaximin therapy (p < 0.002 overall IBS symptom severity). This improvement was most marked in D-IBS patients in whom all symptoms improved, including stool frequency and consistency (all p < 0.004).

CONCLUSIONS & INFERENCES

Combined LHBT/SOCT testing using a H2 5 ppm cutoff may identify a subgroup of IBS patients with SIBO. Pilot data examining the clinical response to rifaximin suggest that this subset of IBS patients may benefit more than those with a normal test.

Effects of high hemodynamics upon the morphology of the walls of the great saphenous vein and splenic vein

AIM

Studies have shown that the incidence and development of pathological changes in the walls of the great saphenous vein and splenic vein are closely related to high venous pressure. Such changes are referred to as "vascular adaptive remodeling responses under high venous pressure". The proposition of the concept of vascular remodeling contributes to our knowledge of pathological changes in the venous wall (dilation of the venous lumen and thickening of the venous wall). In the present study, we compared the histomorphology and cytomorphology of the walls of varicose great saphenous veins (GSVs) and diseased splenic veins (SVs) to investigate the remodeling of the venous wall under high hemodynamic pressure.

METHODS

We collected 34 samples of varicose great saphenous veins and diseased splenic veins. Thirty-four samples of normal great saphenous veins and splenic veins were also collected (control group). Samples were made into slices and observed under light microscopy and electron microscopy. The thickness of the tunica intima and tunica media as well as the inner diameter of the venous lumen were measured.

RESULTS

Under light microscopy, the walls of varicose veins stained with H&E were unevenly thickened, and those of diseased splenic veins were evenly thickened; mucoid degeneration of the tunica intima of varicose veins was not obvious by Masson staining (2/20 cases). The boundary between the tunica intima and tunica media was clearly defined. Uneven hyperplasia of muscular connective tissues was observed. For the diseased splenic-vein group, mucoid degeneration of the tunica intima was obvious (8/14 cases), with an unclearly defined boundary between the tunica intima and tunica extima. Uneven hyperplasia of muscular connective tissues was also observed. Differences in the thickness and inner diameter of the tunica intima and tunica media between the great saphenous vein and the splenic vein were significantly different. Under electron microscopy, mitochondrial degeneration in endothelial cells was observed in both groups. Increased numbers of rough endoplasmic reticula in the cytoplasm of smooth muscle cells, ribosomes and mitochondria and decreased numbers of myofilaments were also observed.

CONCLUSION

High hemodynamics affected the remodeling of varicose great saphenous veins and diseased splenic veins. The histomorphology of visceral veins showed more significant pathological changes than that of peripheral veins. Similar cytomorphological changes were observed in both groups.

Lactose intolerance in irritable bowel syndrome patients with diarrhoea: the roles of anxiety, activation of the innate mucosal immune system and visceral sensitivity

BACKGROUND

Irritable bowel syndrome patients with diarrhoea (IBS-D) often report intolerance to milk; however, the mechanism underlying these symptoms is unknown.

AIM

To assess the role of psychological factors, immune activation and visceral sensitivity on the development of lactose intolerance (LI) in IBS-D patients.

METHODS

Fifty-five IBS-D patients and 18 healthy controls (HCs) with lactase deficiency underwent a 20-g lactose hydrogen breath test (LHBT). Patients were categorised as lactose malabsorption (LM; malabsorption only) or LI [malabsorption plus increase in total symptom score (TSS). Measurements included (i) psychological status; (ii) enteric biopsies with quantification of mast cells (MCs), T-lymphocytes and enterochromaffin cells; (iii) serum cytokines; (iv) rectal sensitivity before and after lactose ingestion.

RESULTS

LI was more prevalent in IBS-D patients than HCs [25/55 (46%) vs. 3/18 (17%), P = 0.029]. IBS-D patients with LI had (i) higher levels of anxiety than those with LM (P = 0.017) or HCs (P = 0.006); (ii) increased mucosal MCs compared with LM (P = 0.006) and HCs (P < 0.001); (iii) raised serum TNF-α compared with LM (P = 0.034) and HCs (P < 0.001) and (iv) increased rectal sensitivity after lactose ingestion compared with LM (P < 0.001) or HCs (P < 0.001). Severity of abdominal symptoms after lactose ingestion was associated with the increase in visceral sensitivity after lactose intake (r = 0.629, P < 0.001), MCs (r = 0.650, P < 0.001) and anxiety (r = 0.519, P < 0.001).

CONCLUSIONS

IBS-D patients with lactose intolerence are characterised by anxiety, mucosal immune activation and increased visceral sensitivity after lactose ingestion. The presence of these biomarkers may indicate an IBS phenotype that responds to dietary therapy and/or mast cell stabilisers.

Noninflammatory necrotizing vasculopathy in lupus nephritis: a single-center experience

In this study, we assessed the clinicopathological features of lupus nephritis patients with renal noninflammatory necrotizing vasculopathy (NNV). A total of 142 renal biopsies with lupus nephritis were reviewed, including nine cases presented with NNV and 36 without renal vascular lesions. The comparisons of clinical, laboratory and pathological features, treatments, as well as renal outcome between the two groups were further performed. In comparison with the no renal vascular lesions group, patients with NNV changes had significantly higher proportions of noninfection leukocyturia (p = 0.013) and leukocytopenia (p = 0.042), significantly higher serum creatinine (p = 0.012), lower hemoglobin (p = 0.002) and serum C3 (p < 0.001) levels. Renal pathological activity indices and chronicity indices were significantly higher in the NNV group (p = 0.002 and p = 0.006, respectively) than those in the no vascular lesions group. Regarding renal prognosis, the presence of NNV was not a risk factor for renal outcome (p = 0.327). In conclusion, NNV was not infrequent in renal biopsies of lupus nephritis. It was commonly associated with active clinical status and proliferative glomerular lesions of lupus.

S100A9 promotes human lung fibroblast cells activation through receptor for advanced glycation end-product-mediated extracellular-regulated kinase 1/2, mitogen-activated protein-kinase and nuclear factor-κB-dependent pathways

S100A9 belongs to the S100 family of calcium-binding proteins and plays a key role in many inflammatory conditions. Recent studies have found that S100A9 was elevated significantly in the bronchoalveolar lavage fluid of idiopathic pulmonary fibrosis patients, and might be a biomarker for fibrotic interstitial lung diseases. However, the exact function of S100A9 in pulmonary fibrosis needs further studies. We performed this study to investigate the effect of S100A9 on human embryo lung fibroblast (HLF) proliferation and production of cytokines and collagen, providing new insights into the possible mechanism. S100A9 promoted proliferation of fibroblasts and up-regulated expression of both proinflammatory cytokines interleukin (IL)-6, IL-8, IL-1β and collagen type III. S100A9 also induced HLF cells to produce α-smooth muscle actin (α-SMA) and receptor for advanced glycation end-product (RAGE). In addition, S100A9 caused a significant increase in extracellular-regulated kinase (ERK)1/2 mitogen-activated protein kinase (MAPK) phosphorylation, while the status of p38 and c-Jun N-terminal kinase (JNK) phosphorylation remained unchanged. Treatment of cells with S100A9 also enhanced nuclear factor kappa B (NF-κB) activation. RAGE blocking antibody pretreatment inhibited the S100A9-induced cell proliferation, cytokine production and pathway phosphorylation. S100A9-mediated cell activation was suppressed significantly by ERK1/2 MAPK inhibitor and NF-κB inhibitor. In conclusion, S100A9 promoted HLF cell growth and induced cells to secret proinflammatory cytokines and collagen through RAGE signalling and activation of ERK1/2 MAPK and NF-κB pathways.

Assessment of vasa vasorum in the walls of thrombophlebitic saphenous vein

AIM

The purpose of this study was to investigate the proliferation of vasa vasorum (VV) in the walls of thrombophlebitic saphenous vein (TSV), and to evaluate the influence of high venous pressure and lack of oxygen on the VV.

METHODS

The specimens of the great saphenous vein were collected: 11 primary varicose vein (PVV), 11 TSV and, as a control, eight normal great saphenous vein. Masson staining and immunohistochemistry for CD34 were used to observe the status of VV, and the number of VV were counted under light microscopy.

RESULTS

VV of the thrombophlebitic saphenous vein group (TSVG) were clustered together in adventitia, increased linearly in media, and scattered appearance in intima, were increased partially in intima of thrombus rupturing. In TSVG, the number of VV observed in adventitia, media and intima was 16.738±7.685, 4.845±2.537, 2.448±3.030, respectively. In the primary varicose vein group (PVVG), the corresponding values were 14.280±4.440, 2.965±1.125, 0.500±0.548. And the number was 8.911±2.629, 0.150±0.424, 0±0 in the control group (CG). Significantly higher numbers of VV were observed in the TSVG as compared to the PVVG or CG (P<0.05). No significant difference was observed between intima and media (P>0.05).

CONCLUSION

Thrombi in varicose veins can induce proliferation of VV, which may be involved in high venous pressure and hypoxia.

Physical properties of poly(N-isopropylacrylamide) hydrogel promote its effects on cardiac protection after myocardial infarction

OBJECTIVE

Studies have demonstrated the protective effects of biomaterials against myocardial infarction (MI), but the relationship between their physical characteristics and their function is incompletely understood. This study investigated such relationships for a hydrogel preparation.

METHODS

Two types of poly(N-isopropylacrylamide) (PNIPAAm) hydrogel with different degradation times (Gel A and Gel B) were synthesized. In vivo hydrogel formation and maintenance were observed and confirmed in mice. The solutions were also injected into the infarct area immediately after MI induction in rats.

RESULTS

PNIPAAm hydrogel exhibited a three-dimensional structure resembling native extracellular matrix (ECM). Compared with phosphate-buffered saline, Gel A and Gel B increased contractility of isolated infarcted myocardium, reduced collagen deposition, increased neovascularization, inhibited left ventricle expansion and improved cardiac function. Myocardial contractility was greater with Gel B than with Gel A.

CONCLUSIONS

Intramyocardial injection of PNIPAAm hydrogel provides structural support and some functional repair of damaged ECM, suggesting that it might be useful for cardiac tissue engineering.

Association between lncrna PCGEM1 polymorphisms and prostate cancer risk

BACKGROUND

Prostate cancer (PCa) gene expression marker 1 (PCGEM1), a long noncoding RNA, has drawn increasing attention for its important role in PCa. However, the association between genetic variations in the PCGEM1 gene and risk of PCa has not been investigated yet.

METHODS

We investigated the effect of two tagging single-nucleotide polymorphism (tSNPs; rs6434568 and rs16834898) in PCGEM1 gene on PCa risk in the Chinese men. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the association.

RESULTS

We found a significantly decreased risk of PCa for rs6434568 AC and AC/AA genotype (adjusted OR=0.76, 95% CI=0.60-0.97 for AC; adjusted OR=0.76, 95% CI=0.61-0.96 for AC/AA), as well as rs16834898 AC and AC/CC genotype (adjusted OR=0.76, 95% CI=0.59-0.97 for AC; adjusted OR=0.79, 95% CI=0.62-0.99 for AC/CC), compared with the CC and AA genotypes, respectively. When we evaluated these two tSNPs together based on the risk alleles (that is, rs6434568 C and rs16834898 A), we found that the combined genotypes with four risk alleles were associated with an increased risk of PCa compared with those carrying 0-3 risk alleles (1.53, 1.19-1.97), and this increased risk was more pronounced among subjects of≤70 years (1.80, 1.24-2.62), Gleason score≥7 (1.68, 1.28-2.22) and PSA level≥20 (1.64, 1.24-2.18).

CONCLUSIONS

Our results indicated that PCGEM1 polymorphisms may contribute to PCa risk in Chinese men. Additional functional analyses are required to detect the detailed mechanism underlying the observed association.

Polymorphisms in the IL-13 and IL-4R genes are associated with the development of renal cell carcinoma

BACKGROUND

Cytokines are the important modulators that bind to their relevant receptors in response to some stimuli to mediate the homeostasis. It has been suggested that the imbalance of immune system of the host might affect the generation of diseases, including cancers.

PATIENTS AND METHODS

We investigated the association between six functional polymorphisms of IL-4, IL-13, and IL-4R genes and susceptibility to renal cell cancer in a hospital-based study, including 620 renal cell carcinoma (RCC) patients and 623 controls. Logistic regression model was used to assess the genetic effects on the development of RCC.

RESULTS

Overall, individuals with IL-4R Ile50Val CT/TT genotypes had a 0.34-fold significantly decreased RCC risk (CT/TT versus CC), and the T variant allele was associated with a decreased risk of RCC in a dose-response manner (Ptrend=0.009). In addition, we also observed that IL-13 C-1055T and Arg130Gln polymorphisms could decrease the risk of RCC [TT versus

CC/CT

odds ratio=0.36, 95% confidence interval (CI)=0.16-0.78; AA versus GG/GA: 0.66, 0.44-0.97, respectively]. Furthermore, a multiplicative interaction association between the combined IL-4R Ile50Val and IL-13 C-1055T genotypes was observed to decrease the risk of RCC (P=0.036).

CONCLUSION

IL-13 and IL-4R may play an important role in the etiology of RCC.

Fabrication of uniform and high resolution copper nanowire using intermediate self-assembled monolayers through direct AFM lithography

Electrochemical AFM lithography was used to directly fabricate copper nanowires. The copper ions were strongly reduced by a negative sample bias at the point where the AFM tip was localized, and copper metal wires were successfully fabricated following the direction of the electrical field of the bias. A TDA⋅HCl self-assembled monolayer (SAM) was found to play an important role as an intermediate layer for enhancing the capability of high resolution and complete development after the AFM lithographic process. The physical and electrical properties of the wires were analyzed by AFM, EFM, SEM, TEM and I-V measurement. The fabricated copper has promising potential for applications such as masks and interconnectors for nanoelectronic devices.

The reduced and altered activities of PAX5 are linked to the protein-protein interaction motif (coiled-coil domain) of the PAX5-PML fusion protein in t(9;15)-associated acute lymphocytic leukemia

The paired box domain of PAX5 was reported to fuse with the sequence of promyelocytic leukemia (PML) to produce PAX5-PML chimeric protein in two patients with B-cell acute lymphoblastic leukemia. In the present studies, we found, by gel shift assays, that PAX5-PML bound to a panel of PAX5-consensus sequence acts as a homodimer with reduction of its DNA-binding affinities in comparison with wild-type PAX5. In transient transfection assays using 293T and HeLa cells, and retrovirus transduction of murine hematopoietic stem/progenitor cells together with quantitative real-time polymerase chain reaction analysis, PAX5-PML inhibited wild-type PAX5 target gene transcriptional activity. Studies comparing PAX5-PML with PAX5-PML(ΔCC) demonstrated that the coiled-coil (CC) protein interaction domain located within the PML moiety was required for PAX5-PML homodimer complex formation and partial transcriptional repression of genes controlled by PAX5. Fluorescent microscopic examination of transiently expressed YFP-tagged proteins in HeLa and 293T cells demonstrated that YFP-PAX5-PML and YFP-PAX5-PML(ΔCC) exhibited a diffuse granular pattern within the nucleus, similar to PAX5 but not PML. By fluorescent recovery after photobleach (FRAP), we have shown that PAX5-PML fusion protein has reduced intranuclear mobility compared with wild-type PAX5. Furthermore, the dimerization domain (CC) of PML was responsible for the reduced intranuclear mobility of PAX5-PML. These results indicate that the CC domain of PAX5-PML is important for each of the known activities of PAX5-PML fusion proteins.

Marginal and conditional approaches to multivariate variables subject to limit of detection

A marginal approach and a variance-component mixed effect model approach (here called a conditional approach) are commonly used to analyze variables that are subject to limit of detection. We examine the theoretical relationship and investigate the numerical performance of these two approaches. We make some recommendations based on our results. The marginal approach is recommended for bivariate normal variables, and the variance-component mixed effect model is preferable for other multivariate analysis in most circumstances. Two approaches are illustrated through one case study from a preclinical experiment.

Lactose intolerance in patients with chronic functional diarrhoea: the role of small intestinal bacterial overgrowth

BACKGROUND

Many studies report a high prevalence of lactose intolerance in patients with functional, gastrointestinal disease.

AIM

To evaluate the role of small intestinal bacterial overgrowth (SIBO) in condition of lactose intolerance and the mechanism by which SIBO may impact lactose tolerance in affected patients.

METHODS

Consecutive out-patients with chronic functional diarrhoea (CFD) and healthy controls underwent a validated 20 g lactose hydrogen breath test (HBT). Patients completed also a 10 g lactulose HBT with concurrent assessment of small bowel transit by scintigraphy.

RESULTS

Lactose malabsorption was present in 27/31 (87%) patients with CFD and 29/32 (91%) healthy controls (P = 0.708). From the patient group 14/27 (52%) had lactose intolerance and 13/27 (48%) experienced no symptoms (lactose malabsorption controls). Only 5 (17%) healthy controls reported symptoms (P < 0.01). The oro-caecal transit time was similar between patient groups with or without symptoms (P = 0.969). SIBO was present in 11 (41%) subjects and was more prevalent in lactose intolerance than in lactose malabsorption [9/14 (64%) vs. 2/13 (15%), P = 0.018]. Symptom severity was similar in lactose intolerance patients with and without SIBO (P = 0.344).

CONCLUSIONS

Small intestinal bacterial overgrowth increases the likelihood of lactose intolerance in patients with CFD as a direct result of lactose fermentation in the small intestine, independent of oro-caecal transit time and visceral sensitivity.