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Hydrogen breath testing (HBT) is frequently used as an alternative to small bowel aspiration in the diagnosis of small intestinal bacterial overgrowth (SIBO). The role of the glucose HBT was assessed in 30 elderly patients. A positive HBT was recorded in 15 of 20 SIBO cases and 7 of 10 culture negatives (sensitivity 75% and specificity 30%). The correlation coefficients between hydrogen gas (H2) rise and total bacterial count (r = 0.21) and H2 rise and anaerobic count (r = 0) were not significant. Fasting H2 levels were raised in only 4 of the 20 SIBO cases. This study indicates that the HBT is not reliable in the diagnosis of SIBO in the elderly. There was no evidence from the data that different H2 levels or bacterial counts would significantly alter the reliability of the HBT. This work suggests that factors other than small bowel bacteria are involved in the production and expiration of H2 in the elderly, and that these factors need to be considered in the interpretation of this breath test.

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Lipid malabsorption is a common clinical manifestation of small bowel bacterial overgrowth. Its pathogenesis, however, remains controversial. Bacteroides melaninogenicus ssp. intermedius, an anaerobic bacterium, is commonly isolated from the upper bowel of patients with small intestinal bacterial overgrowth. The effects of a culture supernate of this organism and deoxycholate, an unconjugated bile salt, on intestinal oleic acid absorption were examined using a rat closed-loop model. The supernatant reduced the in vitro uptake of oleic acid by 19% (P< 0.001). Deoxycholate did not significantly reduce the lipid absorption. Combined supernate and deoxycholate did not have an additive effect on absorption of oleic acid. We conclude that anaerobic bacterial products may contribute to the malabsorption of lipid in the setting of bacterial overgrowth of the small bowel.

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OpenLabs has four major objectives: to improve the efficiency and effectiveness of clinical laboratory services by the integration of Knowledge Based Systems (KBSs) with Laboratory Information Systems (LISs) and equipment; to provide and implement standard solutions for Electronic Data Interchange (EDI) between laboratories and other medical systems; to specify a fully Open architecture for an integrated Clinical LIS and demonstrate the integration of various KBS modules on the open architecture platform; and to demonstrate the integration of OpenLabs modules with existing LISs.

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OBJECTIVES: To assess the prevalence of typical clinical features and need for treatment of small intestinal bacterial overgrowth (SIBO) in the elderly. DESIGN: Random selection of patients, regardless of their nutritional status. SETTING: Acute admissions ward in the Dept. of Medicine for the Elderly. PATIENTS: Thirty elderly patients between 68 and 90 years of age. MEASUREMENTS: Active clinical problems, including the presence of recent weight loss and diarrhea, were recorded. Routine blood tests, including serum vitamin B12, red cell folate, albumin and calcium, and qualitative small bowel bacteriology results, were analyzed. The effect of age on all variables was studied. RESULTS: Twenty of the 30 small bowel aspirates had proven SIBO, and strict anaerobes were isolated in 15. The mean blood test values did not differ significantly between culture-positive and culture-negative patients. There was no significant correlation between those variables and the total bacterial counts. Of the 20 proven SIBO cases, eight had anemia, five had hypoalbuminemia, five had diarrhea, four complained of recent weight loss, and none had B12 deficiency. Alternative causes other than SIBO were identified for many of these abnormalities. Advancing age correlated significantly with rising counts of small bowel strict anaerobes. CONCLUSIONS: These data suggest that age may be a predisposing factor in the development of anaerobic overgrowth but that SIBO is a benign entity in the elderly. Contrary to previous recommendations, treatment of this condition is not routinely indicated.

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Interoperability may be defined as the ability of knowledge-based systems to function together in a symbiotic manner. Cooperativity implies interoperability but with the added benefit that the output quality of the cooperative network exceeds the overall performance of the participating sub-systems. A number of candidate architectures to support interoperability and cooperativity between medical knowledge-based systems in laboratory medicine domains are now becoming available. Using rapid prototyping techniques, we have demonstrated the feasibility of one of these approaches by carrying out pilot implementations in two unrelated laboratory medicine domains (an internal consistency checking system for validating patients' results in the laboratory and a system for generating alarms and alerts in high dependency units based on laboratory data). The results of this study are discussed in the context of the available techniques so as to provide a basis for further development of cooperative systems in laboratory medicine.

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Fifty two strains of anaerobic bacteria isolated from the upper gut of patients with small intestinal bacterial overgrowth were screened for phospholipase activity. Bacteroides melaninogenicus spp intermedius had the greatest activity. The effects of culture supernatants of this organism and deoxycholate on intestinal calcium absorption and disaccharidase activity were studied using a rat closed loop model. The supernatant decreased the in vitro uptake of calcium by 15% (p less than 0.001). Deoxycholate reduced calcium uptake by 16% (p less than 0.001). Combined culture supernatant and deoxycholate reduced calcium uptake by 39% (p less than 0.001) suggesting a potentiation of supernatant activity by deoxycholate. Culture supernatant and deoxycholate, both alone and combined, significantly reduced lactase, sucrase, and maltase activity. Electron microscopic evidence showed degeneration of microvilli, disruption of mitochondrial structure, and swelling of the endoplasmic reticulum after exposure of the intestinal loops to the supernatant or deoxycholate.

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Fasting and postprandial intragastric bile acid concentrations have been estimated and compared in patients with complications of Barrett's oesophagus, patients with Barrett's oesophagus without complications, patients with oesophagitis and a group of normal subjects who acted as controls. There was no significant difference in fasting intragastric bile acid concentrations between the groups. Postprandial bile acid concentrations were significantly greater in the patients with complications of Barrett's than in the remaining groups at 60, 90 and 120 min. Significant concentrations of bile acids were seen in gastric juice of unaltered pH and may be undetected on intra-oesophageal pH monitoring. Duodenogastric reflux may be implicated in the pathogenesis of complications of Barrett's oesophagus.

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The role of stress in infertility, and its treatment, is reviewed in various groups of couples labeled "unexplained infertile." A simplified profile of stress markers based upon basal prolactin estimations and psychological measurements found infertile couples more stressed than fertile controls and revealed a sub-group of women characterized as having significantly high psychological stress scores and intermittent elevations of prolactin (spikers). This group was effectively treated with a combination of clomiphene citrate and bromocriptine. However, attention to the failures as well as the successes suggests optimum benefit to the patients might involve not only provision of a good clinic ambiance and pharmacological preparations, but also relaxation therapies such as Autogenic Training, which significantly lowered psychological and biochemical stress marker scores.

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It has long been recognised that there is a relationship between emotional stress and some forms of infertility. We have endeavoured to estimate "stress' levels before and after Autogenic Training in 15 couples with infertility of at least two years' duration. Potential stress markers were: plasma prolactin, total urinary free cortisol and catecholamines, and four psychological tests: Spielberger State-Trait anxiety scale, Taylor Manifest Anxiety Scale, the Cattell 16 personality factor questionnaire, and the Eysenck Personality Questionnaire. A control group of ten normal couples was included for comparison. The biochemical finding of higher mean prolactin levels in the female patients vs their controls was of particular interest. The significant reduction of the prolactin level, in parallel with decreased anxiety scores following treatment, supports the hypothesis that the elevated prolactin levels in these patients are indeed linked with emotional stress.

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Beta-human chorionic gonadotrophin (beta-hCG) was assayed twice weekly in plasma from 20 subjects from 4 to 16 weeks gestation; 14 of these were normal. There was an initial rise, a plateau at weeks 7 to 9, and a further rise to a maximum at week 11. Levels then dropped steadily to week 16. There was no significant difference when mean levels were subdivided and calculated according to the subsequent sex of the baby. Of the 6 abnormal subjects, the twin pregnancy initially showed normal levels but at week 11 to 13 these were at least one standard deviation above the mean. The plasma beta-hCG levels of the two subjects who aborted were more than one standard deviation below the mean at week 5. Three subjects treated with progestogen therapy had beta-hCG levels which fluctuated within normal limits. The trends of beta-hCG levels were similar to those of plasma hCG levels in the two subjects who had both assays performed but peak times were different. There was considerable within patient and also patient to patient variation in beta-hCG levels.

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Twenty-nine patients with normal blood lipids were placed on diets. Thirteen, mainly attending hospital for varicose veins, were prescribed low-energy diets: HDL-cholesterol was raised after one month and significantly after three months (P less than 0.02); total cholesterol was lowered (P less than 0.05). Sixteen patients, mainly with irritable bowel symptoms, were prescribed high-fibre diet: HDL-C was raised after one month (P less than 0.05), but not significantly so after three months; total cholesterol was unchanged.

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