Empiric antibiotics for community-acquired pneumonia in adult patients: a systematic review and a network meta-analysis.

OBJECTIVE: The main aim of this network meta-analysis is to identify the empiric antibiotic (Em-ATB) with the highest probability of being the best (HPBB) in terms of (1) cure rate and (2) mortality rate in hospitalised patients with community acquired pneumonia (CAP) . METHOD: Inclusion criteria: (1) adult patients (>16 years old) diagnosed with CAP that required hospitalisation; (2) randomised to at least two different Em-ATBs, (3) that report cure rate and (4) are written in English or Spanish. EXCLUSION CRITERIA: (1) ambiguous antibiotics protocol and (2) published exclusively in abstract or letter format. DATA SOURCES: Medline, Embase, Cochrane and citation reviews from 1 January 2000 to 31 December 2018. Risk of bias: Cochrane's tool. Quality of the systematic review (SR): A MeaSurement Tool to Assess systematic Reviews-2. Certainity of the evidence: Grading of Recommendations Assessment, Development and Evaluation. STATISTICAL ANALYSES: frequentist method performed with the 'netmeta' library, R package. RESULTS: 27 randomised controlled trials (RCTs) from the initial 41 307 screened citations were included. Regarding the risk of bias, more than one quarter of the studies presented low risk and no study presented high risk in all domains. The SR quality is moderate. For cure, two networks were constructed. Thus, two Em-ATBs have the HPBB: cetaroline 600 mg (two times a day) and piperacillin 2000 mg (two times a day). For mortality, three networks were constructed. Thus, three Em-ATBs have the HPBB: ceftriaxone 2000 mg (once a day) plus levofloxacin 500 (two times a day), ertapenem 1000 mg (two times a day) and amikacin 250 mg (two times a day) plus clarithromycin 500 mg (two times a day). The certainity of evidence for each results is moderate. CONCLUSION: For cure rate, ceftaroline and piperaciline are the options with the HPBB. However, for mortality rate, the options are ceftriaxone plus levofloxacin, ertapenem and amikacin plus clarithromycin. It seems necessary to conduct an RCT that compares treatments with the HPBB for each event (cure or mortality) (CRD42017060692).

The anatomical and compositional basis of leaf mass per area.

Leaf dry mass per unit leaf area (LMA) is a central trait in ecology, but its anatomical and compositional basis has been unclear. An explicit mathematical and physical framework for quantifying the cell and tissue determinants of LMA will enable tests of their influence on species, communities and ecosystems. We present an approach to explaining LMA from the numbers, dimensions and mass densities of leaf cells and tissues, which provided unprecedented explanatory power for 11 broadleaved woody angiosperm species diverse in LMA (33-262 g m-2 ; R2  = 0.94; P < 0.001). Across these diverse species, and in a larger comparison of evergreen vs. deciduous angiosperms, high LMA resulted principally from larger cell sizes, greater major vein allocation, greater numbers of mesophyll cell layers and higher cell mass densities. This explicit approach enables relating leaf anatomy and composition to a wide range of processes in physiological, evolutionary, community and macroecology.

Climatic events inducing die-off in Mediterranean shrublands: are species' responses related to their functional traits?

Extreme climatic episodes, likely associated with climate change, often result in profound alterations of ecosystems and, particularly, in drastic events of vegetation die-off. Species attributes are expected to explain different biological responses to these environmental alterations. Here we explored how changes in plant cover and recruitment in response to an extreme climatic episode of drought and low temperatures were related to a set of functional traits (of leaves, roots and seeds) in Mediterranean shrubland species of south-west Spain. Remaining aerial green cover 2 years after the climatic event was positively related to specific leaf area (SLA), and negatively to leaf water potential, stable carbon isotope ratio and leaf proline content. However, plant cover resilience, i.e. the ability to attain pre-event values, was positively related to a syndrome of traits distinguished by a higher efficiency of water use and uptake. Thus, higher SLA and lower water-use efficiency characterized species that were able to maintain green biomass for a longer period of time but were less resilient in the medium term. There was a negative relationship between such syndromes and the number of emerging seedlings. Species with small seeds produced more seedlings per adult. Overall, recruitment was positively correlated with species die-off. This study demonstrates the relationship between plant traits and strong environmental pulses related to climate change, providing a functional interpretation of the recently reported episodes of climate-induced vegetation die-off. Our findings reveal the importance of selecting meaningful traits to interpret post-event resilience processes, particularly when combined with demographic attributes.

Exploring variation in leaf mass per area (LMA) from leaf to cell: an anatomical analysis of 26 woody species.

PREMISE OF THE STUDY: Plant species differ widely in the leaf biomass invested per unit area (LMA). LMA can be explained by variation in leaf thickness and/or density, both of which are influenced by anatomical tissue composition. The aim of this study is to quantify the anatomical characteristics that underlie variation in LMA in a range of woody species. • METHODS: Twenty-six woody species, forming 13 species pairs with a deciduous and evergreen species from the same genus or family, were grown in a glasshouse. The youngest full-grown leaves were analyzed for LMA and morpho-anatomical characteristics at leaf, tissue, and cell level. • KEY RESULTS: Considered over all species studied, leaf thickness and density were equally important to explain the variation in LMA, but the class difference between deciduous and evergreen species was mainly determined by thickness, whereas variation within each group was largely due to density. Evergreens had thicker leaves, predominantly caused by a larger volume of mesophyll and air spaces, whereas the higher leaf density within each group was due to a lower proportion of epidermis and air spaces, and overall smaller cells. • CONCLUSIONS: The anatomical basis for variation in LMA in woody species depends on the contrast made. Higher LMA in evergreens is mainly due to a greater leaf thickness, caused by a larger volume of mesophyll and air spaces. Within deciduous species and evergreens, higher LMA is caused by a higher density, due to higher volumetric fractions of mesophyll and lower fractions of air spaces and epidermis.

Randomized phase II clinical trial of ruxolitinib plus simvastatin in COVID19 clinical outcome and cytokine evolution.

Background: Managing the inflammatory response to SARS-Cov-2 could prevent respiratory insufficiency. Cytokine profiles could identify cases at risk of severe disease. Methods: We designed a randomized phase II clinical trial to determine whether the combination of ruxolitinib (5 mg twice a day for 7 days followed by 10 mg BID for 7 days) plus simvastatin (40 mg once a day for 14 days), could reduce the incidence of respiratory insufficiency in COVID-19. 48 cytokines were correlated with clinical outcome. Participants: Patients admitted due to COVID-19 infection with mild disease. Results: Up to 92 were included. Mean age was 64 ± 17, and 28 (30%) were female. 11 (22%) patients in the control arm and 6 (12%) in the experimental arm reached an OSCI grade of 5 or higher (p = 0.29). Unsupervised analysis of cytokines detected two clusters (CL-1 and CL-2). CL-1 presented a higher risk of clinical deterioration vs CL-2 (13 [33%] vs 2 [6%] cases, p = 0.009) and death (5 [11%] vs 0 cases, p = 0.059). Supervised Machine Learning (ML) analysis led to a model that predicted patient deterioration 48h before occurrence with a 85% accuracy. Conclusions: Ruxolitinib plus simvastatin did not impact the outcome of COVID-19. Cytokine profiling identified patients at risk of severe COVID-19 and predicted clinical deterioration. Trial registration: https://clinicaltrials.gov/, identifier NCT04348695.

Physiological and Structural Responses of Olive Leaves Related to Tolerance/Susceptibility to Verticillium dahliae.

Verticillium wilt of olive (VWO), caused by the soil borne fungus Verticillium dahliae, is one of the most relevant diseases affecting this crop worldwide. One of the best VWO management strategies is the use of tolerant cultivars. Scarce information is available about physiological and structural responses in the leaves of olive cultivars displaying different levels of tolerance to VWO. To identify links between this phenotype and variations in functional characteristics of the leaves, this study examined the structural and physiological traits and the correlations among them in different olive varieties. This evaluation was conducted in the presence/absence of V. dahliae. On the one hand, no leaf trait but the area was related to VWO tolerance in the absence of the pathogen. On the other hand, after inoculation, susceptible cultivars showed lower leaf area and higher leaf mass per area and dry matter content. Furthermore, at the physiological level, these plants showed severe symptoms resembling water stress. Analyzing the relationships among physiological and structural traits revealed differences between tolerant and susceptible cultivars both in the absence and in the presence of V. dahliae. These results showed that olive leaves of VWO-tolerant and VWO-susceptible cultivars adopt different strategies to cope with the pathogen.

Unveiling Differences in Root Defense Mechanisms Between Tolerant and Susceptible Olive Cultivars to Verticillium dahliae.

Verticillium wilt of olive (VWO), caused by the soil-borne vascular pathogen Verticillium dahliae, is one of the most devastating diseases affecting olive, the woody crop. One of the best VWO management measures is the use of tolerant cultivars. Yet, our knowledge about defense mechanisms that operate at the root level to explain tolerance to this disease is incomplete. Moreover, most of the approaches so far followed focus only on a specific mechanistic level (e.g., genetic, physiological, or biochemical) rather than on a holistic/multilevel perspective. In this study, eighteen root functional traits, the time-course expression of nine defense-related genes, the root lignin content, and the root membrane permeability were evaluated in six olive varieties differing in their level of tolerance/susceptibility to VWO. The aim was to find links between the level of tolerance to VWO and specific root defense mechanisms at the structural, genetic, biochemical, and physiological levels. Tolerant and susceptible cultivars showed substantial differences in the root system architecture and root lignin content. VWO-susceptible cultivars presented roots with higher specific length and area, but lower diameter and larger number of forks and tips compared to tolerant varieties that also showed less branched roots, higher root diameter, and larger basal content of lignin. Interestingly, VWO-tolerant varieties significantly increased their root lignin content and root membrane permeability after inoculation with V. dahliae. These results were seldom (or not at all) observed in the susceptible plants. At the genetic level, genes related to defense mechanisms, such as cell wall lignin biosynthesis (C4H and CO-MT), production of hydrolytic enzymes able to degrade the fungal cell wall (ß-1.3-glucanase), and activation of innate immunity (BAK1 and WRKY5) increased their expression in tolerant cultivars from early moments after inoculation, in contrast to the susceptible ones. These results showed that differences in the root system architecture and lignin content may greatly determine the performance of olive against colonization and invasion by V. dahliae. Moreover, the increase in root membrane permeability in the presence of the pathogen was a typical response of tolerant cultivars. Finally, VWO-tolerant cultivars were able to mount a more intense and rapid defense-related genetic response to respond to the attack by V. dahliae.

Water-use strategies of six co-existing Mediterranean woody species during a summer drought.

Drought stress is known to limit plant performance in Mediterranean-type ecosystems. We have investigated the dynamics of the hydraulics, gas exchange and morphology of six co-existing Mediterranean woody species growing under natural field conditions during a drought that continued during the entire summer. Based on the observed minimum leaf water potentials, our results suggest that the six co-existing species cover a range of plant hydraulic strategies, from isohydric to anisohydric. These differences are remarkable since the selected individuals grow within several meters of each other, sharing the same environment. Surprisingly, whatever the leaf water potentials were at the end of the dry period, stomatal conductance, photosynthesis and transpiration rates were relatively similar and low across species. This result contradicts the classic view that anisohydric species are able to maintain gas exchange for longer periods of time during drought stress. None of the plants showed the expected structural acclimation response to the increasing drought (reduction of leaf-to-sapwood area ratio), thereby rejecting the functional equilibrium hypothesis for our study system. Instead, three of the six species increased photosynthetic area at the branch level. The observed dissimilar patterns of gas exchange, hydraulics and morphology across species seem to be equally successful given that photosynthesis at the leaf level was maintained at similar rates over the whole dry period.

Functional Traits of Olive Varieties and Their Relationship with the Tolerance Level towards Verticillium Wilt.

Verticillium wilt of olive (VWO), caused by the soil-borne pathogen Verticillium dahliae, is considered one of the most important diseases affecting this tree crop. One of the best VWO management measures is the use of tolerant cultivars. Remarkably, no information is available about olive functional traits and their potential relationship with tolerance to V. dahliae. Twenty-five selected functional traits (for leaf, stem, root and whole plant) were evaluated in six olive varieties differing in their VWO tolerance level to identify possible links between this phenotype and functional traits' variation. High intervarietal diversity was found among cultivars and several functional traits were related with VWO tolerance. Tolerant varieties showed higher leaf area, dry matter content (leaf, stem and plant) and mass fraction for stems, but lower for leaves. Significant differences were also detected for root functional traits, tolerant cultivars displaying larger fine root diameter and lignin content but smaller specific length and area of thick and fine roots. Correlations were found among functional traits both within varieties and between levels of tolerance/susceptibility to VWO. Associations were observed between biomass allocation, dry matter content and VWO tolerance. The most relevant difference between tolerant and susceptible cultivars was related to root system architecture.

Applying the economic concept of profitability to leaves.

Economic principles can be extended to biological organisms as they optimize the use of resources, but their use in biology has been limited. We applied concepts from traditional economics to the main production unit of plants, the leaf. We quantified the profitability (profit/cost of investment) of leaves from seven biomes worldwide and compared those to the profitability of companies. Here we demonstrate for the first time key similarities and differences between leaf and human economics. First, there was a weak, but positive relationship between profitability and size, both for leaves and companies. Second, environment has a strong effect on profitability, with high values in leaves from biomes with short growth periods and, for companies associated with innovation. Third, shorter longevity of productive units was related to higher profitability. In summary, by comparing economic behaviours of plants and humans there is potential to develop new perspectives on plant ecological strategies and plant evolution.

Risk Score for Predicting In-Hospital Mortality in COVID-19 (RIM Score).

Infection by SARS-CoV2 has devastating consequences on health care systems. It is a global health priority to identify patients at risk of fatal outcomes. 1955 patients admitted to HM-Hospitales from 1 March to 10 June 2020 due to COVID-19, were were divided into two groups, 1310 belonged to the training cohort and 645 to validation cohort. Four different models were generated to predict in-hospital mortality. Following variables were included: age, sex, oxygen saturation, level of C-reactive-protein, neutrophil-to-platelet-ratio (NPR), neutrophil-to-lymphocyte-ratio (NLR) and the rate of changes of both hemogram ratios (VNLR and VNPR) during the first week after admission. The accuracy of the models in predicting in-hospital mortality were evaluated using the area under the receiver-operator-characteristic curve (AUC). AUC for models including NLR and NPR performed similarly in both cohorts: NLR 0.873 (95% CI: 0.849-0.898), NPR 0.875 (95% CI: 0.851-0.899) in training cohort and NLR 0.856 (95% CI: 0.818-0.895), NPR 0.863 (95% CI: 0.826-0.901) in validation cohort. AUC was 0.885 (95% CI: 0.885-0.919) for VNLR and 0.891 (95% CI: 0.861-0.922) for VNPR in the validation cohort. According to our results, models are useful in predicting in-hospital mortality risk due to COVID-19. The RIM Score proposed is a simple, widely available tool that can help identify patients at risk of fatal outcomes.

The Economics Spectrum Drives Root Trait Strategies in Mediterranean Vegetation.

Extensive research efforts are devoted to understand fine root trait variation and to confirm the existence of a belowground root economics spectrum (RES) from acquisitive to conservative root strategies that is analogous to the leaf economics spectrum (LES). The economics spectrum implies a trade-off between maximizing resource acquisition and productivity or maximizing resource conservation and longevity; however, this theoretical framework still remains controversial for roots. We compiled a database of 320 Mediterranean woody and herbaceous species to critically assess if the classic economics spectrum theory can be broadly extended to roots. Fine roots displayed a wide diversity of forms and properties in Mediterranean vegetation, resulting in a multidimensional trait space. The main trend of variation in this multidimensional root space is analogous to the main axis of LES, while the second trend of variation is partially determined by an anatomical trade-off between tissue density and diameter. Specific root area (SRA) is the main trait explaining species distribution along the RES, regardless of the selected traits. We advocate for the need to unify and standardize the criteria and approaches used within the economics framework between leaves and roots, for the sake of theoretical consistency.

Linking functional traits with tree growth and forest productivity in Quercus ilex forests along a climatic gradient.

Plant functional traits are highly plastic to changes in climatic factors and nutrient availability. However, the intraspecific plant response to abiotic factors and the overall effect on tree growth and productivity is still under debate. We studied forest productivity for 30 Quercus ilex subsp. ballota forests in Spain along a broad climatic gradient of aridity (mean annual precipitation from 321 to 858 mm). We used linear mixed models to quantify the effect of climatic and edaphic (soil nutrients, topography, and texture) factors on tree functional traits (leaf and branch traits), and subsequently, the effect of such functional traits and abiotic factors on the relative growth rate (RGR) of adult trees. We used piecewise structural equation models (SEMs) to determine the causal effect of intrinsic and extrinsic factors on forest productivity. Our results showed that tree functional traits were mainly explained by climatic and edaphic factors. Functional traits and tree biomass explained forest biomass and RGR, respectively, which ultimately explained forest productivity. In conclusion, intraspecific variability of functional traits has a significant effect on plant biomass and growth, which ultimately may explain forest productivity in Quercus ilex forests.

Interactions of Comorbidity and Five Simple Environmental Unhealthy Habits Concerning Physical and Mental Quality of Life in the Clinical Setting.

The objective of this study was to examine the interactions between comorbidity and five lifestyle single habits concerning different subscales of quality of life (QoL). For the study, 302 patients were consecutively recruited at the internal medicine department of a tertiary teaching hospital. Lifestyle habits, comorbidities and QoL were recorded according to validated questionnaires. Five single unhealthy habits, such as tobacco consumption, dietary intake of ultra-processed pastries, raw nuts or carbonated drinks, sleep time and physical activity patterns were selected according to previously published data. The main outcomes of the study were the scores of the eight subscales of the SF-36 QoL survey. The aggregate of unhealthy habits showed statistically significant association to every category in the SF-36 questionnaire, both in the univariate and the multivariate analysis when adjusting by age, sex and comorbidity. An interaction was found between comorbidity and unhealthy habits in both physical and mental summaries of SF-36. In conclusion, the lifestyle assessment according to five unhealthy habits is associated with a worse QoL. The interaction between comorbidity and unhealthy habits is especially clear in diseased patients due to the interplay between illness and lifestyle in the prediction of QoL.

The worldwide leaf economics spectrum.

Bringing together leaf trait data spanning 2,548 species and 175 sites we describe, for the first time at global scale, a universal spectrum of leaf economics consisting of key chemical, structural and physiological properties. The spectrum runs from quick to slow return on investments of nutrients and dry mass in leaves, and operates largely independently of growth form, plant functional type or biome. Categories along the spectrum would, in general, describe leaf economic variation at the global scale better than plant functional types, because functional types overlap substantially in their leaf traits. Overall, modulation of leaf traits and trait relationships by climate is surprisingly modest, although some striking and significant patterns can be seen. Reliable quantification of the leaf economics spectrum and its interaction with climate will prove valuable for modelling nutrient fluxes and vegetation boundaries under changing land-use and climate.

Projected climate changes are expected to decrease the suitability and production of olive varieties in southern Spain.

World olive production is based on the cultivation of different varieties that respond differently to abiotic factors. Climate change may affect the area of land suitable for olive cultivation and change production levels, thus causing serious damage to this economically-relevant and highly-productive olive grove agroecosystem. In Mediterranean regions such as Andalusia, one of the main areas of olive production, the effect of climate change seems threatening. Thus, our main aims are: (1) to examine the abiotic factors that characterise the current cultivated locations and predict the current and potential distribution of these locations; (2) to evaluate the effect of climate change (based on regional scenarios) on the future environmental suitability of each olive variety; and (3) to analyse the expected alteration in the annual olive production. We used the seven most-productive olive varieties in Andalusia and the wild olive species to develop Species Distribution Models (SDMs), coupled with soil properties, geomorphology, water balance and (bio-)climatic predictors at a fine scale. We also derived future climate projections to assess the effect of climate change on the environmental suitability and productivity of each olive variety. We found that soil pH was the most-important factor for most distribution models, while (bio-)climatic predictors - such as continentality index, summer and autumn precipitation and winter temperature - provided important contributions. In general, projections based on regional climate change scenarios point to a decrease in the area suitable for olive crops in Andalusia, due to an increase in evapotranspiration and a decrease in precipitation. These changes in suitable area are also projected to decrease olive production for almost all the olive-growing provinces investigated. Our findings may anticipate the effects of climate change on olive crops and provide early estimates of fruit production, at local and regional scales, as well as forming the basis of adaptation strategies.

Antioxidant Lifestyle, Co-Morbidities and Quality of Life Empowerment Concerning Liver Fibrosis.

The assessment of liver fibrosis has gained importance since the progression of non-alcoholic fatty liver disease (NAFLD). Indeed, the description of the association between undetected liver fibrosis and lifestyle in terms of antioxidant habits, comorbidity and quality of life (QoL) domains may help in the characterization of subjects with NAFLD. A cross-sectional evaluation of (n = 116) consecutive patients from an Internal Medicine ambulatory evaluation was performed. Demographic data, lifestyle, co-morbidity, QoL (according to the SF-36 index) and analytical values to calculate the oxidative related Fibrosis-4 (FIB-4) index were recorded. The association between FIB-4 and co-morbidity, antioxidant habits in QoL was assessed in univariate analysis (p < 0.05) and confirmed in multivariable analysis for 4 of the 8 SF-36 categories: Physical QoL, Physical role, Social QoL and General QoL, as well as in the Physical summary of SF-36 (p < 0.05). Finally, interactions were assessed between co-morbidity, FIB-4 and antioxidant habits showed in the prediction of mean SF-36 (p < 0.01). Liver fibrosis assessed by the oxidative surrogate index FIB-4 is associated with the interaction between antioxidant lifestyle, co-morbidity and physical, social and general aspects of QoL in apparent liver disease-free individuals, generating a proof of concept for health empowerment and personalized medicine.

Cross-sectional evaluation of the interaction between activity relative-time expenditure and comorbidity concerning physical quality of life.

Quality of life (QoL) is a matter of concern in both healthy and diseased individuals. Lifestyle factors such as physical activity and sleep have a direct impact on QoL. In this context, interactions between activity time expenditure and QoL might be different in comorbid and non comorbid patients. Besides, the quantification and evaluation of time expenditure is ordinarily measured as the absolute time devoted to each activity. The objective of this study is the evaluation of the influence and interactions of activity-relative time expenditure and co-morbidity in Physical QoL.The study involved 302 consecutive patients, from an Internal Medicine ambulatory evaluation. Validated questionnaires were used to collect demographic variables and time expenditure variables. QoL was gathered with de survey short form-36questionnaire. Comorbidity was compiled with de Charlson Comorbidity Index. SPSS v20.0 was used for statistical analysis.As hypothesized, healthy subjects had higher Physical QoL score than comorbid subjects (P < .05). Physical activity and sleep relative time expenditure were statistically significant and associated to a better QoL in comorbid patients (P < .05). Interestingly, sleep was found to have statistically significant interaction with a score of ≥2 in the Charlson Comorbidity Index. Age, gender, comorbidity, physical activity relative time expenditure, and the interaction between relative time dedicated to sleep and comorbidity were found statistically significant in a multivariate model on Physical QoL prediction.Activity-relative time expenditure could be an adequate measure of daily activity pattern in the evaluation of QoL. Relative time spent in physical activity and sleep might be positively associated to Physical QoL. Sleep and comorbidity could have a statistically significant interaction in the prediction of Physical QoL.

Causes and consequences of variation in leaf mass per area (LMA): a meta-analysis.

Here, we analysed a wide range of literature data on the leaf dry mass per unit area (LMA). In nature, LMA varies more than 100-fold among species. Part of this variation (c. 35%) can be ascribed to differences between functional groups, with evergreen species having the highest LMA, but most of the variation is within groups or biomes. When grown in the same controlled environment, leaf succulents and woody evergreen, perennial or slow-growing species have inherently high LMA. Within most of the functional groups studied, high-LMA species show higher leaf tissue densities. However, differences between evergreen and deciduous species result from larger volumes per area (thickness). Response curves constructed from experiments under controlled conditions showed that LMA varied strongly with light, temperature and submergence, moderately with CO2 concentration and nutrient and water stress, and marginally under most other conditions. Functional groups differed in the plasticity of LMA to these gradients. The physiological regulation is still unclear, but the consequences of variation in LMA and the suite of traits interconnected with it are strong. This trait complex is an important factor determining the fitness of species in their environment and affects various ecosystem processes.

A pilot study of fecal serine-protease activity: a pathophysiologic factor in diarrhea-predominant irritable bowel syndrome.

BACKGROUND & AIMS: The pathogenesis of irritable bowel syndrome (IBS) remains only partially understood, and no specific or universally effective patient management procedure has been developed to date. Our study was designed to evaluate if colonic luminal serine-proteases may be a relevant pathophysiologic marker of IBS. METHODS: Fecal samples of 38 IBS patients, 15 patients with ulcerative colitis (UC), and 15 healthy controls were studied. Fecal serine-protease activity was determined photometrically by using azocasein as a proteolytic substrate; fecal pancreatic elastase-1 and mast cell tryptase content were measured by enzyme-linked immunosorbent assay. Fecal secretory leukocyte protease inhibitor concentration was determined by enzyme-linked immunosorbent assay in control subjects and in patients with diarrhea-predominant IBS. RESULTS: Fecal serine-protease activity was 3-fold higher in patients with diarrhea-predominant IBS than in both controls and IBS patients with either constipation or alternating bowel habits. Fecal serine-protease activity was not correlated with the frequency of bowel movements in all groups. Increased serine-protease activity also was detected in stools of UC patients. No significant difference was observed in the fecal mast cell tryptase and pancreatic elastase concentrations between all groups, or in the fecal secretory leukocyte protease inhibitor concentration between controls and diarrhea-predominant IBS patients. CONCLUSIONS: Fecal serine-protease activity is increased markedly in patients with diarrhea-predominant IBS. This increase, however, is not coupled with changes in either mast cell tryptase or pancreatic elastase concentrations. Thus, serine-protease activity in the colon may be a pathophysiologic factor in the development of diarrhea-predominant IBS.