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Lactulose mannitol ratio tests are clinically useful for assessing disorders characterised by changes in gut permeability and for assessing mixing in the intestinal lumen. Variations between currently used test protocols preclude meaningful comparisons between studies. We determined the optimal sampling period and related this to intestinal residence. Half-hourly lactulose and mannitol urinary excretions were determined over 6 hours in 40 healthy female volunteers after administration of either 600 mg aspirin or placebo, in randomised order at weekly intervals. Gastric and small intestinal transit times were assessed by the SmartPill in 6 subjects from the same population. Half-hourly percentage recoveries of lactulose and mannitol were grouped on a basis of compartment transit time. The rate of increase or decrease of each sugar within each group was explored by simple linear regression to assess the optimal period of sampling. The between subject standard errors for each half-hourly lactulose and mannitol excretion were lowest, the correlation of the quantity of each sugar excreted with time was optimal and the difference between the two sugars in this temporal relationship maximal during the period from 2½-4 h after ingestion. Half-hourly lactulose excretions were generally increased after dosage with aspirin whilst those of mannitol were unchanged as was the temporal pattern and period of lowest between subject standard error for both sugars. The results indicate that between subject variation in the percentage excretion of the two sugars would be minimised and the differences in the temporal patterns of excretion would be maximised if the period of collection of urine used in clinical tests of small intestinal permeability were restricted to 2½-4 h post dosage. This period corresponds to a period when the column of digesta column containing the probes is passing from the small to the large intestine.

Background: Heterogeneous laborious analytical methodologies for the determination of urinary lactulose and mannitol limit their utility in intestinal permeability testing. Methods: We developed an assay using a Shimadzu HPLC system, an Aminex HPX87C column, and refractive index detection. The test was calibrated using a series of dilutions from standard stock solutions of lactulose and mannitol ‘spiked’ into urine samples. The utility to quantify urinary excretion during the dual sugar absorption test over 6 h was also determined. Results: Lactulose and mannitol were eluted isocratically at 5.7 and 10.1 min, respectively, with water as a mobile phase at a flow rate of 0.3 mL min−1, 858 psi, 60 °C. The calibration curves for both sugars were linear up to 500 µg mL−1 with a limit of detection in standard solutions at 4 µg mL−1 and in ‘spiked’ urine samples at 15 µg mL−1. The intra-assay and inter-assay CVs were between 2.0–5.1% and 2.0–5.1% for lactulose and 2.5–4.4% and 2.8–3.9% for mannitol. The urinary profiles of the 6 h absorption of lactulose and mannitol showed similar peak-retention times to standard solutions and were well-resolved at 5.9 and 10.4 min, respectively. Conclusions: The assay was easy to automate, using commonly available equipment and convenient requiring no prior laborious sample derivatization. The simplicity, reproducibility, and robustness of this assay facilitates its use in routine clinical settings for the quantification of intestinal permeability.

Abstract Background Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch–anal anastomosis (IPAA). Methods This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. Results We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF–naive children and with adults who were either exposed or naive precolectomy (P < .05). Conclusions There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults. Lay Summary Ileal pouch–anal anastomosis is the most common surgical approach for patients with ulcerative colitis undergoing total proctocolectomy. Outcomes are informed by heterogeneous adult data cohorts often predating anti-tumor necrosis factor uptake. We find that for children in the modern era pouch loss occurs at higher rates.

Background Exercise-induced muscle damage (EIMD) is accompanied by localized oxidative stress / inflammation which, in the short-term at least, is associated with impaired muscular performance. Dietary antioxidants have been shown to reduce excessive oxidative stress; however, their effectiveness in facilitating recovery following EIMD is not clear. Blueberries demonstrate antioxidant and anti-inflammatory properties. In this study we examine the effect of New Zealand blueberries on EIMD after strenuous eccentric exercise. Methods In a randomized cross-over design, 10 females consumed a blueberry smoothie or placebo of a similar antioxidant capacity 5 and 10 hours prior to and then immediately, 12 and 36 hours after EIMD induced by 300 strenuous eccentric contractions of the quadriceps. Absolute peak and average peak torque across the knee, during concentric, isometric, and eccentric actions were measured. Blood biomarkers of oxidative stress, antioxidant capacity, and inflammation were assessed at 12, 36 and 60 hours post exercise. Data were analyzed using a two-way ANOVA. Results A significant ( p  < 0.001) decrease in isometric, concentric and eccentric torque was observed 12 hours following exercise in both treatment groups. During the 60 hour recovery period, a significant ( p  = 0.047) interaction effect was seen for peak isometric tension suggesting a faster rate of recovery in the blueberry intervention group. A similar trend was observed for concentric and eccentric strength. An increase in oxidative stress and inflammatory biomarkers was also observed in both treatment groups following EIMD. Although a faster rate of decrease in oxidative stress was observed in the blueberry group, it was not significant ( p  < 0.05) until 36 hours post-exercise and interestingly coincided with a gradual increase in plasma antioxidant capacity, whereas biomarkers for inflammation were still elevated after 60 hours recovery. Conclusions This study demonstrates that the ingestion of a blueberry smoothie prior to and after EIMD accelerates recovery of muscle peak isometric strength. This effect, although independent of the beverage’s inherent antioxidant capacity, appears to involve an up-regulation of adaptive processes, i.e. endogenous antioxidant processes, activated by the combined actions of the eccentric exercise and blueberry consumption. These findings may benefit the sporting community who should consider dietary interventions that specifically target health and performance adaptation.

Background The objective of this study was to compare short-term outcomes of robotic and laparoscopic proctectomy in patients with inflammatory bowel disease (IBD). Methods This is an IRB-approved case-matched review. Seventeen robotic proctectomies (RP), 10 with ileal pouch anal anastomosis (IPAA) and 7 completion (CP), were matched to laparoscopic proctectomies (LP). Short-term and functional outcomes were compared between LP and RP. Results In CP cohort, operative times were longer in the RP group (351 RP vs 238 LP min, p  = 0.03), mean robotic time 90 min. Estimated blood loss (EBL) was similar between RP-CP and LP-CP groups ( p  = 0.18). Return of bowel function (RBF) was slower in RP-CP group (3.0 vs 1.7 days, p  = 0.04), and length of stay (LOS) was longer (6.4 vs 4.1 days, p  = 0.02). In the IPAA group, there were no differences between operative times ( p  = 0.14), robotic time 86 min; EBL ( p  = 0.15), and postoperative complications. Return of bowel function (3.6 vs 2.6 days, p  = 0.3) and LOS (8.5 vs 6.1 days, p  = 0.17) were similar between RP and LP. Bowel and sexual function were equivalent between LP and RP-IPAA groups. Conclusions Robotic proctectomy is a safe and effective technique for patients with IBD. It is comparable to LP with regard to perioperative outcomes, complications, and short-term functional results.

Whilst the use of the mannitol/lactulose test for intestinal permeability has been long established it is not known whether the doses of these sugars modify transit time Similarly it is not known whether substances such as aspirin that are known to increase intestinal permeability to lactulose and mannitol and those such as ascorbic acid which are stated to be beneficial to gastrointestinal health also influence intestinal transit time. Gastric and intestinal transit times were determined with a SmartPill following consumption of either a lactulose mannitol solution, a solution containing 600 mg aspirin, a solution containing 500 mg of ascorbic acid or an extract of blackcurrant, and compared by doubly repeated measures ANOVA with those following consumption of the same volume of a control in a cross-over study in six healthy female volunteers. The dominant frequencies of cyclic variations in gastric pressure recorded by the Smartpill were determined by fast Fourier transforms. The gastric transit times of lactulose mannitol solutions, of aspirin solutions and of blackcurrant juice did not differ from those of the control. The gastric transit times of the ascorbic acid solutions were significantly shorter than those of the other solutions. There were no significant differences between the various solutions either in the total small intestinal or colonic transit times. The intraluminal pHs during the initial quartiles of the small intestinal transit times were lower than those in the succeeding quartiles. This pattern did not vary with the solution that was consumed. The power of the frequencies of cyclic variation in intragastric pressure recorded by the Smartpill declined exponentially with increase in frequency and did not peak at the reported physiological frequencies of gastric contractile activity. Whilst the segmental residence times were broadly similar to those using other methods, the high degree of variation between subjects generally precluded the identification of all but gross variation between treatments. The lack of any differences between treatments in either total small or large intestinal transit times indicates that the solutions administered in the lactulose mannitol test of permeability had no consistent influence on the temporal pattern of absorption. The negatively exponential profile and lack of any peaks in the frequency spectra of cyclic variation in gastric intraluminal pressure that were consistent with reported physiological frequencies of contractile activity profile suggests that the principal source of this variation is stochastic likely resulting from the effects of external events occasioned by normal daily activities on intra-abdominal pressure. Australian New Zealand Clinical Trials Registry ACTRN12615000596505.

Background Affective responses experienced during exercise are a significant determinant on exercise adherence. We have previously demonstrated that consumption of New Zealand (NZ) blackcurrants preserves cognition by attenuating the feeling of fatigue. This positive affective response correlated with the ability of blackcurrant polyphenols to support monoamine neurotransmission via inhibition of monoamine oxidase-B (MAO-B) activity. Here we explore how the consumption of a NZ blackcurrant juice (BJ) influenced affective responses and potential ergogenic action on the motivation to adhere to a low impact walking exercise. Methods In a parallel randomized controlled study (Trial registration #: ACTRN12617000319370p, registered 28th February 2017, http://www.anzctr.org.au/ ), 40 healthy sedentary male and female participants drank a BJ or matched placebo (PLA) ( n  = 20 per group), 1 h prior to a self-motivated treadmill walk, where heart rate and affective responses (exertion [ES] or feeling / mood [FS]) scores) were recorded at 3 or 5 min intervals. Blood glucose, lactate, malondialdehyde (MDA) and platelet MAO-B activity were measured pre- and post-exercise and comparisons were conducted using with Student’s t -tests. Subjective data were analysed using 2-way ANOVA with appropriate post hoc tests. Results Consuming a BJ 1 h prior to exercise caused a 90% decline in platelet MAO-B activity. The exercise had no significant ( p  > 0.05) effect on blood lactate, glucose or plasma MDA levels. Assessment of affective responses over the first 60 mins (adjusting for participant drop-out) revealed a time-dependent ES increase in both groups, with ES reported by participants in the BJ group consistently lower than those in the PLA group ( p  < 0.05). FS declined in PLA and BJ groups over 60 mins, but an inverse relationship with ES was only observed within the PLA group (r 2  = 0.99, p  = 0.001). Whilst the average time walked by participants in the BJ group was 11 mins longer than the PLA group ( p  = 0.3), and 30% of the BJ group achieving > 10 km compared to only 10% for the PLA group ( p  = 0.28), statistical significance was not achieved. Conclusion Our findings demonstrate that drinking a polyphenolic-rich NZ blackcurrant juice 1 h prior to exercise supports positive affective responses during a self-motivated exercise.

Concerns have been voiced regarding the possibility of health risks to the operating room personnel from exposure to surgical smoke generated from electrocautery. Ovid Medline was queried using search terms “surgical smoke”, “electrosurgery,” “smoke evacuator”. The NIOSH Health Hazard Evaluations Database was searched using terms, “hospital”, “operating room”, “Ames”, “mutagen”, and “salmonella\". Levels of pollutants in the breathable airspace within the operating room have been repeatedly shown to be very low. Absolute counts of particulate matter in the operating room are low when compared to other environments. The possibility for virus transmission with electrocautery in the operating room is unknown. The risks related to the exposure to electrocautery surgical smoke have been overstated. Rigid mandates requiring smoke evacuators in all situations are not justified at this time. •Regulations on Surgical Smoke that supersede the best judgement of the surgeon are not warranted.•Drawing parallels between exposure to surgical smoke and cigarette smoking is not remotely justified.•Numerous studies consistently report negligible levels of pollutants associated with surgical smoke within the operating room's breathable air.•The extent of particulate pollution from surgical smoke has been overstated.•While transmission of HPV is a theoretical concern, conclusive evidence is yet to be established.

The objective of this study was to assess the regional geometry of the Heineke–Mikulicz (HM) strictureplasty. The HM intestinal strictureplasty is commonly performed for the treatment of stricturing Crohn's disease of the small intestine. This procedure shifts relatively normal proximal and distal tissue to the point of narrowing and thus increases the luminal diameter. The overall effect on the regional geometry of the HM strictureplasty, however, has not been previously described in detail.MethodsHM strictureplasties were created in latex tubing and cast with an epoxy resin. The resultant casts of the lumens were then imaged using computed tomography. Using 3-dimensional vascular reconstruction software, the cross-sectional areas were determined and the surface geometry was examined.ResultsThe HM strictureplasty, while increasing the lumen at the point of the stricture, also results in a counterproductive luminal narrowing proximal and distal to the strictureplasty. Within the model used, cross-sectional area was diminished 25% to 50% below baseline. This effect is enhanced when 2 strictureplasties are placed in close proximity to each other.ConclusionsThe HM strictureplasty results in alterations in the regional geometry that may result in a compromise of the lumen proximal and distal to the location of the strictureplasty. When 2 HM strictureplasties are created in close proximity to each other, care should be undertaken to assure that the lumen of the intervening segment is adequate.

Background Surgeons are often asked to provide a diverting colostomy to enable healing or simplify management of sacral pressure ulcers. However, little evidence exists regarding the safety of a diversion in this often compromised patient population. We hypothesized that malnourished patients with sacral pressure ulcers have poor outcomes with fecal diversion. Methods ACS-NSQIP (2012–2018) was used to identify patients who underwent elective diverting colostomy for sacral pressure ulcers. Demographics, comorbidities, and perioperative details were recorded. Postoperative complications and 30-day mortality were compared between patients with moderate/severe hypoalbuminemia (< 2.5 g/dL) vs those with albumin > 2.5 g/dL. Results We identified a total of 863 patients who underwent elective diverting colostomy for sacral pressure ulcer. Mean age was 57.5 years old. Rate of associated comorbidities was high, with most patients classified as ASA class 3 or 4. Over 40% of patients had a preoperative albumin level < 2.5 g/dL. Thirty-day overall postoperative mortality was 6.7%. This was significantly higher in patients with hypoalbuminemia (11.4% vs. 3.5%, p  < 0.001). On multivariable regression analysis, preoperative albumin < 2.5 g/dL was independently associated with mortality (OR 1.92, p  = 0.039). Other factors associated with mortality included increased age (OR 1.04 per year, p  < 0.001), preoperative sepsis (OR 1.66, p  = 0.003), and Black race (OR 2.2, p  = 0.01). Conclusions Diverting colostomy performed for patients with sacral pressure ulcers is associated with a substantial risk of postoperative death. Surgeons should carefully consider risks of diversion in this patient population, especially in malnourished patients with hypoalbuminemia.