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Background: Roux-en-Y gastric bypass surgery provides a novel human model to investigate small bowel mucosal innate immunity, in which there is loss of gastric acid-mediated protection against orally-acquired microorganisms. Aim: To study changes in jejunal mucosal immunoreactivity of human defensin (HD)-5, an antimicrobial peptide normally produced by Paneth cells. Methods: Mucosa/samples were obtained from 18 female patients (24-54 years), from the same segment of jejunum during and after gastric bypass surgery. Samples were used for bacterial culture and immunohistochemistry using anti-HD-5 antibody. The number of immunoreactive cells per crypt and villus were determined and expressed as mean (SD). Results: No bacteria were cultured from any of the perioperative jejunal samples but colonies of bacteria normally present in the pharynx were identified during culture of all postoperative jejunal biopsy specimens (1-> 100 colonies). Paneth cell numbers per crypt were unchanged after gastric bypass (4.16 (0.71) vs 4.24 (0.78)). However, following surgery, there was an increase in HD-5-positive intermediate cells per crypt (0.25 (0.41) vs 1.12 (0.66), p<0.01), HD-5 staining enterocytes per crypt (0.03 (0.09) vs 1.38 (1.10), p<0.01), HD-5 staining material in the crypt lumen (crypt lumens: 5.0% (10.9%) vs 68.1% (27.9%), p<0.01) and HD-5 immunoreactivity coating the luminal surface of villus enterocytes (villi sampled: 15.0% (31.0%) vs 67.5% (42.0%), p<0.01). Conclusions: Bacteria normally resident in the pharynx were present in the proximal jejunal mucosa following Roux-en-Y gastric bypass surgery. After gastric bypass, there was increased secretion of HD-5 and an increase in HD-5 expressing intermediate cells and enterocytes in the crypt. The increase in HD-5 expression in the jejunal mucosa following gastric bypass surgery is likely to be secondary to exposure to orally-acquired microorganisms. [ABSTRACT FROM AUTHOR]

In this article, we discuss the current understanding of how the intestinal mucosa may exert control over luminal bacteria, and how intestinal inflammation could ensue when this control is lost. We shall review research showing how Paneth cells, and evolutionarily conserved innate immune mechanisms, are emerging as key mediators of intestinal mucosal defence. [ABSTRACT FROM AUTHOR]

Background/Objectives: In older people, small bowel bacterial overgrowth syndrome may be a common, but under-diagnosed, cause of diarrhoea and nutrient malabsorption. We aim to determine which clinical features and baseline laboratory investigations indicate a high likelihood of small bowel bacterial overgrowth as defined by a positive glucose breath test. Methods: A retrospective analysis of records for all patients referred for glucose breath test over a 6-year period to a teaching hospital. Results: Out of 197 referrals, 168 patient records were located and analysed (62 male, 106 female; median age 65). Patient characteristics predictive of a positive glucose breath test were: increasing age (p < 0.01), low serum vitamin B12 (p = 0.02), low serum albumin (p = 0.03), previous partial gastrectomy (p < 0.01), previous right hemi-colectomy (p < 0.01), presence of small bowel diverticulae (p = 0.01) and concurrent use of a proton pump inhibitor (p < 0.01). 52.5% (n = 21/40) of patients studied who were over 75 years old versus 21.8% (n = 28/128) of those under 75 years old had a positive glucose breath test (p < 0.01). The median time to diagnosis, from first hospital visit to positive glucose breath test, was 39 weeks. Conclusions: There is often a significant delay in diagnosis of small bowel bacterial overgrowth. We suggest that this diagnosis should be considered earlier in the investigative algorithm in older patients with indicative symptoms and a predisposing factor (including previous partial gastrectomy, previous right hemi-colectomy, small bowel diverticulae or use of a proton pump inhibitor) or concurring laboratory indices (low vitamin B12 or albumin). Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Patients with inoperable esophageal malignancy often undergo palliative self-expanding metal stent insertion. This analysis of cases shows that although such stents provide good palliation of dysphagia, complications frequently occur. Complications reported were pain after insertion, bleeding, food bolus impaction, stent migration and increased gastroesophageal reflux. Furthermore, in patients with esophageal adenocarcinoma, survival was less if the distal end of the stent entered the stomach, rather than lying entirely within the esophagus. Reduced survival, in this group with gastroesophageal junction tumors, may be a result of increased gastroesophageal reflux leading to pulmonary aspiration. Stents incorporating an antireflux valve have been shown to reduce symptomatic gastroesophageal reflux. It may be that such valves offer a survival advantage where stent insertion ablates the function of the lower esophageal sphincter. Further studies are needed to assess the role of antireflux stents on survival in patients with gastroesophageal junction tumors. [ABSTRACT FROM AUTHOR]

Presents an assortment of medical facts from the United Kingdom. Prediction of the extinction of the blond hair gene; Whiplash injuries; The impending advertising ban on the tobacco industry.

Reflects on a patient who was dying of AIDS in Zambia. Way that the patient was treated for diarrhea and cough; Stocks of vitamins, anti-diarrhea medicine, and anti-fungal medicine at the hospital; Opinion that the population of Zambia needs to be educated about HIV and AIDS and how HIV spreads.

For patients with coeliac disease (CD), compliance with a gluten free diet (GFD), when eating outside the home, may be difficult. This may depend on chefs' knowledge of GFD. Eating food not prepared at home may inadvertently expose patients to gluten. A GFD may also cause social restrictions and thus impair quality of life. Chefs know less about CD and peanut allergy than the general public. Non-qualified and take-away chefs appear to have particularly limited knowledge. Patients with CD feel justifiably cautious when eating food not prepared at home, and do so less frequently than the general public. Educating chefs about a GFD may alleviate the social restrictions on CD patients.

Introduction Hazardous alcohol consumption is a growing public health problem. Recent NICE guidance suggests systematic identification of patients who misuse alcohol through the use of validated screening questionnaires such as the World Health Organisation developed AUDIT (Alcohol Use Disorders Identification Test) tool. Studies have shown brief targeted interventions in at risk groups to be cost effective in reducing readmission rates and the amount of alcohol consumed. We aimed to see how effectively patients drinking hazardous amounts of alcohol were being identified on our medical admissions unit and to compare AUDIT with the shorter FAST (Fast Alcohol Screening Tool). Methods A randomly selected cohort of medical patients was prospectively recruited on the day of their admission to Chesterfield Royal Hospital, between January 2010 and March 2010. Case note review for demographic data, documentation of alcohol history, MCV, gGT, and presenting complaint was performed. The AUDIT and FAST questionnaires were then performed with the patient. Results 188 patients (age range 17 – 100, median age 70) were included. AUDIT scores ranged 0–40. 156 (83%) had score £ 7; 21 (11%) had score 8–15 (hazardous); 4 (2%) had score 16–19 (harmful) and 7 (4%) had score 20 (possible dependence). Only 1/32 patients with an alcohol score of >7 had appropriate advice offered and documented according to their AUDIT score (8–15 brief advice, 16–19 extended brief advice, >20 specialist referral offered). 13/68 (19%) patients with no documented alcohol history had an AUDIT score of >7, 3 of whom had an AUDIT score of >20. 2/61 patients with an. alcohol history documented as ‘no alcohol’ had an AUDIT score >7. Chest pain was the most common (n = 7) presenting complaint for patients with an AUDIT score >7, followed by shortness of breath (n = 4). gGT and MCV were poor predictors of hazardous alcohol consumption. The FAST questionnaire achieved 94% sensitivity and 100% specificity in detecting patients with hazardous alcohol consumption judged by the AUDIT score. Furthermore, FAST was considered easier and quicker to use. Conclusion Hazardous alcohol consumption is frequently under recognised, leading to missed opportunities for effective interventions that may reduce harm. Patients admitted with chest pain are not identified as being at high risk in the NICE guidance, but contain the highest number of hazardous drinkers in our study. Abbreviated questionnaires are accurate and easily used, and should be incorporated into an admission clerking of all presenting complaints. [ABSTRACT FROM PUBLISHER]

A letter to the editor is presented regarding oesophogastroduodenoscopy and colonoscopy procedure to evaluate gastrointestinal symptoms.

Introduction Patients commonly have same day bidirectional endoscopy performed. There is no consensus on which order oesophagogastroduodenoscopy (OGD) and colonoscopy should be performed and how this impacts on completion rates, discomfort levels and patient's overall satisfaction. The authors aimed to evaluate these outcomes by comparing patients who had same day bidirectional endoscopy procedures randomised to either OGD first or colonoscopy first. Methods 70 patients who were due to have same day bidirectional endoscopy in a District General Hospital between December 2009 and September 2010 were prospectively randomised to either having an OGD first (Group A, n=35) or colonoscopy first (Group B, n=35). Power calculations to determine sample size based on previously published data showed that 70 patients would be required to demonstrate a difference of 10% between groups at the 5% level of significance with a power of 80%. Sex, age, body mass index (BMI) and previous endoscopy experience were recorded. Procedural completion time, quality of bowel preparation and endoscopic findings were documented. Patients were asked to grade anticipated procedural discomfort scores, actual procedure discomfort and postprocedure discomfort scores on a Numeric Rating Scale ranging from 0 to 10 as well as asked to complete a Hospital Anxiety and Depression Scale. Patients were also questioned on their overall satisfaction with the procedures. Results 70 patients (36 male, 34 female; median 68 (36–87) years) were recruited with a mean BMI of 28 (19–54). After randomisation 17 males were in Group A and 19 in Group B. Both groups were similar in mean age, BMI, anxiety score and procedural completion times. Sedation and analgesic usage, previous endoscopic procedures and quality of bowel preparation were also similar in the two groups. Indications for bidirectional endoscopy were iron deficiency anaemia (60), chronic diarrhoea (9) and polyp surveillance (1). No statistically significant difference was noted in the mean discomfort scores given for colonoscopy between the two groups (5.2 vs 5.3). However, there was a significant reduction in the discomfort scores given for OGD when this was performed first rather than second (mean score 4.6 vs 6.3; p=0.02). Overall satisfaction rates were also slightly higher in group A than B (9.7 vs 9.6), but this did not reach statistical significance. Conclusion This results suggest that when undertaking same day bidirectional endoscopy, an OGD followed by a colonoscopy is the favoured order, with reduced patient discomfort. It may be that the abdominal bloating caused by colonoscopy leads to reduced tolerance of subsequent OGD. [ABSTRACT FROM PUBLISHER]