Antimicrobial sensitivity patterns of Staphylococcus species isolated from mobile phones and implications in the health sector

Objectives

The aim of this research was to determine drug sensitivity profiles of Staphylococcus species isolated from mobile phones of students in Microbiology and Biomedical Laboratory Sciences from UZIMA University, Kisumu (Kenya) and the University Colleges Leuven-Limburg, Leuven (Belgium), respectively.

Results

All mobile phones (16/16, 100%) had gram-positive bacteria. 3/8 (37.5%) mobile devices had Staphylococcus aureus. 2/3 (67%) Staphylococcus aureus strains were resistant to ampicillin, oxacillin, ceftazidime, vancomycin and amoxicillin. Guidelines for disinfection of mobile phones need to be developed urgently to stop transmission of resistant bacteria.

Bariatric Surgery Does Not Appear to Affect Women's Breast-Milk Composition

Background

The breast-milk composition in the first 6 wk postpartum of women who have undergone bariatric surgery (BS) is unknown.

Objective

The aim of this study was to examine 1) the breast-milk macronutrient and vitamin A composition in women who had and who had not undergone BS and 2) the impact of maternal diet on the breast-milk composition. We hypothesized that the milk of women who had undergone BS would be less energy dense and have a lower vitamin A concentration than that of other women.

Methods

A multicenter prospective substudy was conducted at 2 university hospitals. Breast-milk samples were collected from 24 normal-weight [NW; mean ± SD body mass index (BMI; kg/m2): 21.5 ± 1.7; mean ± SD age: 29 ± 6 y], 39 overweight (OW; BMI: 26.9 ± 1.5; aged 29 ± 5 y), and 12 obese women (BMI: 35.0 ± 5.7; aged 29 ± 5 y) as well as from 11 women who had undergone BS (BMI: 28.0 ± 4.4; aged 30 ± 4 y) from day 3 until week 6 of lactation. Milk energy and macronutrients (Human Milk Analyzer; Miris) and vitamin A concentrations (iCheck Fluoro; BioAnalyt) were determined at the end of each week. Maternal diet (food-frequency questionnaire) and physical activity (Kaiser Physical Activity Survey) were measured during the third trimester of pregnancy and on day 3 or 4 and during week 6 of lactation. Statistical analyses include 1-factor ANOVA, Spearman and Pearson correlations, and multiple linear regression.

Results

In all women, a weekly increase in milk energy, total fat, and total carbohydrates was seen, whereas a weekly decrease in proteins and vitamin A was found during the first 2 wk of lactation, followed by a stable concentration of all nutrients. At week 4, milk protein concentrations were higher in women who had undergone BS (14 g/L) compared with NW (8 g/L; P = 0.005) and OW (9 g/L; P = 0.019) women. At week 5, milk carbohydrate concentrations were higher in women who had undergone BS (74 g/L) compared with NW women (68 g/L; P = 0.042).

Conclusions

Breast milk of women who have undergone BS appears to be adequate in energy, macronutrients, and vitamin A during the first 6 wk of lactation. This supports the conclusion that breast feeding should not be discouraged in this group of women. This trial was registered at http://www.clinicaltrials.gov as NCT02515214.

Systemic availability and metabolism of colonic-derived short-chain fatty acids in healthy subjects: a stable isotope study

KEY POINTS

The short-chain fatty acids (SCFAs) are bacterial metabolites produced during the colonic fermentation of undigested carbohydrates, such as dietary fibre and prebiotics, and can mediate the interaction between the diet, the microbiota and the host. We quantified the fraction of colonic administered SCFAs that could be recovered in the systemic circulation, the fraction that was excreted via the breath and urine, and the fraction that was used as a precursor for glucose, cholesterol and fatty acids. This information is essential for understanding the molecular mechanisms by which SCFAs beneficially affect physiological functions such as glucose and lipid metabolism and immune function.

ABSTRACT

The short-chain fatty acids (SCFAs), acetate, propionate and butyrate, are bacterial metabolites that mediate the interaction between the diet, the microbiota and the host. In the present study, the systemic availability of SCFAs and their incorporation into biologically relevant molecules was quantified. Known amounts of ¹³ C-labelled acetate, propionate and butyrate were introduced in the colon of 12 healthy subjects using colon delivery capsules and plasma levels of ¹³ C-SCFAs ¹³ C-glucose, ¹³ C-cholesterol and ¹³ C-fatty acids were measured. The butyrate-producing capacity of the intestinal microbiota was also quantified. Systemic availability of colonic-administered acetate, propionate and butyrate was 36%, 9% and 2%, respectively. Conversion of acetate into butyrate (24%) was the most prevalent interconversion by the colonic microbiota and was not related to the butyrate-producing capacity in the faecal samples. Less than 1% of administered acetate was incorporated into cholesterol and <15% in fatty acids. On average, 6% of colonic propionate was incorporated into glucose. The SCFAs were mainly excreted via the lungs after oxidation to ¹³ CO₂ , whereas less than 0.05% of the SCFAs were excreted into urine. These results will allow future evaluation and quantification of SCFA production from ¹³ C-labelled fibres in the human colon by measurement of ¹³ C-labelled SCFA concentrations in blood.

Low-residue and low-fiber diets in gastrointestinal disease management

Recently, low-residue diets were removed from the American Academy of Nutrition and Dietetics' Nutrition Care Manual due to the lack of a scientifically accepted quantitative definition and the unavailability of a method to estimate the amount of food residue produced. This narrative review focuses on defining the similarities and/or discrepancies between low-residue and low-fiber diets and on the diagnostic and therapeutic values of these diets in gastrointestinal disease management. Diagnostically, a low-fiber/low-residue diet is used in bowel preparation. A bowel preparation is a cleansing of the intestines of fecal matter and secretions conducted before a diagnostic procedure. Therapeutically, a low-fiber/low-residue diet is part of the treatment of acute relapses in different bowel diseases. The available evidence on low-residue and low-fiber diets is summarized. The main findings showed that within human disease research, the terms "low residue" and "low fiber" are used interchangeably, and information related to the quantity of residue in the diet usually refers to the amount of fiber. Low-fiber/low-residue diets are further explored in both diagnostic and therapeutic situations. On the basis of this literature review, the authors suggest redefining a low-residue diet as a low-fiber diet and to quantitatively define a low-fiber diet as a diet with a maximum of 10 g fiber/d. A low-fiber diet instead of a low-residue diet is recommended as a diagnostic value or as specific therapy for gastrointestinal conditions.

Metabonomics and systems biology

Systems biology represents an integrative research strategy that studies the interactions between DNA, mRNA, protein, and metabolite level in an organism, thereby including the interactions with the physical environment and other organisms. The application of metabonomics, or the quantitative study of metabolites in biological systems, in systems biology is currently an emerging area of research, which can contribute to the discovery of (disease) signatures, drug targeting and design, and the further elucidation of basic and more complex biochemical principles. This chapter covers the contribution of metabonomics in advancing our understanding in systems biology.

Inflammation-Induced Downregulation of Butyrate Uptake and Oxidation Is Not Caused by a Reduced Gene Expression

In ulcerative colitis (UC) the butyrate metabolism is impaired, leading to energy-deficiency in the colonic cells. The effect of inflammation on the butyrate metabolism was investigated. HT-29 cells were incubated with pro-inflammatory cytokines (TNF-α and/or IFN-γ) for 1 and 24 h. Cells were additionally stimulated with butyrate to investigate its anti-inflammatory potential. Butyrate uptake and oxidation were measured using (14)C-labeled butyrate. Gene expression of the butyrate metabolism enzymes, interleukin 8 (IL-8; inflammatory marker) and villin-1 (VIL-1; epithelial cell damage marker) was measured via quantitative RT-PCR. Significantly increased IL-8 expression and decreased VIL-1 expression after 24 h incubation with TNF-α and/or IFN-γ confirmed the presence of inflammation. These conditions induced a decrease of both butyrate uptake and oxidation, whereas the gene expression was not reduced. Simultaneous incubation with butyrate counteracted the reduced butyrate oxidation. In contrast, 1 h incubation with TNF-α induced a significant increased IL-8 expression and decreased butyrate uptake. Incubation with TNF-α and/or IFN-γ for 1 h did not induce cell damage nor influence butyrate oxidation. The inflammation-induced downregulation of the butyrate metabolism was not caused by a reduced gene expression, but appeared consequential to a decreased butyrate uptake. Increasing the luminal butyrate levels might have therapeutic potential in UC.

The Influence of CKD on Colonic Microbial Metabolism

There is increasing interest in the colonic microbiota as a relevant source of uremic retention solutes accumulating in CKD. Renal disease can also profoundly affect the colonic microenvironment and has been associated with a distinct colonic microbial composition. However, the influence of CKD on the colonic microbial metabolism is largely unknown. Therefore, we studied fecal metabolite profiles of hemodialysis patients and healthy controls using a gas chromatography-mass spectrometry method. We observed a clear discrimination between both groups, with 81 fecal volatile organic compounds detected at significantly different levels in hemodialysis patients and healthy controls. To further explore the differential impact of renal function loss per se versus the effect of dietary and other CKD-related factors, we also compared fecal metabolite profiles between patients on hemodialysis and household contacts on the same diet, which revealed a close resemblance. In contrast, significant differences were noted between the fecal samples of rats 6 weeks after 5/6th nephrectomy and those of sham-operated rats, still suggesting an independent influence of renal function loss. Thus, CKD associates with a distinct colonic microbial metabolism, although the effect of renal function loss per se in humans may be inferior to the effects of dietary and other CKD-related factors. The potential beneficial effect of therapeutics targeting colonic microbiota in patients with CKD remains to be examined.

Metabolomics in the Clinical Diagnosis of Inflammatory Bowel Disease

BACKGROUND

Crohn's disease and ulcerative colitis represent the 2 major phenotypes of inflammatory bowel disease (IBD) that are characterized by chronic inflammation of all or parts of the gastrointestinal tract. The pathogenesis of both diseases is influenced by genetic predispositions as well as microbial and environmental factors. Currently, there is an emerging consensus hypothesis that a microbial dysbiosis is involved in initiating the disease or in maintaining it. These compositional alterations may be reflected in altered metabolic activities of the gut microbiota and has led to the use of 'omic' profiling to improve the understanding of the pathophysiology of IBD. Key Messages: In the past few years, a metabolic approach has increasingly been applied in a number of studies of experimental and human IBD which were mostly focused on exploring disease-related metabolites to gain more insight into metabolic pathways. Metabolomics involves the high throughput identification, characterization and quantification of small molecule metabolites by different analytical techniques and has been performed in different biofluids such as serum/plasma, urine or fecal samples. The application of such a metabolite profiling technique has revealed different metabolites that allow the discrimination of IBD patients from healthy controls. In addition, separate IBD subtypes could be differentiated. Some of these metabolic changes were directly associated to alterations of specific gut microbial populations, implying a perturbation in the gut microbiome in the development of IBD.

CONCLUSIONS

This review covers the emerging contribution of metabolomics for the discovery of an IBD signature and to identify biomarkers linked with a metabolic imbalance. For the implementation of metabolomics as a diagnostic tool in IBD, large prospective cohort studies are necessary.

Additional Value of CH₄ Measurement in a Combined (13)C/H₂ Lactose Malabsorption Breath Test: A Retrospective Analysis

The lactose hydrogen breath test is a commonly used, non-invasive method for the detection of lactose malabsorption and is based on an abnormal increase in breath hydrogen (H₂) excretion after an oral dose of lactose. We use a combined ¹³C/H₂ lactose breath test that measures breath ¹³CO₂ as a measure of lactose digestion in addition to H₂ and that has a better sensitivity and specificity than the standard test. The present retrospective study evaluated the results of 1051 ¹³C/H₂ lactose breath tests to assess the impact on the diagnostic accuracy of measuring breath CH₄ in addition to H₂ and ¹³CO₂. Based on the ¹³C/H₂ breath test, 314 patients were diagnosed with lactase deficiency, 138 with lactose malabsorption or small bowel bacterial overgrowth (SIBO), and 599 with normal lactose digestion. Additional measurement of CH₄ further improved the accuracy of the test as 16% subjects with normal lactose digestion and no H₂-excretion were found to excrete CH₄. These subjects should have been classified as subjects with lactose malabsorption or SIBO. In conclusion, measuring CH₄-concentrations has an added value to the ¹³C/H₂ breath test to identify methanogenic subjects with lactose malabsorption or SIBO.

Faecal metabolite profiling identifies medium-chain fatty acids as discriminating compounds in IBD

BACKGROUND

Bacteria play a role in the onset and perpetuation of intestinal inflammation in IBD. Compositional alterations may also change the metabolic capacities of the gut bacteria.

OBJECTIVE

To examine the metabolic activity of the microbiota of patients with Crohn's disease (CD), UC or pouchitis compared with healthy controls (HC) and determine whether eventual differences might be related to the pathogenesis of the disease.

METHODS

Faecal samples were obtained from 40 HC, 83 patients with CD, 68 with UC and 13 with pouchitis. Disease activity was assessed in CD using the Harvey-Bradshaw Index, in UC using the UC Disease Activity Index and in pouchitis using the Pouchitis Disease Activity Index. Metabolite profiles were analysed using gas chromatography-mass spectrometry.

RESULTS

The number of metabolites identified in HC (54) was significantly higher than in patients with CD (44, p<0.001), UC (47, p=0.042) and pouchitis (43, p=0.036). Multivariate discriminant analysis predicted HC, CD, UC and pouchitis group membership with high sensitivity and specificity. The levels of medium-chain fatty acids (MCFAs: pentanoate, hexanoate, heptanoate, octanoate and nonanoate), and of some protein fermentation metabolites, were significantly decreased in patients with CD, UC and pouchitis. Hexanoate levels were inversely correlated to disease activity in CD (correlation coefficient=-0.157, p=0.046), whereas a significant positive correlation was found between styrene levels and disease activity in UC (correlation coefficient=0.338, p=0.001).

CONCLUSIONS

Faecal metabolic profiling in patients with IBD relative to healthy controls identified MCFAs as important metabolic biomarkers of disease-related changes.

TRIAL REGISTRATION NO

NCT 01666717.

High dose of prebiotics reduces fecal water cytotoxicity in healthy subjects

SCOPE

In vitro and animal studies have shown differential colonic fermentation of structurally different prebiotics. We evaluated the impact of two structurally different prebiotics (wheat bran extract (WBE, containing arabinoxylan-oligosaccharides) and oligofructose) on colonic fermentation and markers of bowel health in healthy volunteers.

METHODS AND RESULTS

Nineteen healthy subjects completed a double-blind, cross-over randomized controlled trial. Interventions with WBE, oligofructose or placebo for 2 wk (week 1: 15 g/day; week 2: 30 g/day) were separated by 2-wk wash-out periods. At the end of each study period, colonic fermentation was characterized through a metabolomics approach. Fecal water genotoxicity and cytotoxicity were determined using the comet and WST-1 assay, respectively, as parameters of gut health. Cluster analysis revealed differences in effects of WBE and oligofructose on colonic fermentation. WBE, but not oligofructose, reduced fecal p-cresol (p = 0.009) and isovaleric acid concentrations (p = 0.022), markers of protein fermentation. Fecal water cytotoxicity was significantly lower after intake of WBE (p = 0.015). Both WBE- and oligofructose-intake tended to reduce fecal water genotoxicity compared to placebo (WBE: p = 0.060; oligofructose: p = 0.057). Changes in fermentation were not related to changes in fecal water toxicity.

CONCLUSION

Structurally different prebiotics affect colonic fermentation and gut health in a different way.

A decrease of the butyrate-producing species Roseburia hominis and Faecalibacterium prausnitzii defines dysbiosis in patients with ulcerative colitis

OBJECTIVE

Bacteria play an important role in the onset and perpetuation of intestinal inflammation in inflammatory bowel disease (IBD). Unlike in Crohn's disease (CD), in which dysbiosis has been better characterised, in ulcerative colitis (UC), only small cohorts have been studied and showed conflicting data. Therefore, we evaluated in a large cohort if the microbial signature described in CD is also present in UC, and if we could characterise predominant dysbiosis in UC. To assess the functional impact of dysbiosis, we quantified the bacterial metabolites.

DESIGN

The predominant microbiota from 127 UC patients and 87 age and sex-matched controls was analysed using denaturing gradient gel electrophoresis (DGGE) analysis. Differences were quantitatively validated using real-time PCR. Metabolites were quantified using gas chromatography-mass spectrometry.

RESULTS

Based on DGGE analysis, the microbial signature previously described in CD was not present in UC. Real-time PCR analysis revealed a lower abundance of Roseburia hominis (p<0.0001) and Faecalibacterium prausnitzii (p<0.0001) in UC patients compared to controls. Both species showed an inverse correlation with disease activity. Short-chain fatty acids (SCFA) were reduced in UC patients (p=0.014), but no direct correlation between SCFA and the identified bacteria was found.

CONCLUSIONS

The composition of the fecal microbiota of UC patients differs from that of healthy individuals: we found a reduction in R hominis and F prausnitzii, both well-known butyrate-producing bacteria of the Firmicutes phylum. These results underscore the importance of dysbiosis in IBD but suggest that different bacterial species contribute to the pathogenesis of UC and CD.

Metabolomics as a diagnostic tool in gastroenterology

Metabolomics has increasingly been applied in addition to other “omic” approaches in the study of the pathophysiology of different gastrointestinal diseases. Metabolites represent molecular readouts of the cell status reflecting a physiological phenotype. In addition, changes in metabolite concentrations induced by exogenous factors such as environmental and dietary factors which do not affect the genome, are taken into account. Metabolic reactions initiated by the host or gut microbiota can lead to “marker” metabolites present in different biological fluids that allow differentiation between health and disease. Several lines of evidence implicated the involvement of intestinal microbiota in the pathogenesis of inflammatory bowel disease (IBD). Also in irritable bowel syndrome (IBS), a role of an abnormal microbiota composition, so-called dysbiosis, is supported by experimental data. These compositional alterations could play a role in the aetiology of both diseases by altering the metabolic activities of the gut bacteria. Several studies have applied a metabolomic approach to identify these metabolite signatures. However, before translating a potential metabolite biomarker into clinical use, additional validation studies are required. This review summarizes contributions that metabolomics has made in IBD and IBS and presents potential future directions within the field.

Modulation of protein fermentation does not affect fecal water toxicity: a randomized cross-over study in healthy subjects

OBJECTIVE

Protein fermentation results in production of metabolites such as ammonia, amines and indolic, phenolic and sulfur-containing compounds. In vitro studies suggest that these metabolites might be toxic. However, human and animal studies do not consistently support these findings. We modified protein fermentation in healthy subjects to assess the effects on colonic metabolism and parameters of gut health, and to identify metabolites associated with toxicity.

DESIGN

After a 2-week run-in period with normal protein intake (NP), 20 healthy subjects followed an isocaloric high protein (HP) and low protein (LP) diet for 2 weeks in a cross-over design. Protein fermentation was estimated from urinary p-cresol excretion. Fecal metabolite profiles were analyzed using GC-MS and compared using cluster analysis. DGGE was used to analyze microbiota composition. Fecal water genotoxicity and cytotoxicity were determined using the Comet assay and the WST-1-assay, respectively, and were related to the metabolite profiles.

RESULTS

Dietary protein intake was significantly higher during the HP diet compared to the NP and LP diet. Urinary p-cresol excretion correlated positively with protein intake. Fecal water cytotoxicity correlated negatively with protein fermentation, while fecal water genotoxicity was not correlated with protein fermentation. Heptanal, 3-methyl-2-butanone, dimethyl disulfide and 2-propenyl ester of acetic acid are associated with genotoxicity and indole, 1-octanol, heptanal, 2,4-dithiapentane, allyl-isothiocyanate, 1-methyl-4-(1-methylethenyl)-benzene, propionic acid, octanoic acid, nonanoic acid and decanoic acid with cytotoxicity.

CONCLUSION

This study does not support a role of protein fermentation in gut toxicity. The identified metabolites can provide new insight into colonic health.

TRIAL REGISTRATION

ClinicalTrial.gov NCT01280513.

Decreased mucosal sulfide detoxification is related to an impaired butyrate oxidation in ulcerative colitis

BACKGROUND

Defective detoxification of sulfides leads to damage to the mucosa and may play a role in the etiology of ulcerative colitis (UC). The colonic mucosal thiosulfate sulfurtransferase (TST) enzyme removes H(2) S by conversion to the less toxic thiocyanate. In this study we measured colonic mucosal TST enzyme activity and gene expression in UC and controls. In addition, the influence of sulfides on butyrate oxidation was evaluated.

METHODS

Colonic mucosal biopsies were collected from 92 UC patients and 24 controls. TST activity was measured spectrophotometrically. To assess gene expression, total RNA from biopsies was used for quantitative reverse-transcription polymerase chain reaction (RT-PCR). In 20 UC patients, gene expression was reassessed after their first treatment with infliximab. To evaluate the effect of sulfides on butyrate oxidation, biopsies were incubated with 1.5 mM NaHS.

RESULTS

TST enzyme activity and gene expression were significantly decreased in UC patients vs. controls (P < 0.001). UC patients, classified into disease activity subgroups, showed a significantly decreased TST activity and gene expression in the subgroups as compared to healthy subjects (P < 0.05 for all). In 20 patients, gene expression was reassessed after their first infliximab therapy. In responders to infliximab, a significant increase in TST gene expression was observed. However, TST mRNA levels did not return to control values after therapy in the responders. In controls, but not in UC, sulfide significantly decreased butyrate oxidation.

CONCLUSIONS

We found an impaired detoxification mechanism of sulfide at TST protein and RNA level in UC. Inflammation was clearly associated with the observed TST deficiency.

Impaired butyrate oxidation in ulcerative colitis is due to decreased butyrate uptake and a defect in the oxidation pathway

BACKGROUND

In ulcerative colitis (UC) butyrate metabolism is impaired due to a defect in the butyrate oxidation pathway and/or transport. In the present study we correlated butyrate uptake and oxidation to the gene expression of the butyrate transporter SLC16A1 and the enzymes involved in butyrate oxidation (ACSM3, ACADS, ECHS1, HSD17B10, and ACAT2) in UC and controls.

METHODS

Colonic mucosal biopsies were collected during endoscopy of 88 UC patients and 20 controls with normal colonoscopy. Butyrate uptake and oxidation was measured by incubating biopsies with (14) C-labeled Na-butyrate. To assess gene expression, total RNA from biopsies was used for quantitative reverse-transcription polymerase chain reaction (qRT-PCR). In 20 UC patients, gene expression was reassessed after treatment with infliximab.

RESULTS

Butyrate uptake and oxidation were significantly decreased in UC versus controls (P < 0.001 for both). Butyrate oxidation remained significantly reduced in UC after correction for butyrate uptake (P < 0.001), suggesting that the butyrate oxidation pathway itself is also affected. Also, the mucosal gene expression of SLC16A1, ACSM3, ACADS, ECHS1, HSD17B10, and ACAT2 was significantly decreased in UC as compared with controls (P < 0.001 for all). In a subgroup of patients (n = 20), the gene expression was reassessed after infliximab therapy. In responders to therapy, a significant increase in gene expression was observed. Nevertheless, only ACSM3 mRNA levels returned to control values after therapy in the responders groups.

CONCLUSIONS

The deficiency in the colonic butyrate metabolism in UC is initiated at the gene expression level and is the result of a decreased expression of SLC16A1 and enzymes in the β-oxidation pathway of butyrate.

Functional analysis of colonic bacterial metabolism: relevant to health?

With the use of molecular techniques, numerous studies have evaluated the composition of the intestinal microbiota in health and disease. However, it is of major interest to supplement this with a functional analysis of the microbiota. In this review, the different approaches that have been used to characterize microbial metabolites, yielding information on the functional end products of microbial metabolism, have been summarized. To analyze colonic microbial metabolites, the most conventional way is by application of a hypothesis-driven targeted approach, through quantification of selected metabolites from carbohydrate (e.g., short-chain fatty acids) and protein fermentation (e.g., p-cresol, phenol, ammonia, or H(2)S), secondary bile acids, or colonic enzymes. The application of stable isotope-labeled substrates can provide an elegant solution to study these metabolic pathways in vivo. On the other hand, a top-down approach can be followed by applying metabolite fingerprinting techniques based on (1)H-NMR or mass spectrometric analysis. Quantification of known metabolites and characterization of metabolite patterns in urine, breath, plasma, and fecal samples can reveal new pathways and give insight into physiological regulatory processes of the colonic microbiota. In addition, specific metabolic profiles can function as a diagnostic tool for the identification of several gastrointestinal diseases, such as ulcerative colitis and Crohn's disease. Nevertheless, future research will have to evaluate the relevance of associations between metabolites and different disease states.

Relevance of protein fermentation to gut health

It is generally accepted that carbohydrate fermentation results in beneficial effects for the host because of the generation of short chain fatty acids, whereas protein fermentation is considered detrimental for the host's health. Protein fermentation mainly occurs in the distal colon, when carbohydrates get depleted and results in the production of potentially toxic metabolites such as ammonia, amines, phenols and sulfides. However, the effectivity of these metabolites has been established mainly in in vitro studies. In addition, some important bowel diseases such as colorectal cancer (CRC) and ulcerative colitis appear most often in the distal colon, which is the primary site of protein fermentation. Finally, epidemiological studies revealed that diets rich in meat are associated with the prevalence of CRC, as is the case in Western society. Importantly, meat intake not only increases fermentation of proteins but also induces increased intake of fat, heme and heterocyclic amines, which may also play a role in the development of CRC. Despite these indications, the relationship between gut health and protein fermentation has not been thoroughly investigated. In this review, the existing evidence about the potential toxicity of protein fermentation from in vitro animal and human studies will be summarized.

The prebiotic, oligofructose-enriched inulin modulates the faecal metabolite profile: an in vitro analysis

SCOPE

Health benefits of prebiotic administration have been judged mainly from the increased numbers of bifidobacteria and the enhanced production of short-chain fatty acids in the colon. Only a few studies have focused on the capacity of prebiotics to decrease the proteolytic fermentation, which might contribute to health as well.

METHODS AND RESULTS

The influence of the prebiotic oligofructose-enriched inulin (OF-IN) on the pattern of volatile organic compounds was characterized using an in vitro faecal model. Faecal slurries, obtained from healthy subjects, were anaerobically incubated at 37 °C with and without different doses of OF-IN (2.5, 5, 10, or 20 mg) and changes in the metabolite pattern and pH were evaluated. A total of 107 different volatile organic compounds were identified and classified according to their chemical classes. The concentration of esters and acids significantly increased with increasing doses of OF-IN. Similar effects were observed for some aldehydes. To the contrary, OF-IN dose-dependently inhibited the formation of S-compounds. Also, the generation of other protein fermentation metabolites such as phenolic compounds was inhibited in the presence of OF-IN.

CONCLUSION

Our results confirmed a clear dose-dependent stimulation of saccharolytic fermentation. Importantly, a significant decrease in toxic protein fermentation metabolites such as sulphides attended these effects.

Dysbiosis of the faecal microbiota in patients with Crohn's disease and their unaffected relatives

BACKGROUND AND AIMS

A general dysbiosis of the intestinal microbiota has been established in patients with Crohn's disease (CD), but a systematic characterisation of this dysbiosis is lacking. Therefore the composition of the predominant faecal microbiota of patients with CD was studied in comparison with the predominant composition in unaffected controls. Whether dysbiosis is present in relatives of patients CD was also examined.

METHODS

Focusing on families with at least three members affected with CD, faecal samples of 68 patients with CD, 84 of their unaffected relatives and 55 matched controls were subjected to community fingerprinting of the predominant microbiota using denaturing gradient gel electrophoresis (DGGE). To analyse the DGGE profiles, BioNumerics software and non-parametric statistical analyses (SPSS V.17.0) were used. Observed differences in the predominant microbiota were subsequently confirmed and quantified with real-time PCR.

RESULTS

Five bacterial species characterised dysbiosis in CD, namely a decrease in Dialister invisus (p=0.04), an uncharacterised species of Clostridium cluster XIVa (p = 0.03), Faecalibacterium prausnitzii (p < 1.3 × 10⁻⁵) and Bifidobacterium adolescentis (p = 5.4 × 10⁻⁶), and an increase in Ruminococcus gnavus (p = 2.1 × 10⁻⁷). Unaffected relatives of patients with CD had less Collinsella aerofaciens (p = 0.004) and a member of the Escherichia coli-Shigella group (p = 0.01) and more Ruminococcus torques (p = 0.02) in their predominant microbiota as compared with healthy subjects.

CONCLUSION

Unaffected relatives of patients with CD have a different composition of their microbiota compared with healthy controls. This dysbiosis is not characterised by lack of butyrate producing-bacteria as observed in CD but suggests a role for microorganisms with mucin degradation capacity.

Impact of the synbiotic combination of Lactobacillus casei shirota and oligofructose-enriched inulin on the fecal volatile metabolite profile in healthy subjects

SCOPE

Hypothesis-driven approaches have mainly focused on the quantification of SCFAs as mediators of beneficial effects of synbiotics. However, the emergence of metabolite profiling strategies allows to evaluate the colonic metabolism from a top-down approach. In the present study, we evaluated the impact of a synbiotic combination on fecal metabolite profiles.

METHODS AND RESULTS

A synbiotic combination (Lactobacillus casei Shirota cells+oligofructose-enriched inulin) was evaluated in nine healthy volunteers. Before the start, during and after 4-wk treatment, fecal samples were obtained. GC-MS technology was applied to analyze the volatile metabolites. Application of a Type III test revealed that the metabolite profiles from the three conditions were significantly different. We identified three volatile organic compounds, acetate, dimethyl trisulfide and ethyl benzene, which were significantly affected. The acetate levels increased, whereas the dimethyl trisulfide levels decreased during and after the intervention. For ethyl benzene only an effect during the synbiotic intervention period was observed.

CONCLUSION

We report a detailed analysis of the influence of L. casei Shirota combined with oligofructose-enriched inulin on fermentation metabolites. Our results indicated a stimulation of saccharolytic fermentation and, importantly, a reduction of potentially toxic protein fermentation metabolites dimethyl trisulfide and ethyl benzene attended these effects.

The impact of pre- and/or probiotics on human colonic metabolism: does it affect human health?

Since many years, the role of the colonic microbiota in maintaining the host's overall health and well-being has been recognized. Dietary modulation of the microbiota composition and activity has been achieved by the use of pre-, pro- and synbiotics. In this review, we will summarize the available evidence on the modification of bacterial metabolism by dietary intervention with pre-, pro- and synbiotics. Enhanced production of SCFA as a marker of increased saccharolytic fermentation is well documented in animal and in vitro studies. Decreased production of potentially toxic protein fermentation metabolites, such as sulfides, phenolic and indolic compounds, has been less frequently demonstrated. Besides, pre-, pro- and synbiotics also affect other metabolic pathways such as the deconjugation of secondary bile acids, bacterial enzyme activities and mineral absorption. Data from human studies are less conclusive. The emergence of new analytical techniques such as metabolite profiling has revealed new pathways affected by dietary intervention. However, an important challenge for current and future research is to relate changes in bacterial metabolism to concrete health benefits. Potential targets and expected benefits have been identified: reduced risk for the metabolic syndrome and prevention of colorectal cancer.

Quantification of (15)N-nitrate in urine with gas chromatography combustion isotope ratio mass spectrometry to estimate endogenous NO production

The use of stable isotope labeled substrates and subsequent analysis of urinary nitrate, forms a noninvasive test for evaluation of the in vivo NO metabolism. The present paper describes a new method for simultaneous quantification of (15)N-nitrate and total nitrate with gas chromatography combustion isotope ratio mass spectrometry (GC-C-IRMS). Nitrate, isolated from urine with a nitrate selective resin, was reduced to nitrite using copperized cadmium. Subsequently, Sudan I was formed by diazotation. Sudan II was added as internal standard, and both molecules were analyzed with GC-C-IRMS as tert-butyldimethylsilyl derivatives. The accuracy was determined during a recovery study of two different known nitrate concentrations and two (15)N-enrichments. A recovery of 101.6% and 103.9% for total nitrate and 107.6% and 91.2% for (15)N-nitrate was obtained, respectively. The validated method was applied on complete 72 h urine collections after intravenous administration of (15)N-nitrate and (15)N-arginine in humans. On average, 51.8% (47.0-71.0%) of administered (15)N-nitrate was excreted, while 0.68% (0.44-1.17%) of (15)N-arginine was metabolized to nitrate. In conclusion, this method can be used for accurate simultaneous determination of (15)N-nitrate and total nitrate concentrations in urine and can be applied in clinical studies for noninvasive evaluation of NO metabolism in vivo.

p-Cresyl sulfate serum concentrations in haemodialysis patients are reduced by the prebiotic oligofructose-enriched inulin

INTRODUCTION

Protein-bound uraemic retention solutes, including p-cresyl sulfate and indoxyl sulfate, contribute substantially to the uraemic syndrome. These and several other uraemic retention solutes originate from intestinal bacterial protein fermentation. We investigated whether the prebiotic oligofructose-enriched inulin reduced serum concentration of p-cresyl sulfate and indoxyl sulfate, through interference with intestinal generation.

METHODS

We performed a single centre, non-randomized, open-label phase I/II study in maintenance HD patients with a 4-week, escalating dose regimen of oligofructose-enriched inulin (ORAFTI Synergy 1, Tienen, Belgium) (www.clinicaltrials.gov NCT00695513). Changes in p-cresyl sulfate and indoxyl sulfate serum concentrations as well as changes in p-cresyl sulfate and indoxyl sulfate generation rates were analysed.

RESULTS

Compliance with therapy was excellent. p-Cresyl sulfate serum concentrations at 4 weeks were significantly reduced by 20% (intention to treat, P = 0.01; per protocol, P = 0.03). Also p-cresyl sulfate generation rates were reduced (P = 0.007). In contrast, neither indoxyl sulfate generation rates (P = 0.9) nor serum concentrations (P = 0.4) were significantly changed.

CONCLUSION

The prebiotic oligofructose-inulin significantly reduced p-cresyl sulfate generation rates and serum concentrations in haemodialysis patients. Whether reduction of p-cresyl sulfate serum concentrations, an independent predictor of cardiovascular disease in HD patients, will result in improved cardiovascular outcomes remains to be proven.

Pouchitis, similar to active ulcerative colitis, is associated with impaired butyrate oxidation by intestinal mucosa

BACKGROUND

Healthy colonic mucosa uses butyrate as the major energy source. In ulcerative colitis (UC) butyrate oxidation has been shown to be disturbed, but it remains unclear whether this is a primary defect. The aim of this study was to measure mucosal butyrate oxidation in UC (involved and noninvolved colon) and in pouchitis and to study the relationship with endoscopic as well as histological disease activity.

METHODS

Butyrate oxidation was measured in 73 UC patients, 22 pouchitis patients, and 112 controls (95 colon, 17 ileum) by incubating biopsies with 1 mM 14C-labeled Na-butyrate and measuring the released 14CO2.

RESULTS

Compared with that in normal colon, butyrate oxidation was significantly impaired in endoscopically active but not in quiescent disease or uninvolved colon segments. The severity of the metabolic defect was related to histological disease activity and decreased epithelial cell height. In active pouchitis, butyrate oxidation was significantly decreased compared with that in normal ileum and excluded pouches without inflammation. The histological pouchitis score correlated significantly with butyrate oxidation.

CONCLUSIONS

Active UC and pouchitis show the same inflammation-related metabolic defect. Our data suggest that the defect is a consequence of inflammation and that pouchitis is metabolically similar to active UC.

Dose-response effect of arabinoxylooligosaccharides on gastrointestinal motility and on colonic bacterial metabolism in healthy volunteers

OBJECTIVE

Arabinoxylooligosaccharides (AXOS) are non-digestible in the upper gastrointestinal tract and have been shown to exert prebiotic effects in animals. The aim of this study was to characterize the influence of AXOS with an average degree of polymerization of 15 and an average degree of arabinose substitution of 0.26 (AXOS-15-0.26) on gastrointestinal motility and colonic bacterial metabolism in healthy human volunteers.

METHODS

Twelve healthy volunteers received five test meals, containing different amounts of AXOS-15-0.26, with one week intervals between each test meal. Breath tests were used to measure gastric emptying rate, oro-cecal transit time (OCTT) and hydrogen excretion. Colonic bacterial metabolism was estimated using the biomarkers lactose-[(15)N, (15)N']-ureide ((15)N-LU) and p-cresol.

RESULTS

Gastric emptying and OCTT were not influenced by addition of varying amounts of AXOS-15-0.26. Administration of 2.2g or 4.9 g AXOS-15-0.26 significantly decreased the urinary (15)N-excretion (respectively p = 0.008 and p = 0.035) as compared to the baseline, whereas fecal (15)N-excretion was significantly increased (respectively p = 0.034 and p = 0.019). This shift from urinary to fecal (15)N-excretion suggests a higher uptake or incorporation by bacteria due to the stimulation of colonic bacterial growth and/or metabolic activity. Furthermore, a significant increase in hydrogen excretion after administration of 2.2g (p = 0.002) and 4.9 g (p = 0.004) AXOS-15-0.26 was observed. No influence on urinary p-cresol excretion was observed.

CONCLUSION

These findings suggest that a minimal dose of 2.2g AXOS-15-0.26 favorably modulates the colonic bacterial metabolism in healthy humans. However, long term studies are required to confirm a possible prebiotic effect.

Does the biomarker 15N-lactose ureide allow to estimate the site of fermentation of resistant starch?

We evaluated the effect of resistant starch (RS) and resistant starch with wheat bran (RS+WB) on the colonic ammonia metabolism in healthy volunteers using the biomarker (15)N-lactose ureide ((15)N-LU). Particularly, it was investigated whether this biomarker allowed to estimate differences in the site of fermentation. Ten volunteers were included in a placebo-controlled crossover study. They consumed in random order 2 x 15 g RS/day for 2 weeks and placebo for 2 weeks separated by 2 weeks wash-out. At baseline, on the first day of each intake period and after each intake period, they consumed a (15)N-labelled test meal and collected all urine in different fractions for 48 h. In ten other volunteers, the effect of 2 x 15 g RS/day and of 2 x 15 g RS + 2 x 6 g WB was compared. These volunteers collected urine and feces for 72 h. (15)N-content of urine and feces was measured using combustion-isotope ratio mass spectrometry. RS exerted a significant decrease in cumulative urinary (15)N-excretion which was different from placebo. The effect was most pronounced in the 6-24 h urine fraction which suggest fermentation in the proximal colon. The effect of RS+WB on cumulative urinary (15)N-excretion was not significantly different from the effect of RS. A less pronounced decrease in the 6-24 h fraction was observed suggesting less fermentation in the proximal colon whereas no indications for more distal fermentation were observed. Since about 80% of the cumulative urinary (15)N was recovered within 24 h, it was concluded that the biomarker (15)N-LU was useful to monitor processes in the proximal colon rather than in the distal colon.

Influence of resistant starch alone or combined with wheat bran on gastric emptying and protein digestion in healthy volunteers

OBJECTIVE

Resistant starch (RS) is not absorbed in the small intestine, but is partly fermented in the colon and may positively influence putative risk factors for colon cancer. The purpose of the study was to investigate the influence of RS type 3 (retrograded amylose) alone or combined with wheat bran on gastric emptying (GE) and protein assimilation.

MATERIAL AND METHODS

GE and protein assimilation were investigated by means of breath-test technology in 20 healthy volunteers who were randomly divided into two groups, each subject performing two tests. In each test, the volunteers received a labelled test meal either as such or in combination with, respectively, 15 g RS3 or 15 g RS3 combined with 6 g wheat bran (WB). Breath samples were collected during the 6 h after administration of a test meal containing egg proteins, intrinsically labelled with (13)C-leucine, to measure protein digestion and sodium-(14)C-octanoate for measurement of GE.

RESULTS

Intake of RS3 +WB did not influence GE time compared to baseline values, whereas intake of RS3 seemed to hasten GE: from 93 +/- 32 min to 55 +/- 15 min (p = 0.012). The overall protein assimilation parameters at baseline were not significantly different from those obtained after simultaneous intake of RS3 +WB, whereas RS3 significantly shortened the time of maximum excretion compared to baseline, but the extent of protein digestion after RS3 intake was not affected (12.54 +/- 3.60% versus 13.43 +/- 3.40%).

CONCLUSIONS

The presence of RS3 alone or in combination with wheat bran demonstrates that there are no adverse effects on protein digestion and no influence on the nitrogen supply to the colon.

The influence of inulin on the absorption of nitrogen and the production of metabolites of protein fermentation in the colon

In the present study, the production and fate of bacterial metabolites in the colon were investigated in a direct way using two substrates labelled with stable isotopes: lactose [15N,15N]ureide as a source of labelled ammonia and egg proteins intrinsically labelled with [2H4]tyrosine as a precursor of [2H4]p-cresol. Both ammonia and phenolic compounds are believed to be carcinogenic. Stimulation of carbohydrate fermentation in order to prevent accumulation of these toxic metabolites was induced by inclusion of inulin in a test meal or by addition of inulin to the daily diet, allowing us to distinguish between changes induced by the actual presence of a fermentable carbohydrate and effects caused by a long-term dietary intervention. When a single dose of inulin was administered together with the labelled substrates, a significant increase in faecal15N excretion, accompanied by a proportional decrease in urinary15N excretion was observed, probably reflecting an enhanced uptake of ammonia for bacterial biosynthesis, since an increased concentration of labelled N in bacterial pellets was found. A statistically significant reduction of urinary [2H4]p-cresol excretion was also noted. Upon supplementation of inulin to the daily diet during 4 weeks, however, only a tendency towards decreased urinary excretion of both labelled and unlabelledp-cresol was noted. Further studies are warranted to confirm these results in a larger cohort.

Influence of long-term administration of lactulose and Saccharomyces boulardii on the colonic generation of phenolic compounds in healthy human subjects

OBJECTIVE

Proteins are degraded in the colon by bacterial fermentation into potentially toxic metabolites such as phenolic compounds. The aim of the present study was to investigate whether long-term administration of lactulose or Saccharomyces boulardii cells would result in a lower protein degradation. In addition, the influence of a long-term dietary intake on different gastrointestinal parameters was investigated.

METHODS

The effect of long-term intervention of the substrates was evaluated in a randomized, cross-over study in 43 healthy volunteers. At the start of the study and at the end of each 4-week treatment period, urine was collected during 48 h in different fractions and faeces during 72 h. Breath test samples and blood samples were taken to study gastrointestinal parameters.

RESULTS

No influence of long-term administration of both substrates was found on GE, OCTT and serum lipids. A significant decrease in small intestinal permeability was found after long-term dietary intervention with lactulose. Long-term administration of lactulose significantly decreased urinary p-cresol excretion, but did not lower fecal p-cresol excretion. No significant effects were observed after S. boulardii intake.

CONCLUSION

The results obtained in present study have indicated that colonic amino acid fermentation can be reduced by the administration of lactulose as a fermentable carbohydrate.

Effects of Lactobacillus casei Shirota, Bifidobacterium breve, and oligofructose-enriched inulin on colonic nitrogen-protein metabolism in healthy humans

Pre- and/or probiotics can cause changes in the ecological balance of intestinal microbiota and hence influence microbial metabolic activities. In the present study, the influence of oligofructose-enriched inulin (OF-IN), Lactobacillus casei Shirota, and Bifidobacterium breve Yakult on the colonic fate of NH3 and p-cresol was investigated. A randomized, placebo-controlled, crossover study was performed in 20 healthy volunteers to evaluate the influence of short- and long-term administration of OF-IN, L. casei Shirota, B. breve Yakult, and the synbiotic L. casei Shirota + OF-IN. The lactose[15N,15N]ureide biomarker was used to study the colonic fate of NH3. Urine and fecal samples were analyzed for 15N content by combustion-isotope ratio mass spectrometery and for p-cresol content by gas chromatography-mass spectrometry. RT-PCR was applied to determine the levels of total bifidobacteria. Both short- and long-term administration of OF-IN resulted in significantly decreased urinary p-cresol and 15N content. The reduction of urinary 15N excretion after short-term OF-IN intake was accompanied by a significant increase in the 15N content of the fecal bacterial fraction. However, this effect was not observed after long-term OF-IN intake. In addition, RT-PCR results indicated a significant increase in total fecal bifidobacteria after long-term OF-IN intake. Long-term L. casei Shirota and B. breve Yakult intake showed a tendency to decrease urinary 15N excretion, whereas a significant decrease was noted in p-cresol excretion. In conclusion, dietary addition of OF-IN, L. casei Shirota, and B. breve Yakult results in a favorable effect on colonic NH3 and p-cresol metabolism, which, in the case of OF-IN, was accompanied by an increase in total fecal bifidobacteria.

Molecular monitoring of the fecal microbiota of healthy human subjects during administration of lactulose and Saccharomyces boulardii

Diet is a major factor in maintaining a healthy human gastrointestinal tract, and this has triggered the development of functional foods containing a probiotic and/or prebiotic component intended to improve the host's health via modulation of the intestinal microbiota. In this study, a long-term placebo-controlled crossover feeding study in which each subject received several treatments was performed to monitor the effect of a prebiotic substrate (i.e., lactulose), a probiotic organism (i.e., Saccharomyces boulardii), and their synbiotic combination on the fecal microbiota of three groups of 10 healthy human subjects differing in prebiotic dose and/or intake of placebo versus synbiotic. For this purpose, denaturing gradient gel electrophoresis (DGGE) analysis of 16S rRNA gene amplicons was used to detect possible changes in the overall bacterial composition using the universal V(3) primer and to detect possible changes at the subpopulation level using group-specific primers targeting the Bacteroides fragilis subgroup, the genus Bifidobacterium, the Clostridium lituseburense group (cluster XI), and the Clostridium coccoides-Eubacterium rectale group (cluster XIVa). Although these populations remained fairly stable based on DGGE profiling, one pronounced change was observed in the universal fingerprint profiles after lactulose ingestion. Band position analysis and band sequencing revealed that a band appearing or intensifying following lactulose administration could be assigned to the species Bifidobacterium adolescentis. Subsequent analysis with real-time PCR (RT-PCR) indicated a statistically significant increase (P < 0.05) in total bifidobacteria in one of the three subject groups after lactulose administration, whereas a similar but nonsignificant trend was observed in the other two groups. Combined RT-PCR results from two subject groups indicated a borderline significant increase (P = 0.074) of B. adolescentis following lactulose intake. The probiotic yeast S. boulardii did not display any detectable universal changes in the DGGE profiles, nor did it influence the bifidobacterial levels. This study highlighted the capacity of an integrated approach consisting of DGGE analysis and RT-PCR to monitor and quantify pronounced changes in the fecal microbiota of healthy subjects upon functional food administration.

Evaluation of the necessity of induction for lactose-[15N, 15N]-ureide to study the colonic ammonia metabolism

OBJECTIVE

Stable isotope labelled glycosyl ureides have been described as non-invasive markers for measurement of gastrointestinal processes. Lactose-[13C]-ureide is used for the evaluation of orocaecal transit time (OCTT), whereas lactose-[15N, 15N]-ureide is used to study the fate of the NH3 metabolism in the colon. Induction with unlabelled lactose ureide is necessary for the determination of the OCTT. In the present study, the effect of a preceding induction on the fate of 15NH3 in the colon was evaluated.

MATERIAL AND METHODS

Ten healthy volunteers performed two tests: the first test without induction, the second test one week later with induction, i.e. administration of 1 g lactose ureide the evening before the test. Each test consisted of a fractionated 24-h urine collection after the subjects had received a pancake test meal labelled with 75 mg lactose-[15N, 15N]-ureide. All samples were analysed for [15N]-content by combustion IRMS (isotope ratio mass spectrometry) and results were expressed as a percentage of the administered dose.

RESULTS

No significant differences were found in the percentage dose 15N excreted in the different urine fractions between the test without and with preceding induction. The cumulative excretion rates of the 15N-isotope after 24 h were 44.35% without induction and 44.27% with induction.

CONCLUSIONS

The results in this study show that predosing with unlabelled lactose ureide is unnecessary for the evaluation of the ammonia metabolism in the colon by means of lactose-[15N, 15N]-ureide.

Validation of lactose[15N,15N]ureide as a tool to study colonic nitrogen metabolism

In vitro experiments have shown that fermentation of carbohydrates prevents accumulation of nitrogen in the colon. Variable results have been obtained on modulation of dietary intakes in vivo. Lactose[15N,15N]-labeled ureide has been proposed as a tool to study colonic nitrogen metabolism. However, on oral administration of the marker, different urinary excretion patterns of the 15N label have been found. In this study, 50 mg lactose[15N,15N]ureide was directly instilled in the colon through an orocecal tube to investigate the colonic handling of this molecule in a direct way. In basal conditions, 42% (range, 37-48%) of labeled nitrogen administered as lactose[15N,15N]ureide was retrieved in urine after 72 h. A substantial variability in total urinary excretion of the label was found, but the urinary excretion pattern of the label was similar in all volunteers. When inulin, a fermentable carbohydrate, was administered together with the labeled marker, a significant decrease in urinary excretion of 15N after 72 h was found, to 29% (range, 23-34%). The effect of a smaller dose of inulin (250 mg) on colonic handling of lactose[15N,15N]ureide (50 mg), was investigated in another group of volunteers, and this time, fecal excretion of the marker was also evaluated. The results seem to indicate that fermentation of inulin causes an increased fecal excretion of the marker, thereby reducing urinary excretion but not retention in the human nitrogen pool. This instillation study shows that lactose[15N,15N]ureide is a tool with good properties to investigate the effect of different types of carbohydrates on nitrogen metabolism in the proximal colon in vivo.