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Mattio N, Pradat P, Machon C, Mialon A, Roman S, Cuerq C, Mion F. Glucose breath test for the detection of small intestine bacterial overgrowth: Impact of diet prior to the test. Neurogastroenterol Motil 2024:e14801. [PMID: 38606691 DOI: 10.1111/nmo.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/20/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Glucose breath test (GBT) is used for the diagnosis of small intestine bacterial overgrowth. A restrictive diet without fibers and/or fermentable food is recommended on the day before the test. The aim of our retrospective study was to evaluate the impact of two different restrictive diets on the results of GBT. METHODS A change of the pretest restrictive diet was applied in our lab on September 1, 2020. The recommended diet was a fiber-free diet before this date, and a fiber-free diet plus restriction of all fermentable food afterward. We thus compared the results of GBT performed before (group A) and after (group B) this pretest diet modification. Demographics, reasons to perform GBT, digestive symptoms, and hydrogen and methane baseline values and variations after glucose ingestion were compared between the two groups. KEY RESULTS 269 patients underwent GBT in group A, and 316 patients in group B. The two groups were comparable in terms of demographics. Methane and hydrogen baseline values were significantly higher in group A (respectively 14 [18] vs. 8 [14] ppm, p < 0.01 and 11 [14] vs. 6 [8] ppm, p < 0.01). The percentage of positive tests was higher in group A for methane (43% vs. 28%, p < 0.05), and for hydrogen (18% vs. 12%, p = 0.03). CONCLUSION & INFERENCES This retrospective study suggests the importance of the restrictive diet prior to GBT. A strict limitation of fibers and fermentable food decreased hydrogen and methane baseline values, and the prevalence of positive GBT. Thus a strict restrictive diet should be recommended on the day before the test, in order to limit the impact of food on hydrogen and methane breath levels, and possibly improve the diagnosis quality of GBT.
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Affiliation(s)
- Nastasia Mattio
- Hospices Civils de Lyon, Digestive Functional Explorations, Lyon, France
| | - Pierre Pradat
- Hospices Civils de Lyon, Centre de recherche clinique Nord, Lyon, France
| | - Christelle Machon
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - Anne Mialon
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - Sabine Roman
- Hospices Civils de Lyon, Université Lyon 1, Digestive Functional Explorations, Lyon, France
| | - Charlotte Cuerq
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - François Mion
- Hospices Civils de Lyon, Université Lyon 1, Digestive Functional Explorations, Lyon, France
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Karas D, Bužga M, Stejskal D, Kocna P, Holéczy P, Novotná A, Švagera Z. Breath Tests Used in the Context of Bariatric Surgery. Diagnostics (Basel) 2022; 12:diagnostics12123170. [PMID: 36553178 PMCID: PMC9777764 DOI: 10.3390/diagnostics12123170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/01/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
This review article focuses on the use of breath tests in the field of bariatrics and obesitology. The first part of the review is an introduction to breath test problematics with a focus on their use in bariatrics. The second part provides a brief history of breath testing. Part three describes how breath tests are used for monitoring certain processes in various organs and various substances in exhaled air and how the results are analyzed and evaluated. The last part covers studies that described the use of breath tests for monitoring patients that underwent bariatric treatments. Although the number of relevant studies is small, this review could promote the future use of breath testing in the context of bariatric treatments.
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Affiliation(s)
- Daniel Karas
- Institute of Laboratory Medicine, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Marek Bužga
- Department of Human Movement Studies, Faculty of Education, University of Ostrava, Fráni Šrámka 3, 709 00 Ostrava, Czech Republic
- Department of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
- Institute of Laboratory Medicine, University Hospital Ostrava, 17. Listopadu 1790/5, 708 52 Ostrava, Czech Republic
- Correspondence:
| | - David Stejskal
- Institute of Laboratory Medicine, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
- Institute of Laboratory Medicine, University Hospital Ostrava, 17. Listopadu 1790/5, 708 52 Ostrava, Czech Republic
| | - Petr Kocna
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University in Prague, Kateřinská 1660/32, 121 08 Prague, Czech Republic
| | - Pavol Holéczy
- Department of Surgery, Vítkovice Hospital, Zalužanského 1192/15, 703 00 Ostrava, Czech Republic
- Department of Surgical Disciplines, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Adéla Novotná
- Department of Epidemiology and Public Health, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Zdeněk Švagera
- Institute of Laboratory Medicine, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
- Institute of Laboratory Medicine, University Hospital Ostrava, 17. Listopadu 1790/5, 708 52 Ostrava, Czech Republic
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Haworth JJ, Pitcher CK, Ferrandino G, Hobson AR, Pappan KL, Lawson JLD. Breathing new life into clinical testing and diagnostics: perspectives on volatile biomarkers from breath. Crit Rev Clin Lab Sci 2022; 59:353-372. [PMID: 35188863 DOI: 10.1080/10408363.2022.2038075] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Human breath offers several benefits for diagnostic applications, including simple, noninvasive collection. Breath is a rich source of clinically-relevant biological information; this includes a volatile fraction, where greater than 1,000 volatile organic compounds (VOCs) have been described so far, and breath aerosols that carry nucleic acids, proteins, signaling molecules, and pathogens. Many of these factors, especially VOCs, are delivered to the lung by the systemic circulation, and diffusion of candidate biomarkers from blood into breath allows systematic profiling of organismal health. Biomarkers on breath offer the capability to advance early detection and precision medicine in areas of global clinical need. Breath tests are noninvasive and can be performed at home or in a primary care setting, which makes them well-suited for the kind of public screening program that could dramatically improve the early detection of conditions such as lung cancer. Since measurements of VOCs on breath largely report on metabolic changes, this too aids in the early detection of a broader range of illnesses and can be used to detect metabolic shifts that could be targeted through precision medicine. Furthermore, the ability to perform frequent sampling has envisioned applications in monitoring treatment responses. Breath has been investigated in respiratory, liver, gut, and neurological diseases and in contexts as diverse as infectious diseases and cancer. Preclinical research studies using breath have been ongoing for some time, yet only a few breath-based diagnostics tests are currently available and in widespread clinical use. Most recently, tests assessing the gut microbiome using hydrogen and methane on breath, in addition to tests using urea to detect Helicobacter pylori infections have been released, yet there are many more applications of breath tests still to be realized. Here, we discuss the strengths of breath as a clinical sampling matrix and the technical challenges to be addressed in developing it for clinical use. Historically, a lack of standardized methodologies has delayed the discovery and validation of biomarker candidates, resulting in a proliferation of early-stage pilot studies. We will explore how advancements in breath collection and analysis are in the process of driving renewed progress in the field, particularly in the context of gastrointestinal and chronic liver disease. Finally, we will provide a forward-looking outlook for developing the next generation of clinically relevant breath tests and how they may emerge into clinical practice.
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Hong H, Hahn S, Kim H, Choi Y. Nomogram for sample size calculation in assessing validity of a new method based on a regression line. COMMUN STAT-THEOR M 2022. [DOI: 10.1080/03610926.2021.2023182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Hyunsook Hong
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seokyoung Hahn
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Kim
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
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van den Brink W, Bloem R, Ananth A, Kanagasabapathi T, Amelink A, Bouwman J, Gelinck G, van Veen S, Boorsma A, Wopereis S. Digital Resilience Biomarkers for Personalized Health Maintenance and Disease Prevention. Front Digit Health 2021; 2:614670. [PMID: 34713076 PMCID: PMC8521930 DOI: 10.3389/fdgth.2020.614670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
Health maintenance and disease prevention strategies become increasingly prioritized with increasing health and economic burden of chronic, lifestyle-related diseases. A key element in these strategies is the empowerment of individuals to control their health. Self-measurement plays an essential role in achieving such empowerment. Digital measurements have the advantage of being measured non-invasively, passively, continuously, and in a real-world context. An important question is whether such measurement can sensitively measure subtle disbalances in the progression toward disease, as well as the subtle effects of, for example, nutritional improvement. The concept of resilience biomarkers, defined as the dynamic evaluation of the biological response to an external challenge, has been identified as a viable strategy to measure these subtle effects. In this review, we explore the potential of integrating this concept with digital physiological measurements to come to digital resilience biomarkers. Additionally, we discuss the potential of wearable, non-invasive, and continuous measurement of molecular biomarkers. These types of innovative measurements may, in the future, also serve as a digital resilience biomarker to provide even more insight into the personal biological dynamics of an individual. Altogether, digital resilience biomarkers are envisioned to allow for the measurement of subtle effects of health maintenance and disease prevention strategies in a real-world context and thereby give personalized feedback to improve health.
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Affiliation(s)
- Willem van den Brink
- Department of Microbiology and Systems Biology, Netherlands Organization for Applied Scientific Research (TNO), Zeist, Netherlands
| | - Robbert Bloem
- Department of Environmental Modeling Sensing and Analysis, Netherlands Organization for Applied Scientific Research (TNO), Utrecht, Netherlands
| | - Adithya Ananth
- Department of Optics, Netherlands Organization for Applied Scientific Research (TNO), Delft, Netherlands
| | - Thiru Kanagasabapathi
- Holst Center, Netherlands Organization for Applied Scientific Research (TNO), Eindhoven, Netherlands
| | - Arjen Amelink
- Department of Optics, Netherlands Organization for Applied Scientific Research (TNO), Delft, Netherlands
| | - Jildau Bouwman
- Department of Microbiology and Systems Biology, Netherlands Organization for Applied Scientific Research (TNO), Zeist, Netherlands
| | - Gerwin Gelinck
- Holst Center, Netherlands Organization for Applied Scientific Research (TNO), Eindhoven, Netherlands
| | - Sjaak van Veen
- Department of Environmental Modeling Sensing and Analysis, Netherlands Organization for Applied Scientific Research (TNO), Utrecht, Netherlands
| | - Andre Boorsma
- Department of Microbiology and Systems Biology, Netherlands Organization for Applied Scientific Research (TNO), Zeist, Netherlands
| | - Suzan Wopereis
- Department of Microbiology and Systems Biology, Netherlands Organization for Applied Scientific Research (TNO), Zeist, Netherlands
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Mathews SC, Templeton S, Taylor SK, Harris S, Stewart M, Raja SM. Evaluation of a Digital Handheld Hydrogen Breath Monitor to Diagnose Lactose Malabsorption: Interventional Crossover Study. JMIR Form Res 2021; 5:e33009. [PMID: 34544034 PMCID: PMC8561400 DOI: 10.2196/33009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Lactose malabsorption is a common condition that affects a broad segment of the population. Clinical diagnosis based on symptom recall can be unreliable and conventional testing can be inconvenient, requiring expensive laboratory-based equipment and conduction of the testing in a clinical setting. Objective The aim of this study is to assess the performance of a digital handheld hydrogen breath monitor (GIMate) in diagnosing lactose malabsorption compared to a US Food and Drug Administration (FDA)–cleared device (H2 Check) for the same indication. Methods An interventional crossover study was performed in adult participants with a prior confirmed diagnosis of lactose malabsorption or a suspected history of lactose intolerance. Results A total of 31 participants (mean age 33.9 years) were enrolled in the study. There was 100% positive percent agreement and 100% negative percent agreement between the GIMate monitor and the H2 Check. Correlation between gastrointestinal symptoms and hydrogen values was positive at 0.82 (P<.001). Conclusions The digital handheld GIMate breath monitor achieved equivalent diagnostic performance to that of an FDA-cleared device in the diagnosis of lactose malabsorption. Trial Registration ClinicalTrials.gov NCT04754724; https://clinicaltrials.gov/ct2/show/NCT04754724
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Affiliation(s)
| | - Sandy Templeton
- Electronics Program, Penn Foster College, Scottsdale, AZ, United States
| | | | - Sten Harris
- Duke Early Phase Clinical Research Unit, Durham, NC, United States
| | - Margaret Stewart
- Duke Early Phase Clinical Research Unit, Durham, NC, United States
| | - Shruti M Raja
- Duke Early Phase Clinical Research Unit, Durham, NC, United States
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Hammer HF, Fox MR, Keller J, Salvatore S, Basilisco G, Hammer J, Lopetuso L, Benninga M, Borrelli O, Dumitrascu D, Hauser B, Herszenyi L, Nakov R, Pohl D, Thapar N, Sonyi M. European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus. United European Gastroenterol J 2021; 10:15-40. [PMID: 34431620 PMCID: PMC8830282 DOI: 10.1002/ueg2.12133] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Measurement of breath hydrogen (H2) and methane (CH4) excretion after ingestion of test‐carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. Methods This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of H2‐CH4‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. Results The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro‐cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2‐CH4‐breath tests in these indications and recommends approaches to mitigate these issues. Conclusion This clinical practice guideline should facilitate pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.
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Affiliation(s)
- Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Mark R Fox
- Centre for Integrative Gastroenterology, Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Klinik Arlesheim, Arlesheim, Switzerland.,Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital of the University of Hamburg, Hamburg, Germany
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Guido Basilisco
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Johann Hammer
- Department of Gastroenterology and Hepatology, University Hospital of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Loris Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italia.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK
| | - Dan Dumitrascu
- Department of Gastroenterology, Clinica Medicala 2, Cluj-Napoca, Romania
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussel, Brussels, Belgium
| | - Laszlo Herszenyi
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Sonyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria.,Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
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Shrestha A, Barnett MPG, Perry JK, Cameron-Smith D, Milan AM. Evaluation of breath, plasma, and urinary markers of lactose malabsorption to diagnose lactase non-persistence following lactose or milk ingestion. BMC Gastroenterol 2020; 20:204. [PMID: 32600320 PMCID: PMC7325051 DOI: 10.1186/s12876-020-01352-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/17/2020] [Indexed: 12/19/2022] Open
Abstract
Background Adult lactase non-persistence (LNP) is due to low lactase expression, resulting in lactose malabsorption (LM). LNP is a genetic trait, but is typically determined by LM markers including breath H2, blood glucose, and urinary galactose after a lactose tolerance test. Known validity of these markers using milk is limited, despite being common practice. Compositional variation, such as β-casein variants, in milk may impact diagnostic efficacy. This study aimed to evaluate the diagnostic accuracy to detect LNP using these commonly measured LM markers after both lactose and milk challenges. Methods Fourty healthy young women were challenged with 50 g lactose then randomized for separate cross-over visits to ingest 750 mL milk (37.5 g lactose) as conventional (both A1 and A2 β-casein) and A1 β-casein-free (a2 Milk™) milk. Blood, breath and urine were collected prior to and up to 3 h following each challenge. The presence of C/T13910 and G/A22018 polymorphisms, determined by restriction fragment length polymorphism, was used as the diagnostic reference for LNP. Results Genetic testing identified 14 out of 40 subjects as having LNP (C/C13910 and G/G22018). All three LM markers (breath H2, plasma glucose and urinary galactose/creatinine) discriminated between lactase persistence (LP) and LNP following lactose challenge with an area under the receiver operating characteristic (ROC) curve (AUC) of 1.00, 0.75 and 0.73, respectively. Plasma glucose and urinary galactose/creatinine were unreliable (AUC < 0.70) after milk ingestion. The specificity of breath H2 remained high (100%) when milk was used, but sensitivity was reduced with conventional (92.9%) and a2 Milk™ (78.6%) compared to lactose (sensitivities adjusted for lactose content). The breath H2 optimal cut-off value was lower with a2 Milk™ (13 ppm) than conventional milk (21 ppm). Using existing literature cut-off values the sensitivity and specificity of breath H2 was greater than plasma glucose to detect LNP following lactose challenge whereas values obtained for urinary galactose/creatinine were lower than the existing literature cut-offs. Conclusion This study showed accurate diagnosis of LNP by breath H2 irrespective of the substrate used, although the diagnostic threshold may vary depending on the lactose substrate or the composition of the milk. Trial registration ACTRN12616001694404. Registered prospectively on December 9, 2016.
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Affiliation(s)
- Aahana Shrestha
- The Liggins Institute, The University of Auckland, Auckland, New Zealand.,The Riddet Institute, Palmerston North, New Zealand
| | - Matthew P G Barnett
- The Riddet Institute, Palmerston North, New Zealand.,Food Nutrition & Health Team, AgResearch Limited, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand
| | - Jo K Perry
- The Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - David Cameron-Smith
- The Liggins Institute, The University of Auckland, Auckland, New Zealand.,The Riddet Institute, Palmerston North, New Zealand.,Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore, Singapore
| | - Amber M Milan
- The Liggins Institute, The University of Auckland, Auckland, New Zealand. .,Food Nutrition & Health Team, AgResearch Limited, Palmerston North, New Zealand. .,The High-Value Nutrition National Science Challenge, Auckland, New Zealand.
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