Is Gluten the Only Culprit for Non-Celiac Gluten/Wheat Sensitivity?

The gluten-free diet (GFD) has gained increasing popularity in recent years, supported by marketing campaigns, media messages and social networks. Nevertheless, real knowledge of gluten and GF-related implications for health is still poor among the general population. The GFD has also been suggested for non-celiac gluten/wheat sensitivity (NCG/WS), a clinical entity characterized by intestinal and extraintestinal symptoms induced by gluten ingestion in the absence of celiac disease (CD) or wheat allergy (WA). NCG/WS should be regarded as an "umbrella term" including a variety of different conditions where gluten is likely not the only factor responsible for triggering symptoms. Other compounds aside from gluten may be involved in the pathogenesis of NCG/WS. These include fructans, which are part of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), amylase trypsin inhibitors (ATIs), wheat germ agglutinin (WGA) and glyphosate. The GFD might be an appropriate dietary approach for patients with self-reported gluten/wheat-dependent symptoms. A low-FODMAP diet (LFD) should be the first dietary option for patients referring symptoms more related to FODMAPs than gluten/wheat and the second-line treatment for those with self-reported gluten/wheat-related symptoms not responding to the GFD. A personalized approach, regular follow-up and the help of a skilled dietician are mandatory.

A retrospective study of ulinastatin for the treatment of severe sepsis.

This retrospective study aimed to investigate the efficacy and safety of existing approach of ulinastatin for the treatment of severe sepsis (SS).A total of 130 eligible patients with SS were included in this study. We divided them into an intervention group (n = 65) and a control group (n = 65). Patients in both groups received conventional therapy. In addition, patients in the intervention group received ulinastatin for 7 days. Outcomes were measured by Acute Physiology and Chronic Health Evaluation II (APACHE II), Multiple Organ Failure (MOF), Glasgow Coma Scale (GCS), CD3, CD4, CD8, CD4/CD8, and adverse events. We assessed all outcomes before and after treatment.After treatment, patients in the intervention group showed better improvement in APACHE II (P < .01), MOF (P < .01), GCS (P < .01), CD3 (P = .03), CD4 (P = .03), and CD4/CD8 (P < .01), than those of patients in the control group. There are similar safety profiles between both groups.This study suggests that ulinastatin may be beneficial for SS. Future studies are still needed to warrant the results of this study.

Wheat Consumption Aggravates Colitis in Mice via Amylase Trypsin Inhibitor-mediated Dysbiosis.

BACKGROUND & AIMS: Wheat has become the world's major staple and its consumption correlates with prevalence of noncommunicable disorders such as inflammatory bowel diseases. Amylase trypsin inhibitors (ATIs), a component of wheat, activate the intestine's innate immune response via toll-like receptor 4 (TLR4). We investigated the effects of wheat and ATIs on severity of colitis and fecal microbiota in mice. METHODS: C57BL/6 wild-type and Tlr4-/- mice were fed wheat- or ATI-containing diets or a wheat-free (control) diet and then given dextran sodium sulfate to induce colitis; we also studied Il10-/- mice, which develop spontaneous colitis. Changes in fecal bacteria were assessed by taxa-specific quantitative polymerase chain reaction and 16S ribosomal RNA metagenomic sequencing. Feces were collected from mice on wheat-containing, ATI-containing, control diets and transplanted to intestines of mice with and without colitis on control or on ATI-containing diets. Intestinal tissues were collected and analyzed by histology, immunohistochemistry, and flow cytometry. Bacteria with reported immunomodulatory effects were incubated with ATIs and analyzed in radial diffusion assays. RESULTS: The wheat- or ATI-containing diets equally increased inflammation in intestinal tissues of C57BL/6 mice with colitis, compared with mice on control diets. The ATI-containing diet promoted expansion of taxa associated with development of colitis comparable to the wheat-containing diet. ATIs inhibited proliferation of specific human commensal bacteria in radial diffusion assays. Transplantation of microbiota from feces of mice fed the wheat- or ATI-containing diets to intestines of mice on control diets increased the severity of colitis in these mice. The ATI-containing diet did not increase the severity of colitis in Tlr4-/- mice. CONCLUSIONS: Consumption of wheat or wheat ATIs increases intestinal inflammation in mice with colitis, via TLR4, and alters their fecal microbiota. Wheat-based, ATI-containing diets therefore activate TLR4 signaling and promote intestinal dysbiosis.

Dietary wheat amylase trypsin inhibitors promote features of murine non-alcoholic fatty liver disease.

We previously demonstrated that a common dietary protein component, wheat amylase trypsin inhibitors (ATI), stimulate intestinal macrophages and dendritic cells via toll like receptor 4. Activation of these intestinal myeloid cells elicits an inflammatory signal that is propagated to mesenteric lymph nodes, and that can facilitate extraintestinal inflammation. Mice were fed a well-defined high fat diet, with (HFD/ATI) or without (HFD) nutritionally irrelevant amounts of ATI. Mice on HFD/ATI developed only mild signs of intestinal inflammation and myeloid cell activation but displayed significantly higher serum triglycerides and transaminases compared to mice on HFD alone. Moreover, they showed increased visceral and liver fat, and a higher insulin resistance. ATI feeding promoted liver and adipose tissue inflammation, with M1-type macrophage polarization and infiltration, and enhanced liver fibrogenesis. Gluten, the major protein component of wheat, did not induce these pathologies. Therefore, wheat ATI ingestion in minute quantities comparable to human daily wheat consumption exacerbated features of the metabolic syndrome and non-alcoholic steatohepatitis, despite its irrelevant caloric value.

Efficacy and safety of inhaled α1-antitrypsin in patients with severe α1-antitrypsin deficiency and frequent exacerbations of COPD.

Patients with inherited α1-antitrypsin (AAT) deficiency (ZZ-AATD) and severe chronic obstructive pulmonary disease (COPD) frequently experience exacerbations. We postulated that inhalation of nebulised AAT would be an effective treatment.We randomly assigned 168 patients to receive twice-daily inhalations of 80 mg AAT solution or placebo for 50 weeks. Patients used an electronic diary to capture exacerbations. The primary endpoint was time from randomisation to the first event-based exacerbation. Secondary endpoints included change in the nature of the exacerbation as defined by the Anthonisen criteria. Safety was also assessed.Time to first moderate or severe exacerbation was a median of 112 days (interquartile range (IQR) 40-211 days) for AAT and 140 days (IQR 72-142 days) for placebo (p=0.0952). The mean yearly rate of all exacerbations was 3.12 in the AAT-treated group and 2.67 in the placebo group (p=0.31). More patients receiving AAT reported treatment-related treatment-emergent adverse events compared to placebo (57.5% versus 46.9%, respectively) and they were more likely to withdraw from the study. After the first year of the study, when modifications to the handling of the nebuliser were introduced, the rate of safety events in the AAT-treated group dropped to that of the placebo group.We conclude that in AATD patients with severe COPD and frequent exacerbations, AAT inhalation for 50 weeks showed no effect on time to first exacerbation but may have changed the pattern of the episodes.

Metabolism of wheat proteins by intestinal microbes: Implications for wheat related disorders.

Wheat is a common cereal in the Western diet and an important source of protein as well as fiber. However, some individuals develop adverse reactions to a wheat-containing diet. The best characterized is celiac disease which develops after intake of gluten in individuals with genetic predisposition. Other wheat-related conditions are less well defined in terms of diagnosis, specific trigger and underlying pathways. Despite this, the overall prevalence of wheat-related disorders has increased in the last decades and the role of microbial factors has been suggested. Several studies have described an altered intestinal microbiota in celiac patients compared to healthy subjects, but less information is available regarding other wheat-related disorders. Here, we discuss the importance of the intestinal microbiota in the metabolism of wheat proteins and the development of inflammatory or functional conditions. Understanding these interactions will open new directions for therapeutic development using bacteria with optimal wheat protein degrading capacity.

Rationale and design of a prospective, multicentre, randomised, conventional treatment-controlled, parallel-group trial to evaluate the efficacy and safety of ulinastatin in preventing acute respiratory distress syndrome in high-risk patients.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is challenging in the intensive care unit (ICU). Although pharmacotherapy for ARDS has gained increasing attention, most trials have yielded negative results. Patients with ARDS have usually been recruited as subjects; the inflammatory reaction has already expanded into a cascade at this point, and its severity is sufficient to damage the lung parenchyma. This raises the question of whether early treatment can prevent ARDS and the associated lung injury. We hypothesise that ARDS is preventable in high-risk patients by administration of ulinastatin as an anti-inflammatory drug before ARDS onset, and we are performing a study to test ulinastatin, a protease inhibitor, versus treatment-as-usual in a group of patients at increased risk for ARDS. METHODS AND ANALYSIS: This report presents the protocol for a multicentre, randomised, conventional treatment-controlled, parallel group study to prevent the development of ARDS using ulinastatin in high-risk patients. The study population will comprise patients at risk of ARDS in the ICU (≥18 years of age and Lung Injury Prediction Score of >4); patients with confirmed ARDS and some other conditions (immunodeficiency, use of some drugs, etc.) will be excluded. The enrolled patients will be randomly allocated to an ulinastatin group (ulinastatin will be intravenously administered every 8 hours for a total of 600 000 U/day for five consecutive days) or control group. The efficacy of ulinastatin in preventing ARDS development will be evaluated by the incidence rate of ARDS as the primary outcome; the secondary outcomes include the severity of ARDS, clinical outcome, extrapulmonary organ function and adverse events incurred by ulinastatin. Based on the results of preliminary studies and presuming the incidence of ARDS will decrease by 9% in high-risk patients, 880 patients are needed to obtain statistical power of 80%. ETHICS AND DISSEMINATION: This study has been approved by the Peking University Third Hospital Medical Science Research Ethics Committee. The findings will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT03089957; Pre-results.

The overlap of irritable bowel syndrome and noncoeliac gluten sensitivity.

PURPOSE OF REVIEW: There has been significant interest in gluten over the last decade, with an increase in interest of gluten-related disorders outside coeliac disease. Particularly, there has been a focus on the role of gluten in noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). There is significant overlap between both of these conditions, with the aim of this review to explore their complex relationship. RECENT FINDINGS: Gluten has been demonstrated to generate symptoms in individuals with NCGS. However, there appears to be an increasing role for gluten in symptom generation in patients with IBS also. Other components of wheat, other than gluten, are now also thought to be contributing factors in symptom generation. SUMMARY: There appears to be significant overlap between IBS and NCGS. It is likely that a subset of patients presenting with IBS actually have NCGS. In addition, it is likely that individuals with IBS may also have symptoms triggered by gluten. With the pathophysiology of both conditions not fully understood, as well as increasing knowledge of wheat components in symptom generation, further research is required to help distinguish between both.

Amylase-Trypsin Inhibitors in Wheat and Other Cereals as Potential Activators of the Effects of Nonceliac Gluten Sensitivity.

Nonceliac gluten sensitivity (NCGS) is a gluten-related gastrointestinal disorder distinct from celiac disease (CD) and gluten allergy that is not easy to diagnose due to the lack of biomarkers. It is characterized by intestinal symptoms and extraintestinal manifestations with the consumption of gluten-containing foods. In contrast to CD, NCGS patients do not present a genetic predisposition or intestinal villi atrophy. Recent studies question the proinflammatory triggering activity of α-gliadin fraction contained in wheat, since it has been demonstrated that the amylase-trypsin inhibitors (ATIs) exert a strong activating effect on the innate immune response. We aimed to analyze the role of ATIs in the activation of innate immunity and in the development of the symptoms characteristic of NCGS. A systematic literature search was made using databases such as MEDLINE, SciELO, Science Direct, and Scopus, with focus on key words such as "amylase-trypsin inhibitors," "wheat," "gluten," and "celiac." Many studies are available on the structure, inhibition mechanism, and immune system effects of ATIs, mainly focused on IgE-mediated reactions. Recently, with the increase of NCGS interest, has increased the literature on the capacity of ATIs contained in wheat to activate the innate immune system. Literature published to date questions the relationship between activation of the innate immune system and gluten in NCGS. ATIs may have acted as interfering contaminant of gluten and appear as potential activator of innate immunity in NCGS patients. In view of their potential impact, more interventional studies are needed to demonstrate the proinflammatory effect of ATIs.

Growth Impairment Caused by Raw Linseed Consumption: Can Trypsin Inhibitors Be Harmful for Health?

Linseed (Linun usitatissimum L.) is an important oilseed whose nutritional value can be impaired due to presence of antinutritional factors and low protein digestibility. Protein fractions from raw linseed meal were extracted, isolated and analyzed in vitro and in vivo. Globulins, the major protein fraction of linseed, showed low in vitro susceptibility to trypsin and chymotrypsin, but its in vivo digestibility was 93.2 %. Albumin fraction had high trypsin inhibition activity (5250 Inhibition Units g(-1)) and presented low molecular mass protein bands, similar to known trypsin inhibitors. Raw linseed consumption caused negative effects on rat growth and reduction of intestinal villi. Results indicate that raw linseed meal must not be used as an exclusive source of protein regardless of the major proteins have high digestibility; digestive enzymes inhibitors in raw linseed probably reduces the protein utilization.

[Use of the urinary trypsin inhibitor ulinastatin for acute Kawasaki disease].

Intravenous immunoglobulin (IVIG) therapy is widely recognized as standard treatment for Kawasaki disease(KD). However, about 20 % of KD patients are resistant to IVIG and are considered to be a high risk group for coronary artery lesions (CAL). Ulinastatin(UTI) is one of the neutrophil elastase inhibitors used for patients with pancreatitis or circulatory shock, and several studies have shown its efficacy for KD. Recently, we demonstrated that initial UTI treatment combined with IVIG decreased the number of patients requiring addi- tional rescue treatment and the occurrence of CAL. In this study, no severe adverse events occurred. Further research and a prospective trial are needed to prove the clinical efficacy and demonstrate the limits of UTI in patients with KD.

Efficacy and safety of intravenous ulinastatin versus placebo along with standard supportive care in subjects with mild or severe acute pancreatitis.

BACKGROUND: Ulinastatin is reported to inhibit pro-inflammatory markers and also inhibits coagulation and fibrinolysis. The drug is available in East Asia for the treatment of acute pancreatitis. AIM: To study the effect of addition of ulinastatin to standard care on mortality and morbidity in Indian subjects with acute pancreatitis. DESIGN: Randomized, double-blind, placebo-controlled, multi-centre trial across 15 centres in India. METHODS: Subjects, aged 18 to 70 years, with acute pancreatitis and elevated serum C-reactive protein (CRP) levels, were eligible for enrolment. Acute pancreatitis was diagnosed if the patient had at least two of the following criteria: suggestive abdominal pain, serum amylase and/or lipase > 3 times upper limit of normal, and imaging findings of acute pancreatitis. Subjects were classified as having mild or severe acute pancreatitis on the basis of the APACHE II score (< 8 mild, > or = 8 severe). Standard care was given to all subjects as per the treating physician's protocol. Eligible subjects were randomized to receive intravenous infusion of 200,000 IU ulinastatin or placebo in 100 mL of 0.9% saline given over one hour every 12 hours for 5 days. RESULTS: Of 135 randomized subjects, 129 completed the study (mild 62, severe 67). Pancreatitis was due to alcohol intake in a majority (81%) of subjects. Baseline characteristics were similar between the ulinastatin and placebo groups. Efficacy was evaluated in subjects who had received at least 3 days (6 doses) of ulinastatin/placebo. One subject with severe pancreatitis in the ulinastatin group versus six in the placebo group died (p = 0.048). New organ dysfunction developed in 5 ulinastatin vs 4 placebo group subjects (p = 0.744) with mild pancreatitis and 12 ulinastatin vs 29 placebo group subjects (p = 0.0026) with severe pancreatitis. Adverse events were significantly lower in subjects with severe pancreatitis in the ulinastatin group as compared to the placebo group (p = 0.00001). Reduction in serum CRP was not different between the groups. Median hospitalization was shorter by one day in the ulinastatin group; the difference was not significant. There was no infusion-related adverse event. CONCLUSIONS: Ulinastatin prevents new organ dysfunction and reduces mortality in subjects with severe pancreatitis.

Wheat amylase trypsin inhibitors drive intestinal inflammation via activation of toll-like receptor 4.

Ingestion of wheat, barley, or rye triggers small intestinal inflammation in patients with celiac disease. Specifically, the storage proteins of these cereals (gluten) elicit an adaptive Th1-mediated immune response in individuals carrying HLA-DQ2 or HLA-DQ8 as major genetic predisposition. This well-defined role of adaptive immunity contrasts with an ill-defined component of innate immunity in celiac disease. We identify the α-amylase/trypsin inhibitors (ATIs) CM3 and 0.19, pest resistance molecules in wheat, as strong activators of innate immune responses in monocytes, macrophages, and dendritic cells. ATIs engage the TLR4-MD2-CD14 complex and lead to up-regulation of maturation markers and elicit release of proinflammatory cytokines in cells from celiac and nonceliac patients and in celiac patients' biopsies. Mice deficient in TLR4 or TLR4 signaling are protected from intestinal and systemic immune responses upon oral challenge with ATIs. These findings define cereal ATIs as novel contributors to celiac disease. Moreover, ATIs may fuel inflammation and immune reactions in other intestinal and nonintestinal immune disorders.

Optimization of process for reduction of antinutritional factors in edible cereal brans.

Reduction of various antinutritional factors in cereal brans by different treatments (microwave heating, dry heating and wet heating) were studied. There was significant difference (p ≤ 0.05) in reduction of antinutritional factors of treated cereal brans except for dry heating at low temperature. Microwave heating at 2450 MHz for 2.5 min resulted in 53.85%, 57.21%, 65.00% and 100% reduction in phytic acid, polyphenols, oxalates and saponins, respectively. Wet heating resulted in maximum reduction in trypsin inhibitor activity (83.07%) at 110 °C for 25 min. Processing treatment resulted in increase in bulk density and slight darkening of the brans. The most effective method of detoxifying most of the toxicants was microwave heating for 2.5 min, and therefore it could be exploited for making treated brans an ideal source for potential food application.

Ulinastatin, a urinary trypsin inhibitor, for the initial treatment of patients with Kawasaki disease: a retrospective study.

BACKGROUND: Markedly activated neutrophils or higher plasma levels of neutrophil elastase are involved in the poor response to intravenous immunoglobulin (IVIG) and the formation of coronary artery lesions (CAL) in patients with acute Kawasaki disease. We hypothesized that ulinastatin (UTI), by both direct and indirect suppression of neutrophils, would reduce the occurrence of CAL. METHODS AND RESULTS: We retrospectively analyzed the clinical records of patients with Kawasaki disease between 1998 and 2009. Three hundred sixty-nine patients were treated with a combination of UTI, aspirin, and IVIG as an initial treatment (UTI group), and 1178 were treated with a conventional initial treatment, and IVIG with aspirin (control group). The baseline characteristics did not demonstrate notable differences between the two groups. The occurrence of CAL was significantly lower in the UTI group than in the control group (3% versus 7%; crude odds ratio [OR], 0.46; 95% confidence interval [CI], 0.25-0.86; P=0.01). The OR adjusted for sex, Gunma score (the predictive score for IVIG unresponsiveness), and dosage of initial IVIG (1 or 2 g/kg) was 0.32 (95% CI, 0.17-0.60; P<0.001). In addition, most CAL occurred in patients requiring additional rescue treatment and the proportion of those patients was significantly lower in the UTI group than in the control group (13% versus 22%; crude OR, 0.52; 95% CI, 0.38-0.73; P<0.001). The adjusted OR was 0.30 (95% CI, 0.20-0.44; P<0.001). CONCLUSIONS: UTI was associated with fewer patients requiring additional rescue treatment and reduction of CAL in this retrospective study.

Increased incidence of acute kidney injury with aprotinin use during cardiac surgery detected with urinary NGAL.

BACKGROUND: Use of aprotinin has been associated with acute kidney injury after cardiac surgery. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel, very sensitive marker for renal injury. Urinary NGAL may be able to detect renal injury caused by aprotinin. This study determined if the use of aprotinin is associated with an increased incidence of acute kidney injury and increased levels of urinary NGAL. METHODS: In this prospective, observational study 369 patients undergoing cardiac surgery were enrolled. 205 patients received aprotinin and 164 received epsilon amino-caproic acid intraoperatively. Urinary NGAL was measured before and immediately after cardiac surgery and 3, 18 and 24 h later. The association of aprotinin use with the incidence of acute kidney injury (increase of serum creatinine >0.5 mg/dl) and NGAL levels was determined using logistic and linear regression models. RESULTS: 51 of 205 patients (25%) who received aprotinin developed acute kidney injury compared to 19 of 164 patients (12%) who received epsilon amino-caproic acid (p = 0.0013). Aprotinin use was associated with a two-fold higher risk of acute kidney injury when adjusted for potential confounders (age, Parsonnet score, preoperative serum creatinine, cardiopulmonary bypass and cross-clamp times; multiple logistic regression: OR = 2.164; CI (95%) = 1.102 to 4.249; p = 0.0249. Urinary NGAL was 19 times higher immediately after cardiopulmonary bypass and 18 times higher 3 h later in patients who had received aprotinin (postoperative: 19.23; CI (95%) = 12.60 to 29.33; p < 0.0001; 3 h post-cardiopulmonary bypass 18.67; CI (95%) = 11.45 to 30.43; p < 0.0001). CONCLUSIONS: Postoperative urinary NGAL - a novel marker for renal injury - is increased in cardiac surgical patients receiving aprotinin compared to patients receiving epsilon amino-caproic acid. These results further support the hypothesis that aprotinin may cause renal injury. The substantial rise of urinary NGAL associated with aprotinin use may in part be due to aprotinin blocking the uptake of NGAL by megalin/gp330 receptors in the proximal tubules.

Ulinastatin therapy in kawasaki disease.

BACKGROUND AND OBJECTIVE: Ulinastatin therapy may be an additional therapeutic approach to Kawasaki disease (KD). This study set out to determine whether primary intravenous ulinastatin therapy has more beneficial effects than intravenous immunoglobulin (IVIG) therapy in the acute phase of KD, and whether addition of ulinastatin to IVIG might improve outcomes in KD. METHODS: Patients were included in the study if they had a diagnosis of KD with a Harada's score that predicted coronary artery lesions. Subjects were selected to receive either primary ulinastatin therapy (30 000 U/kg/day for 3 days) or IVIG therapy (1 g/kg/dose) using sealed envelopes. Of the 27 study subjects, 18 were assigned to the ulinastatin group, and nine to the IVIG group. IVIG therapy could be added to ulinastatin therapy if patients experienced adverse effects of ulinastatin, were found to have complicated coronary artery lesions, or developed prolonged fever or elevated white blood cell counts or C-reactive protein levels. RESULTS: More patients receiving IVIG as primary therapy had reduced fever and C-reactive protein levels than patients receiving ulinastatin as primary therapy. Five patients in the ulinastatin group (28%) improved without additional IVIG therapy. These patients had lower white blood cell counts and C-reactive protein levels on admission. CONCLUSION: Primary ulinastatin therapy prevented coronary artery lesions in only 28% of cases of KD with a Harada's score predictive of such lesions. Primary ulinastatin therapy may not be the treatment of first choice for preventing coronary artery lesions in patients with KD.

Bacterial community structures in honeybee intestines and their response to two insecticidal proteins.

In this study, the effects of the Bt-toxin Cry1Ab and a soybean trypsin inhibitor (SBTI) on intestinal bacterial communities of adult honeybees (Apis mellifera) were investigated. It was hypothesized that changes in intestinal bacterial communities of honeybees may represent a sensitive indicator for altered intestinal physiology. Honeybees were fed in a laboratory set-up with maize pollen from the Bt-transgenic cultivar MON810 or from the non-transgenic near isoline. Purified Cry1Ab (0.0014% w/v) and SBTI (0.1% or 1% w/v) represented supplementary treatments. For comparison, free-flying honeybees from two locations in Switzerland were analysed. PCR-amplification of bacterial 16S rRNA gene fragments and terminal restriction fragment length polymorphism analyses revealed a total of 17 distinct terminal restriction fragments (T-RFs), which were highly consistent between laboratory-reared and free-flying honeybees. The T-RFs were affiliated to Alpha-, Beta-, and Gammaproteobacteria, to Firmicutes, and to Bacteriodetes. Neither Bt-maize pollen nor high concentrations of Cry1Ab significantly affected bacterial communities in honeybee intestines. Only the high concentration of SBTI significantly reduced the number of T-RFs detected in honeybee midguts, a concentration that also increases bee mortality. Therefore, total bacterial community structures may not be a sensitive indicator for providing evidence for the impact of insecticidal proteins on honeybees at sublethal levels.

Systemic allergic reactions to aprotinin injection around the Achilles tendon.

Local aprotinin injections are used in the treatment of chronic tendinopathy. Severe allergic reactions, although uncommon, have been reported. We highlight two instances of systemic allergic reaction, and discuss the potential side effects of local aprotinin injections in the orthopaedic setting as well as the evidence base for its use.