Cancer management from a chronic gastrointestinal function perspective.

Bowel dysfunction in cancer is a significant and challenging issue for both clinicians and patients. As cancer survival improves, the impact of gastrointestinal symptoms on quality of life is of ever-increasing relevance. This review aims to provide an overview of the common gastrointestinal complaints seen in cancer sufferers and discuss the principles of management and up to date treatment options available.

Boosting student performance with inclusive writing-to-learn assignments through graphic organizers in large enrollment undergraduate biology courses.

Logistical challenges in large enrollment classes are often mentioned as obstacles to active learning. Writing is an integral part of being a scientist and is often one of the first tools considered by STEM instructors to increase student engagement, but iterative writing assignments in large classes require creativity on the part of the instructor. We found an association between writing-to-learn assignments designed to be consistent with inclusive learning pedagogies and student performance measures in a large enrollment undergraduate biology course. They provide ample opportunity for deliberate practice and inclusive engagement, components of the "heads and hearts" hypothesis posed to explain the variation in active learning impacts on the performance of minoritized students.

Robotic segmentectomy for early-stage lung cancer.

Lobectomies have long been the gold standard for surgical treatment of early-stage non-small cell lung cancer (NSCLC), with segmentectomies limited to instances of benign disease or as an alternative in patients where lung preservation is indicated. However, a recently published randomized control trial has demonstrated the superiority of segmentectomy over lobectomy in terms of overall survival for early-stage lung cancer. Segmentectomy could thus be considered a standard procedure for small-sized peripheral NSCLC. While segmentectomy via video-assisted thoracic surgery (VATS) is the most widespread approach, development in video instrumentation and thoracic robotic surgery is rapidly gaining interest. Indeed, robotic surgery pioneers boast the advantages in three-dimensional view, improved magnification, ergonomics, dexterity, safety, and ease of surgery with this technology. This review aims to outline robotic-assisted segmentectomy indications, preoperative evaluation, and the operative conduct for the different lung segments from a single surgeon console. There are many ways to perform segmentectomies and therefore this review describes generalized approaches that can be tailored based on experience.

Consumption of 2 Green Kiwifruits Daily Improves Constipation and Abdominal Comfort-Results of an International Multicenter Randomized Controlled Trial.

INTRODUCTION: Consumption of green kiwifruit is known to relieve constipation. Previous studies have also reported improvements in gastrointestinal (GI) comfort. We investigated the effect of consuming green kiwifruit on GI function and comfort. METHODS: Participants included healthy controls (n = 63), patients with functional constipation (FC, n = 60), and patients with constipation-predominant irritable bowel syndrome (IBS-C, n = 61) randomly assigned to consume 2 green kiwifruits or psyllium (7.5 g) per day for 4 weeks, followed by a 4-week washout, and then the other treatment for 4 weeks. The primary outcome was the number of complete spontaneous bowel movements (CSBM) per week. Secondary outcomes included GI comfort which was measured using the GI symptom rating scale, a validated instrument. Data (intent-to-treat) were analyzed as difference from baseline using repeated measures analysis of variance suitable for AB/BA crossover design. RESULTS: Consumption of green kiwifruit was associated with a clinically relevant increase of ≥ 1.5 CSBM per week (FC; 1.53, P < 0.0001, IBS-C; 1.73, P = 0.0003) and significantly improved measures of GI comfort (GI symptom rating scale total score) in constipated participants (FC, P < 0.0001; IBS-C, P < 0.0001). No significant adverse events were observed. DISCUSSION: This study provides original evidence that the consumption of a fresh whole fruit has demonstrated clinically relevant increases in CSBM and improved measures of GI comfort in constipated populations. Green kiwifruits are a suitable dietary treatment for relief of constipation and associated GI comfort.

Screening Criteria Evaluation for Expansion in Pulmonary Neoplasias (SCREEN).

The SCREEN study investigated screening eligibility and survival outcomes between heavy smokers and light-or-never-smokers with lung cancer to determine whether expanded risk factor analysis is needed to refine screening criteria. SCREEN is a retrospective study of 917 lung cancer patients diagnosed between 2005 and 2018 in Nova Scotia, Canada. Screening eligibility was determined using the National Lung Screening Trial (NSLT) criteria. Mortality risk between heavy smokers and light-or-never-smokers was compared using proportional-hazards models. The median follow-up was 2.9 years. The cohort was comprised of 179 (46.1%) female heavy smokers and 306 (57.8%) female light-or-never-smokers. Light-or-never-smokers were more likely to have a diagnosis of adenocarcinoma [n=378 (71.6%)] compared to heavy smokers [n=234 (60.5%); P< 0.001]. Heavy smokers were more frequently diagnosed with squamous cell carcinoma [n=111 (28.7%)] compared to light-or-never-smokers, [n=100 (18.9%); P< 0.001]. Overall, 36.9% (338) of patients met NLST screening criteria. There was no difference in 5-year survival between light-or-never-smokers and heavy smokers [55.2% (338) vs 58.5% (529); P = 0.408; HR 1.06, 95% CI 0.80-1.40; P = 0.704]. Multivariate analysis showed that males had an increased mortality risk [HR 2.00 (95% CI 1.57-2.54); P< 0.001]. Half of lung cancer patients were missed with the conventional screening criteria. There were more curable, stage 1 tumors among light-or-never-smokers. Smoking status and age alone may be insufficient predictors of lung cancer risk and prognosis. Expanded risk factor analysis is needed to refine lung cancer screening criteria.

Pleural solitary fibrous tumour with brain metastasis: an aggressive tumour and pathologic conundrum.

Solitary fibrous tumours of the pleura are a rare finding; those with brain metastases are rarer still. Here, we present the evolution of a pleural solitary fibrous tumour in a 70-year-old male treated surgically, and subsequent brain metastasis requiring emergent craniotomy and excision. The patient received adjuvant radiotherapy to the brain and had no recurrence of brain metastases; however, 1 year surveillance imaging demonstrated metastases to the lungs, liver and spleen for which he received chemotherapy but eventually succumbed to the disease process. Solitary fibrous tumours are most often slow-growing, relatively benign neoplasms. However, up to 10% are malignant. This case highlights the importance of surgical resection of these benign tumours with malignant potential.

Mass food challenges in a vacant COVID-19 stepdown facility: Exceptional opportunity provides a model for the future.

BACKGROUND: Internationally, the COVID-19 pandemic severely curtailed access to hospital facilities for those awaiting elective/semi-elective procedures. For allergic children in Ireland, already waiting up to 4 years for an elective oral food challenge (OFC), the restrictions signified indefinite delay. At the time of the initiative, there were approx 900 children on the Children's Health Ireland (CHI) waiting list. In July 2020, a project was facilitated by short-term (6 weeks) access to an empty COVID stepdown facility built, in a hotel conference centre, commandeered by the Health Service Executive (HSE), Ireland. The aim of this study was to achieve the rapid roll-out of an offsite OFC service, delivering high throughput of long waiting patients, while aligning with existing hospital policies and quality standards, international allergy guidelines and national social distancing standards. METHODS: The working group engaged key stakeholders to rapidly develop an offsite OFC facility. Consultant paediatric allergists, consultant paediatricians, trainees and allergy clinical nurse specialists were seconded from other duties. The facility was already equipped with hospital beds, bedside monitors (BP, pulse and oxygen saturation) and bedside oxygen. All medication and supplies had to be brought from the base hospital. Daily onsite consultant anaesthetic cover was resourced and a resuscitation room equipped. Standardized food challenge protocols were created. Access to the onsite hotel chef facilitated food preparation. A risk register was established. RESULTS: After 6 weeks of planning, the remote centre became operational on 7/9/2020, with the capacity of 27 OFC/day. 474 challenges were commenced: 465 (98%) were completed and 9 (2%) were inconclusive. 135 (29%) OFCs were positive, with 25 (5%) causing anaphylaxis. No child required advanced airway intervention. 8 children were transferred to the base hospital. The CHI allergy waiting list was reduced by almost 60% in only 24 days. CONCLUSIONS: Oral food challenges remain a vital tool in the care of allergic children, with their cost saving and quality-of-life benefits negatively affected by a delay in their delivery. This project has shown it is possible to have huge impacts on a waiting list efficiently, effectively and safely with good planning and staff buy-in-even in a pandemic. Adoption of new, flexible and efficient models of service delivery will be important for healthcare delivery in the post-COVID-19 era.

Large bilateral pulmonary arterial venous malformations treated with embolization and lingulectomy in a patient with hereditary hemorrhagic telangiectasia.

A 76-year-old woman with hereditary hemorrhagic telangiectasia presented to the emergency department with chest pain. Workup revealed multiple bilateral pulmonary arteriovenous malformations (PAVMs) with large aneurysmal venous outflow. A collaborative approach between interventional radiology and thoracic surgery was used in the treatment of these PAVMs.

Megaprepuce: A New Surgical Technique with Excellent Cosmetic and Functional Results.

Background: Congenital megaprepuce (CMP) is a malformation consisting of redundant inner foreskin, normal penile shaft, and severe phimosis. The excess inner prepuce pushes the penile shaft deeper causing the appearance of a buried penis. We describe a novel surgical technique using dartos fascial flaps to reconstruct the prepuce giving excellent cosmetic and functional results. Patients and Methods: Penile reconstruction was performed by a single surgeon in 07 cases of CMP between January 2018 and December 2019. In all cases, the described surgical technique was used. Following surgery, cosmetic and functional outcomes were reviewed as well as the incidence of complications. The patients' ages ranged from 15 to 27 months (mean = 19). Mean hospital stay was 9 hours (range = 7-12). Operating time was between 50 and 85 minutes. Results: Postoperative appearance of the penis was satisfactory for all the parents in our group. Swelling of the penile shaft was seen in all of our patients but settled within one week of surgery. Scrotal hematoma was seen in only one of our patients, but that also did not need any intervention and settled spontaneously. During the follow-up period (mean = 14.5 months, range 6-24) no patient underwent revision surgery. In all our patients, the final appearance was of a circumcised penis. The final similarity to a normal circumcised penis was excellent in all of our patients. Correction of penoscrotal transposition was done in all patients achieving an elongated penile shaft and almost invisible postoperative scarring. Conclusion: Our modified surgical procedure to correct CMP is a safe and simple technique, providing good cosmetic results with the appearance of a standard circumcised penis. This also provides a good functional outcome with complication rate quite low. This technique is also easy to reproduce and teach compared with other complex procedures.

Three-stage approach to resection of left pancoast tumour with spinal and major vessel involvement.

Here we describe the successful outcome of a complex and challenging resection of a left-sided pancoast tumour involving the left subclavian artery and vertebral bodies. The resection was performed following neoadjuvant chemoradiotherapy in a multi-staged fashion involving multiple teams including thoracic surgery, plastic surgery, neurosurgery and vascular surgery. Each operation was less than 6 h, without complication, and the patient was discharged within 1 week of each procedure. This case report highlights the importance of multidisciplinary team collaboration and planning in order to achieve a successful oncologic outcome and a good quality of life following treatment of these challenging tumours. The patient had a good functional outcome and no evidence of recurrence 1.5 years later.

Microbiota Composition of Breast Milk from Women of Different Ethnicity from the Manawatu-Wanganui Region of New Zealand.

Human breastmilk components, the microbiota and immune modulatory proteins have vital roles in infant gut and immune development. In a population of breastfeeding women (n = 78) of different ethnicities (Asian, Maori and Pacific Island, New Zealand European) and their infants living in the Manawatu-Wanganui region of New Zealand, we examined the microbiota and immune modulatory proteins in the breast milk, and the fecal microbiota of mothers and infants. Breast milk and fecal samples were collected over a one-week period during the six to eight weeks postpartum. Breast milk microbiota differed between the ethnic groups. However, these differences had no influence on the infant's gut microbiota composition. Based on the body mass index (BMI) classifications, the mother's breast milk and fecal microbiota compositions were similar between normal, overweight and obese individuals, and their infant's fecal microbiota composition also did not differ. The relative abundance of bacteria belonging to the Bacteroidetes phylum was higher in feces of infants born through vaginal delivery. However, the bacterial abundance of this phylum in the mother's breast milk or feces was similar between women who delivered vaginally or by cesarean section. Several immune modulatory proteins including cytokines, growth factors, and immunoglobulin differed between the BMI and ethnicity groups. Transforming growth factor beta 1 and 2 (TGFß1, TGFß2) were present in higher concentrations in the milk from overweight mothers compared to those of normal weight. The TGFß1 and soluble cluster of differentiation 14 (sCD14) concentrations were significantly higher in the breast milk from Maori and Pacific Island women compared with women from Asian and NZ European ethnicities. This study explores the relationship between ethnicity, body mass index, mode of baby delivery and the microbiota of infants and their mothers and their potential impact on infant health.

The Effects on Immune Function and Digestive Health of Consuming the Skin and Flesh of Zespri® SunGold Kiwifruit (Actinidia Chinensis var. Chinensis 'Zesy002') in Healthy and IBS-Constipated Individuals.

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that results in constipation (IBS-C) or diarrhoea with abdominal pain, flatulence, nausea and bloating. Kiwifruit (Actinidia spp.) are nutrient-dense fruit with a number of reported health benefits that include lowering glycaemic response, improving cardiovascular and inflammatory biomarkers, and enhancing gut comfort and laxation. This study investigated the effect of consuming three whole Zespri® SunGold kiwifruit (Actinidia chinensis var. chinensis 'Zesy002') with or without skin on cytokine production and immune and gut health in healthy people and those with IBS-C symptoms. This study enrolled thirty-eight participants in a 16 week randomized cross-over study (19 healthy and 19 participants with IBS-C). Participants were randomized to consume either three kiwifruit without eating the skin or three kiwifruit including the skin for 4 weeks each, with a 4 week washout in between each intervention. There was a significant decrease in the pro-inflammatory cytokine, TNF-α, for both the healthy and the IBS-C participants when they consumed whole kiwifruit and skin, and also for the healthy participants when they ate whole kiwifruit without the skin (p < 0.001). The kiwifruit interventions increased bowel frequency and significantly reduced the gastrointestinal symptom rating scale constipation and Birmingham IBS pain scores for both participant groups. We have demonstrated that consuming the skin of SunGold kiwifruit might have beneficial effects on gastrointestinal health that are not produced by consuming the flesh alone.

Control of Antibody Impurities Induced by Riboflavin in Culture Media During Production.

During the manufacturing of protein biologics, product variability during cell culture production and harvest needs to be actively controlled and monitored to maintain acceptable product quality. To a large degree, variants that have previously been described are covalent in nature and are easily analyzed by a variety of techniques. Here, we describe a noncovalent post translational modification of recombinantly expressed antibodies, containing variable domain tryptophans, that are exposed to culture media components and ambient laboratory light. The modified species, designated as conformer, can be monitored by hydrophobic interaction chromatography and often exhibits reduced potency. We studied conformer formation and identified key elements driving its accelerated growth using an IgG2 monoclonal antibody. Conformer is a result of a noncovalent interaction of the antibody with riboflavin, an essential vitamin added to many production cell culture formulations. Chemical and physical factors that influence the impact of riboflavin are identified, and methods for process control of this product quality attribute are addressed in order to prevent loss of antibody potency and potential safety issues. Identifying therapeutic antibody drug candidates with the potential to form conformers can be performed early in development to avoid this undesirable product quality propensity.

The effect of 'Zesy002' kiwifruit (Actinidia chinensis var. chinensis) on gut health function: a randomised cross-over clinical trial.

Functional gastrointestinal disorders including constipation affect up to 14 % of the world's population. Treatment is difficult and challenging resulting in a need for alternative safe and effective therapies. The present study investigated whether daily consumption of three gold-fleshed kiwifruit could alleviate constipation and improve gastrointestinal discomfort in mildly constipated individuals with and without pain. A total of thirty-two participants were enrolled in a 16-week randomised, single-blind, crossover study. Participants received either three 'Zesy002' kiwifruit or 14·75 g Metamucil® (5 g dietary fibre/d (a positive control)) for 4 weeks each with a 4-week washout between treatments. A 2-week washout period was included at the beginning and end of the study. Daily bowel habit diaries were kept throughout the study. The primary outcome measure was differences in the number of complete spontaneous bowel movements (CSBM). Secondary outcome measures were bowel movement frequency and stool form as well as digestive symptoms and comfort. The number of CSBM per week was significantly greater during daily consumption of three kiwifruit compared with the baseline (6·3 v. 3·3; P < 0·05) and the Metamucil® treatment (6·3 v. 4·5; P < 0·05). Stool consistency was also improved, with kiwifruit producing softer stools and less straining (P < 0·05). Gastrointestinal discomfort was also improved compared with baseline for abdominal pain, constipation and indigestion (P < 0·05) during the kiwifruit intervention and constipation during the Metamucil® intervention (P < 0·05). This randomised controlled trial demonstrates that daily consumption of three gold-fleshed kiwifruit is associated with a significant increase of two CSBM per week and reduction in gastrointestinal discomfort in mildly constipated adults.

Young People's Satisfaction With the Online Mental Health Service eheadspace: Development and Implementation of a Service Satisfaction Measure.

BACKGROUND: Online youth mental health services are an expanding approach to meeting service need and can be used as the first step in a stepped-care approach. However, limited evidence exists regarding satisfaction with online services, and there is no standardized service satisfaction measure. OBJECTIVE: This study implemented an online youth mental health service satisfaction questionnaire within eheadspace, an online youth mental health service. The aims were to test the questionnaire's psychometric properties and identify current levels of satisfaction among service users, as well as to identify client and service contact characteristics that affect satisfaction. METHODS: Data were collected from 2280 eheadspace clients via an online questionnaire advertised and accessed through the eheadspace service platform between September 2016 and February 2018. Client and service contact characteristics, potential outcomes, and session and service feedback data were collected. RESULTS: The service satisfaction questionnaire demonstrated high internal consistency for the overall satisfaction scale (alpha=.95) and its three subscales: session satisfaction, potential outcomes, and service satisfaction. A three-factor model was the best fit to the data, although including a higher order unidimensional construct of overall satisfaction was also a reasonable fit. Overall, young people were very satisfied with eheadspace (mean 3.60, SD 0.83). Service characteristics, but not client characteristics, were significantly associated with satisfaction. Young people were more satisfied with eheadspace when they had greater engagement as evident through receiving esupport rather than briefer service provision, having a longer session and greater interaction with the clinician, and not previously attending a face-to-face headspace center. CONCLUSIONS: The online youth mental health service satisfaction questionnaire developed for and implemented in eheadspace showed good psychometric properties. The measure is brief, has good internal consistency, and has a clear factor structure. The measure could be adapted for use in other online youth mental health services. The young people using eheadspace and completing the feedback survey were highly satisfied. Greater engagement with the online service was shown to be associated with greater satisfaction. No specific client demographic groups were shown to be more or less satisfied.

Anterior mediastinal mass 4 years after type A aortic dissection.

A 47-year-old male who previously underwent emergency surgery for type A aortic dissection presented to the emergency department 4 years later with acute chest pain radiating to his back and a significant drop in hemoglobin. Clinical presentation was concerning for aortic graft failure, but imaging revealed a large (6.0 × 3.2 × 12.8 cm3) soft tissue mediastinal mass that was not present 4 years before. Pathologic analysis revealed a rare thymic cyst with a hemorrhagic component. This was a challenging case from diagnostic and operative perspectives, involving the expertise of both cardiac and thoracic surgical teams.

Consumption of kiwifruit capsules increases Faecalibacterium prausnitzii abundance in functionally constipated individuals: a randomised controlled human trial.

This study investigated the impact of ACTAZIN™ green (2400 and 600 mg) and Livaux™ (2400 mg) gold kiwifruit supplements on faecal microbial composition and metabolites in healthy and functionally constipated (FC) participants. The participants were recruited into the healthy group (n 20; one of whom did not complete the study) and the FC group (n 9), each of whom consumed all the treatments and a placebo (isomalt) for 4 weeks in a randomised cross-over design interspersed with 2-week washout periods. Modification of faecal microbiota composition and metabolism was determined by 16S rRNA gene sequencing and GC, and colonic pH was calculated using SmartPill® wireless motility capsules. A total of thirty-two taxa were measured at greater than 1 % abundance in at least one sample, ten of which differed significantly between the baseline healthy and FC groups. Specifically, Bacteroidales and Roseburia spp. were significantly more abundant (P < 0·05) in the healthy group and taxa including Ruminococcaceae, Dorea spp. and Akkermansia spp. were significantly more abundant (P < 0·05) in the FC group. In the FC group, Faecalibacterium prausnitzii abundance significantly increased (P = 0·024) from 3·4 to 7·0 % following Livaux™ supplementation, with eight of the nine participants showing a net increase. Lower proportions of F. prausnitzii are often associated with gastrointestinal disorders. The discovery that Livaux™ supplementation increased F. prausnitzii abundance offers a potential strategy for improving gut microbiota composition, as F. prausnitzii is a butyrate producer and has also been shown to exert anti-inflammatory effects in many studies.

Patient-reported outcomes and survival in multiple sclerosis: A 10-year retrospective cohort study using the Multiple Sclerosis Impact Scale-29.

BACKGROUND: There is increasing emphasis on using patient-reported outcomes (PROs) to complement traditional clinical outcomes in medical research, including in multiple sclerosis (MS). Research, particularly in oncology and heart failure, has shown that PROs can be prognostic of hard clinical endpoints such as survival time (time from study entry until death). However, unlike in oncology or cardiology, it is unknown whether PROs are associated with survival time in neurological diseases. The Multiple Sclerosis Impact Scale-29 (MSIS-29) is a PRO sensitive to short-term change in MS, with questions covering both physical and psychological quality of life. This study aimed to investigate whether MSIS-29 scores can be prognostic for survival time in MS, using a large observational cohort of people with MS. METHODS AND FINDINGS: From 15 July 2004 onwards, MSIS-29 questionnaires were completed by people with MS registered with the MS Society Tissue Bank (n = 2,126, repeated 1 year later with n = 872 of the original respondents). By 2014, 264 participants (12.4%) had died. Higher baseline MSIS-29 physical (MSIS-29-PHYS) score was associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: hazard ratio [HR] 5.7, 95% CI 3.1-10.5, p < 0.001). Higher baseline MSIS-29 psychological score was also associated with reduced survival time (subgroup with highest scores versus subgroup with lowest scores: HR 2.8, 95% CI 1.8-4.4, p < 0.001). In those with high baseline MSIS-29 scores, mortality risk was even greater if the MSIS-29 score worsened over 1 year (HR 2.3, 95% CI 1.2-4.4, p = 0.02). MSIS-29-PHYS scores were associated with survival time independent of age, sex, and patient-reported Expanded Disability Status Scale score in a Cox regression analysis (per 1-SD increase in MSIS-29-PHYS score: HR 1.8, 95% CI 1.1-2.9, p = 0.03). A limitation of the study is that this cohort had high baseline age and disability levels; the prognostic value of MSIS-29 for survival time at earlier disease stages requires further investigation. CONCLUSIONS: This study reports that PROs can be prognostic for hard clinical outcomes in neurological disease, and supports PROs as a meaningful clinical outcome for use in research and clinical settings.

A Pilot Randomized Cross-Over Trial to Examine the Effect of Kiwifruit on Satiety and Measures of Gastric Comfort in Healthy Adult Males.

'Hayward' kiwifruit anecdotally are associated with improved gastrointestinal comfort following the consumption of high protein meals, possibly because of the presence of a protease enzyme, actinidin. The study aimed to use SmartPill™ technology to investigate the acute effect of kiwifruit with actinidin (Actinidia chinensis var. deliciosa 'Hayward') and kiwifruit without actinidin (A. chinensis var. chinensis 'Hort16A') on digestion of a large protein meal. Ten healthy male subjects were recruited. The participants attended the clinic three times, having fasted overnight. They consumed a test meal consisting of 400 g lean steak and two 'Hort16A' or two 'Hayward kiwifruit'. Subjects completed visual analogue scales (VAS) by rating feelings of hunger, satisfaction, fullness, and comfort and swallowed a SmartPill™ before completing further VAS scales. After 5 h, participants consumed an ad libitum lunch to assess satiety. SmartPill™ transponders were worn for five days. There were no significant differences in gastric emptying time, small bowel, or colonic transit time between the two kiwifruit arms of the study measured by SmartPill™. Similarly, no significant differences were observed in VAS satiety measures or energy consumption at the ad libitum meal. However, the measurement of overall gastric comfort tended to be lower, and bloating was significantly reduced following the consumption of the steak meal with 'Hayward' kiwifruit (p < 0.028). CONCLUSIONS: The SmartPill™ is marketed as a diagnostic tool for patients presenting with gastrointestinal disorders and is usually used with a standard 'SmartBar'. This small pilot study suggests that it is less likely to measure gastric emptying effectively following a high protein meal, as it may be delayed because of the meal's physical consistency. However, green kiwifruit, containing actinidin, may reduce bloating and other measures of gastric discomfort in healthy males. Possible future studies could use repeated measures with more readily digested protein and larger numbers of participants.