Transient loss of Polycomb components induces an epigenetic cancer fate.

Although cancer initiation and progression are generally associated with the accumulation of somatic mutations1,2, substantial epigenomic alterations underlie many aspects of tumorigenesis and cancer susceptibility3-6, suggesting that genetic mechanisms might not be the only drivers of malignant transformation7. However, whether purely non-genetic mechanisms are sufficient to initiate tumorigenesis irrespective of mutations has been unknown. Here, we show that a transient perturbation of transcriptional silencing mediated by Polycomb group proteins is sufficient to induce an irreversible switch to a cancer cell fate in Drosophila. This is linked to the irreversible derepression of genes that can drive tumorigenesis, including members of the JAK-STAT signalling pathway and zfh1, the fly homologue of the ZEB1 oncogene, whose aberrant activation is required for Polycomb perturbation-induced tumorigenesis. These data show that a reversible depletion of Polycomb proteins can induce cancer in the absence of driver mutations, suggesting that tumours can emerge through epigenetic dysregulation leading to inheritance of altered cell fates.

Improving dairy performance through molecular characterization of SREBP-1 gene in Sarda sheep breed.

This research has two aims: (i) to characterize the coding sequence of the SREBP-1 gene in dairy sheep in order to investigate possible relationships between single nucleotide polymorphisms (SNPs) and milk traits; and (ii) to investigate possible relationship between SREBP-1 gene expression and nucleotide variation. Four hundred adult and multiparous lactating Sarda breed ewes were selected from two farms. Milk samples were collected from Day 30 to Day 150 of lactation to determine the mean yield, somatic cell count, lactose, fat, and protein content of the milk. RNA was extracted from the milk samples, after which the SREBP-1 gene coding regions were amplified and sequenced to scan mutations. Whilst eight SNPs were identified, none had statistically significant association with the analysed milk traits. Moreover, the identified expression patterns were not affected by the SNP or combined genotypes. High SREBP-1 gene expression levels were found to be correlated with high milk fat content (P < 0.01), indicating the crucial role of this gene in the milk fat synthesis. In conclusion, the polymorphisms found within SREBP-1 gene exhibited no significant associations with milk traits or with individual SREBP-1 mRNA expression patterns. The findings thus suggest that this small genetic variability may derive from the selection carried out in Sarda breed to improve milk yield.

Two nasal swabs may not be enough to exclude SARS-CoV-2 infection in symptomatic patients.

Abstracts: The spread of COVID-19 (COronaVIrus Disease 2019), due to SARS-CoV-2 (Severe Acute Respiratory Syndrome CoronaVirus 2) has taken on dramatic pandemic proportions, affecting over 100 countries in a matter of weeks. Italy has had 237,828 confirmed cases according to the Istituto Superiore di Sanità as of May 13, and 34,448 deaths (1).

Basal and stimulated calcitonin for the diagnosis of medullary thyroid cancer: updated thresholds and safety assessment.

PURPOSE: Reliable cut-offs for basal (bCT) and calcium stimulated calcitonin (casCT) are needed for an early and accurate diagnosis of medullary thyroid cancer (MTC). PATIENTS AND METHODS: Fifty-four new patients with nodular goiter were enrolled and analysed together with those previously published by our group for a total of 135 cases. bCT and casCT were measured by a highly sensitive method and the results compared with histological findings. In a subgroup of patients, cardiac rhythm was recorded before and during the calcium test. RESULTS: In both females (F) and males (M), there was a significant correlation between tumor size and bCT levels (P < 0.001). The receiver operating characteristic plot analyses showed that, for bCT, the new cut-off points able to separate non-MTC from MTC patients were > 30 (F) and > 34 pg/mL (M), whereas the best casCT thresholds were > 79 (F) and > 466 pg/mL (M). bCT was shown to harbour a high accuracy, though some cases were diagnosed only upon stimulation test. Importantly, combining bCT, below or above the cut-offs, with casCT above the cut-offs, all the MTC cases were correctly identified. A reversible sinus bradycardia was observed in 9% of cases during the test. CONCLUSIONS: Refined cut-offs for bCT and casCT in patients with nodular goiter are reported. Sensitive bCT was shown to have a high accuracy, but the combination with casCT data was needed to identify all MTC cases. The reliability and safety of calcium test strongly favour the routine use of CT determination in nodular thyroid disease.

Integration of Homeopathy and Complementary Medicine in the Tuscan Public Health System and the Experience of the Homeopathic Clinic of the Lucca Hospital.

INTRODUCTION: The healthcare programs of the Region of Tuscany (Italy) have started the process of integration of some types of complementary medicine (CM), including homeopathy, which began in 1996. The Homeopathic Clinic of Lucca was opened in 1998, followed by the Homeopathic Clinic for Women in 2003, and the Clinic for CM and Diet in Oncology in 2013. METHODS: Observational longitudinal studies conducted on 5,877 patients (3,937 in the general clinic, 1,606 in the women's clinic and 334 in oncology) were consecutively examined from 2003 to 2016. The Outcome in Relation to Impact on Daily Living (ORIDL) was generally used to assess outcomes. RESULTS: Comparing the clinical conditions before and after homeopathic treatment, improvement was observed in 88.8% of general medicine patients with follow-up (45.1%); in particular, 68.1% of the patients had a major improvement in or resolution (ORIDL +2, +3, +4) of their condition. In women, an improvement was obtained in 74.1% cases and a major improvement in 61.2%. In cancer patients with homeopathic and integrative treatment, a significant improvement was observed for all the symptoms during anti-cancer therapy, particularly for hot flashes, nausea, depression, asthenia, and anxiety. CONCLUSIONS: These results suggest that homeopathy can effectively be integrated with allopathic medicine and that the Tuscan experience could provide a useful reference for developing national and European regulations on the use of CM and homeopathy in public healthcare.

The Driver Behaviour Questionnaire for older drivers: Do errors, violations and lapses change over time?

The aim of the current study was to examine how self-reported aberrant driving behaviours change across a three time-points in a group of older drivers. Two hundred and twenty-seven older drivers (males = 69.6%) from the Candrive/Ozcandrive longitudinal study completed the Driving Behaviour Questionnaire (DBQ) each yearacross three time-points (i.e., Year 1, Year 2, Year 3). At the third time-point, older drivers ranged in age from 77 to 96 years (M = 81.74 years; SD = 3.44 years). A longitudinal confirmatory factor analysis showed that a modified 21-item, 3-factor (errors, lapses and violations) DBQ was invariant across the time period, suggesting that the structure of the questionnaire was stable across each time-point. Further, multiple domain latent growth analysis on the resultant factors for errors, lapses and violations showed that the frequency of errors remained similar across the three-year period, while violations and lapses showed very marginal decreases in frequency. These changes were independent of the absolute number of these behaviours; Drivers with higher violations or lapses in Year one, showed similar decreases in frequency as those who self-reported lower frequencies of the behaviours. These results suggest that the DBQ is a reliable tool to measure older drivers' self-reported aberrant driving behaviours, and that these behaviours do not show much change across time. Future research should validate the self-reported responses from the DBQ with more objective measures such as those collected through naturalistic driving study (NDS) methodology or on-road driving tasks.

Are older drivers' driving patterns during an on-road driving task representative of their real-world driving patterns?

OBJECTIVE: The current study investigated whether older drivers' driving patterns during a customized on-road driving task were representative of their real-world driving patterns. METHODS: Two hundred and eight participants (male: 68.80%; mean age = 81.52 years, SD = 3.37 years, range = 76.00-96.00 years) completed a customized on-road driving task that commenced from their home and was conducted in their own vehicle. Participants' real-world driving patterns for the preceding 4-month period were also collected via an in-car recording device (ICRD) that was installed in each participant's vehicle. RESULTS: During the 4-month period prior to completing the on-road driving task, participants' median real-world driving trip distance was 2.66 km (interquartile range [IQR] = 1.14-5.79 km) and their median on-road driving task trip distance was 4.41 km (IQR = 2.83-6.35 km). Most participants' on-road driving task trip distances were classified as representative of their real-world driving trip distances (95.2%, n = 198). CONCLUSIONS: These findings suggest that most older drivers were able to devise a driving route that was representative of their real-world driving trip distance. Future research will examine whether additional aspects of the on-road driving task (e.g., average speed, proportion of trips in different speed zones) are representative of participants' real-world driving patterns.

The epidemiology of osteoporosis in Italian postmenopausal women according to the National Bone Health Alliance (NBHA) diagnostic criteria: a multicenter cohort study.

PURPOSE: The study was aimed at evaluating the prevalence of osteoporosis, defined by BMD and the National Bone Health Alliance (NBHA) criteria, and the prevalence of clinical risk factors for fractures in Italian postmenopausal women. METHODS: This is a cross-sectional, multicenter, cohort study evaluating 3247 postmenopausal women aged ≥ 50 and older in different areas of Italy in the period 2012-2014. All the participants were evaluated as far as anthropometrics; questionnaires for FRAX® and DeFRA calculation were administered and bone mineral density was measured at lumbar spine, femoral neck and total hip by DXA. RESULTS: The prevalence of osteoporosis, as assessed by BMD and NBHA criteria was 36.6 and 57%, respectively. Mean ± SD values of FRAX® and DeFRA were: 10.2 ± 7.3 and 11 ± 9.4 for major fractures, and 3.3 ± 4.9 and 3.9 ± 5.9 for hip fractures, respectively. Among clinical risk factors for fracture, the presence of previous fracture, particularly non-spine/non-hip fracture, parental history of hip fracture and current smoking were the most commonly observed. CONCLUSIONS: Our study showed that more that the half of postmenopausal women aged 50 and older in Italy has osteoporosis on the basis of the NBHA criteria. There is a relevant high risk of femur fracture, as assessed by the FRAX® and DeFRA and previous fracture, parental history of hip fracture and current smoking are the most common risk factors. The data should be considered particularly in relation to the need to increase prevention strategies on modifiable risk factors and therapeutic intervention.

Interventions for cancer-related fatigue: a scoping review.

Cancer-related fatigue (CRF) is common and can be distressing for some survivors. There is increasing interest in measuring levels of CRF, highlighting its impact on quality of life. This review describes the nature and scope of evidence relating to interventions for CRF. Scoping review methodology was used to identify studies, extract data, collate and summarise results. Data were collated according to cancer tumour streams, stage of illness and the types of trial interventions. A total of 447 trials and 37 systematic reviews met the inclusion criteria. Nine papers reported longitudinal results. Populations studied were predominantly of mixed cancer diagnoses and breast cancer. The most frequent interventions were exercise, pharmacological, psycho-education and mind-body interventions. Fatigue was identified as a primary outcome measure (OM) in 58% of studies, with 58 different fatigue measures reported. Emerging evidence exists for the effectiveness of fatigue interventions for some cancer types. More research on interventions with participants with the same cancer type and illness phase is needed. Measurement of severity and impact of CRF using fewer, robust OMs will permit comparisons across studies.

In irritable bowel syndrome, postprandial abdominal distention is associated with a reduction of intestinal tone.

BACKGROUND: The pathophysiology of abdominal distention in irritable bowel syndrome (IBS) is still a matter of debate, but the relationship between modifications of intestinal tone and abdominal volume has never been analyzed. METHODS: Eighty-four patients affected by IBS and reporting moderate to severe abdominal distention were enrolled. Thirty-nine presented abdominal distention immediately after and forty-five presented abdominal distention independently of meal intake. Twenty healthy volunteers (HV), comparable for gender and age, were also enrolled. All the subjects underwent fasting and postprandial recto-sigmoid volume monitoring with barostat and abdominal girth measurement to evaluate abdominal distention. KEY RESULTS: In comparison with HV (75±13 mL) and with patients with meal-unrelated abdominal distention (135±56 mL), in the subgroup of patients with severe meal-related abdominal distention recto-sigmoid tone response to the meal was significantly reduced (mean increase of balloon volume 184±89 mL; P<.001), paralleling abdominal girth increase and occurring immediately after test meal intake. Meal-induced abdominal girth modification was significantly correlated with meal-related modification of recto-sigmoid tone (r=.71) and abdominal symptoms. CONCLUSIONS: In patients with IBS suffering from severe postprandial abdominal distention, a postprandial reduction of intestinal tone is associated with this bothersome symptom. Further studies are needed to evaluate whether drugs acting on the modification of intestinal tone could be useful in the treatment of these patients.

Impact of bevacizumab containing first line chemotherapy on recurrent disease in epithelial ovarian cancer: A case-control study.

OBJECTIVE: To evaluate the timing and pattern of relapse, and duration of response to second line chemotherapy in advanced ovarian cancer (AOC) patients treated with first line carboplatin-paclitaxel chemotherapy with or without bevacizumab. PATIENTS AND METHODS: This is a case-control study including 222 AOC patients. Seventy-four women treated with first line carboplatin-paclitaxel-bevacizumab chemotherapy (Cases) were matched based on laparoscopic predictive index value, and residual tumor at first surgery with 148 AOC patients treated with carboplatin-paclitaxel. Distribution of pattern of relapse, and response to second line chemotherapy was compared between the two groups. Time to Progression (TTP) for second line chemotherapy was also analyzed for study purpose. RESULTS: Median platinum-free interval (PFI) was 16months (range 2-65) in Cases, compared with 9months (1-83) in Controls (p-value=0.001). Twenty patients (51.3%) among Cases showed recurrence in multiple anatomic sites, compared with 31 (31.9%) in the Control group (p-value=0.035). Peritoneal recurrence occurred as diffuse in 30 Cases (96.8%), and 60 Controls (82.2%; p-value=0.046). Secondary cytoreductive surgery (SCS) was successfully completed in 53.5% of Controls compared to 10.0% of Cases (p-value=0.016). In women with fully platinum-sensitive relapse, response rate to second line chemotherapy was 85.2% in Controls, compared to 38.4% in Cases (p-value=0.002). Finally, Cases showed a shorter TTP, compared to Controls (5months vs 8months; p-value=0.041). CONCLUSIONS: Incorporation of bevacizumab into upfront regimens prolongs PFI in AOC patients, but is associated with wider presentation of relapse, lower rate of complete SCS, and shorter TTP to second line chemotherapy in women with platinum-sensitive disease.

Melatonin treatment in spring and reproductive recovery in sheep with different body condition score and age.

With the aim to evaluate the effect of melatonin treatment on the advanced reproductive recovery in sheep with different body condition score (BCS) and age, 800 ewes were selected from two farms. These ewes (3-6 years old, multiparous and with BCS 2.5-4.0) were subdivided into two Groups (200 M and 200 C), balanced on their BCS and age. On 20 March, Group M was treated with one melatonin implant (18 mg). Group C was untreated. Males were introduced to the groups 35 days after treatment. Gestation was diagnosed between day 45 and 90 after mating by transabdominal ultrasonography. From day 150 to 190 after rams introduction, lambing date and newborns' number were recorded. The average time in days between male introduction and lambing resulted shorter in treated than in control ewes (166.4 ± 0.48 vs. 172.5 ± 0.50) (P < 0.05). At day 160 and 170 from ram introduction the fertility rate was higher in Group M than in C (P < 0.05). The overall fertility at day 190 from rams introduction showed no differences between Group M and C (337 and 339, respectively). At day 170 from male introduction the number of the 5-6 years-old lambed ewes were 2-fold higher than the youngers (P < 0.05). The animals with a BCS 3.5-4.0 had a faster response to male effect, and a shorter mean distance in days from rams introduction to lambing, compared to those scored 2.5-3.0 (166.1 ± 0.48 vs. 174.8 ± 0.51) (P < 0.05). We concluded that the ewes with BCS 3.5-4.0 and aged 5-6 years showed a better response to melatonin treatment in spring.

A rise in NAD precursor nicotinamide mononucleotide (NMN) after injury promotes axon degeneration.

NAD metabolism regulates diverse biological processes, including ageing, circadian rhythm and axon survival. Axons depend on the activity of the central enzyme in NAD biosynthesis, nicotinamide mononucleotide adenylyltransferase 2 (NMNAT2), for their maintenance and degenerate rapidly when this activity is lost. However, whether axon survival is regulated by the supply of NAD or by another action of this enzyme remains unclear. Here we show that the nucleotide precursor of NAD, nicotinamide mononucleotide (NMN), accumulates after nerve injury and promotes axon degeneration. Inhibitors of NMN-synthesising enzyme NAMPT confer robust morphological and functional protection of injured axons and synapses despite lowering NAD. Exogenous NMN abolishes this protection, suggesting that NMN accumulation within axons after NMNAT2 degradation could promote degeneration. Ectopic expression of NMN deamidase, a bacterial NMN-scavenging enzyme, prolongs survival of injured axons, providing genetic evidence to support such a mechanism. NMN rises prior to degeneration and both the NAMPT inhibitor FK866 and the axon protective protein Wld(S) prevent this rise. These data indicate that the mechanism by which NMNAT and the related Wld(S) protein promote axon survival is by limiting NMN accumulation. They indicate a novel physiological function for NMN in mammals and reveal an unexpected link between new strategies for cancer chemotherapy and the treatment of axonopathies.

Hydrogen breath test in patients with severe constipation: the interference of the mixing of intestinal content.

BACKGROUND: The diagnostic accuracy of the hydrogen (H2 ) breath test might be reduced by the release of preformed H2 , trapped in hard stools. Test solution ingestion might induce the mixing of colonic content and a false positive result. We studied severely constipated patients, at diagnosis and after the normalization of bowel function, to clarify whether this mechanism affects test results. METHODS: Twenty functional constipated patients, 10 consecutive patients with functional diarrhea and 10 healthy volunteers underwent (i) a H2 breath test after lactulose, to exclude differences among the groups in fermenting capacity; (ii) breath H2 excretion monitoring after non-absorbable, non-fermentable PEG-electrolyte solution, to exclude the role of the delivery to the colon of preexisting fermentable substrates or of the release of preformed H2 entrapped in the feces; (iii) H2 measurement during a 7-h fasting period, to exclude the role of spontaneous variations of breath gas excretion; and (iv) breath H2 excretion monitoring after PEG, after normalization of bowel function. KEY RESULTS: All the subjects excreted similar amounts of H2 after lactulose. After PEG, only severely constipated patients showed significant breath H2 excretion, theoretically able to induce a false positivity of the lactose breath test in 70% of patients and a false positivity of glucose breath tests in 50% of patients. Breath H2 excretion after PEG disappeared if fecal consistency improved after therapy. CONCLUSIONS & INFERENCES: Severely constipated patients may harbor preformed gas in hard stools which can be released when mixing of the intestinal content is induced. This mechanism may interfere with breath test results.

Serum regenerating islet-derived 3-alpha is a biomarker of mucosal enteropathies.

BACKGROUND: The clinical presentation of organic and functional intestinal disorders can overlap and clinicians often rely on invasive and time-consuming procedures to make a final diagnosis. Regenerating islet-derived 3-alpha (Reg3α) is detectable in the circulation of patients with intestinal graft-versus host disease and patients with inflammatory bowel disease (IBD). AIM: To determine whether serum Reg3α testing is useful for discriminating mucosal enteropathies from functional intestinal disorders. METHODS: We prospectively included 47 patients with active coeliac disease (ACD), 13 patients with refractory coeliac disease (RCD), seven patients with common variable immunodeficiency (CVID), 72 patients with active Crohn's disease, 22 patients with active ulcerative colitis (UC) and 28 patients with irritable bowel syndrome (IBS)-related diarrhoea. Sera were also taken from 10 CD patients before and after 6-12 months of a gluten-free diet (GFD) and from 14 patients with IBD before and after induction therapy with Infliximab (IFX). Sera of 119 healthy volunteers were used to determine the cut-off value. Reg3α levels were measured by a commercial ELISA kit. RESULTS: Levels of Reg3α exceeded the cut-off value of the assay in 43/47(91%) ACD patients, 13/13(100%) RCD patients, 7/7(100%) CVID patients, 65/72(90%) Crohn's disease patients, 17/22(77%) UC patients and one patient with IBS(4%). Reg3α levels distinguished mucosal enteropathies from IBS with a sensitivity of 90% and a specificity of 96%. Reg3α levels significantly decreased in CD patients following a GFD and in IBD patients after treatment with IFX. CONCLUSION: Reg3α is a serum biomarker of intestinal damage that, combined with clinical data, identifies patients who should undergo invasive tests for diagnosing enteropathies.

Development and evaluation of a driving observation schedule (DOS) to study everyday driving performance of older drivers.

This paper describes the development and evaluation of an on-road procedure, the Driving Observation Schedule (DOS), for monitoring individual driving behavior. DOS was developed for use in the Candrive/Ozcandrive five-year prospective study of older drivers. Key features included observations in drivers' own vehicles, in familiar environments chosen by the driver, with start/end points at their own homes. Participants were 33 drivers aged 75+ years, who drove their selected route with observations recorded during intersection negotiation, lane-changing, merging, low speed maneuvers and maneuver-free driving. Driving behaviors were scored by a specialist occupational therapy driving assessor and another trained observer. Drivers also completed a post-drive survey about the acceptability of DOS. Vehicle position, speed, distance and specific roadways traveled were recorded by an in-vehicle device installed in the participant's vehicle; this device was also used to monitor participants' driving over several months, allowing comparison of DOS trips with their everyday driving. Inter-rater reliability and DOS feasibility, acceptability and ecological validity are reported here. On average, drivers completed the DOS trip in 30.48min (SD=7.99). Inter-rater reliability measures indicated strong agreement between the trained and the expert observers: intra-class correlations (ICC)=0.905, CI 95% 0.747-0.965, p<0.0001; Pearson product correlation, r (18)=.83, p<0.05. Standard error of the measurement (SEM), method error (ME) and coefficient of variation (CV) measures were consistently small (3.0, 2.9 & 3.3%, respectively). Most participants reported being 'completely at ease' (82%) with the driving task and 'highly familiar with the route' (97%). Vehicle data showed that DOS trips were similar to participants' everyday driving trips in roads used, roadway speed limits, drivers' average speed and speed limit compliance. In summary, preliminary findings suggest that DOS can be scored reliably, is of feasible duration, is acceptable to drivers and representative of everyday driving. Pending further research with a larger sample and other observers, DOS holds promise as a means of quantifying and monitoring changes in older drivers' performance in environments typical of their everyday driving.

Rehabilitation of acquired brain injuries: a multicentric prospective survey.

BACKGROUND: The rehabilitation of the persons with Severe Acquired Brain Injury (ABI) is an important concern to be approached with a comprehensive program aimed to improve the recovery of patients.The efficacy of an early and intensive rehabilitation program has been shown in large number of studies. Few studies focused on the prevalence of TBI and the data are often extrapolated in indirect ways. AIM: An analysis of the demographic characteristics of the population included in the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione- Italian Group for the Study of the severe ABI) database, type and conditions associated to the index event; the treatment administered during hospitalization; and the prognosis according to outcome measures. DESIGN: The study was an observational prospective survey looking at management of ABI (both traumatic and non-traumatic). SETTING: In hospital rehabilitation. POPULATION: Patients consecutively admitted in each of the 52 GISCAR centres. METHODS: Every centre included a consecutive cohort and recorded demographic data and index event characteristics. RESULTS: In the study population were included 2626 subjects suffering of a severe ABI. The difference of length of stay (LOS) was significantly different with 67.5 days for traumatic patients compared to the 80 days of non traumatic ones. In the study population the probability of discharge at home is significantly greater for the traumatic condition (odds ratio 0,4587; CI 0.3671-0.5731). The overall benefit of the rehabilitative treatment was encountered in a net gain in all disability scores taken into account: LCF classes; DRS as well as GOS scores. At discharge the main destination for severe ABI patients was home (67.2%). CONCLUSIONS: A large number of patients admitted in Italian rehabilitative facilities for a severe ABI suffered from a TBI, more often these subjects were young male victims of road accident. The majority of subjects during the rehabilitative hospitalization demonstrated a significant recovery. CLINICAL REHABILITATION IMPACT: Considering the evidence of an early treatment benefit the delay ofthe rehabilitation program start is far from being satisfactory. The high frequency of the home discharge indicate a good compliance of national family network.

Hydrogen breath test and intestinal gas production.

Despite extensive use in clinical practice, difficulties regarding interpretation of hydrogen breath test are still very frequent, even on research grounds. After the administration of a non-absorbable sugar, such as lactulose, an increase of breath hydrogen and methane is evident; this phenomenon is considered an index of colonic fermentation. It is not clear, however, if the levels of these compounds correlate with the presence and severity of functional symptoms, nor if they accurately reflect gas production at colonic level. So far, apart from flatulence, we have no indications regarding the ability of hydrogen or methane to act as biomarkers of intraluminal events. On the other hand, it has been shown that in functional bowel disease a colonic dysbiosis exists, and that the modification of bacterial flora might result in a reduction of symptom severity. Consequently, it is not clear if hydrogen and methane colonic production could have a role in the pathophysiology of functional complaints, but it is possible that other fermentation products should be taken into consideration, such as acetate, propionate, and alcohol.