心率变异性对急性脑卒中患者心脏自主神经功能的评估价值

目的:探讨动态心电图心率变异性指标对急性脑卒中患者心脏自主神经功能评估的价值。方法:选择我院收治的80例急性脑卒中患者(脑卒中组),同期80例住院非心脑血管疾病的患者(对照组),采用Holter记录仪对两组患者进行24h心率动态监测,对比两组监测结果。结果:与对照组比较,脑卒中组24h窦性R-R间期的标准差[SDNN,(129.89±5.42)ms比(92.58±4.36)ms]、24h每5min窦性R-R间期平均值的标准差[SDANN,(118.85±5.79)ms比(77.36±4.82)ms]、相邻窦性R-R间期的均方根[rMSSD,(27.04±1.18)ms比(7.31±1.09)ms]以及相邻正常R-R间期差值50ms的心搏数占24h总R-R间期数的百分比[PNN50,(8.97±1.48)%比(2.62±0.54)%]均明显下降(P均0.01);而脑卒中患者中脑梗死与脑出血患者上述指标比较差异均无统计学意义(P均0.05)。结论:心率变异性指标在评估急性脑卒中患者心脏自主神经功能方面有重要价值,能对患者的病情变化和发展做出预测,有助于预防和发现严重脑血管疾病。     

窦性心率震荡在冠心病患者中的变化及其预测价值（英文）

目的:探讨冠心病(CAD)患者窦性心率震荡(HRT)的变化及其预测价值。方法:选择58例冠状动脉造影(CAG)证明的CAD患者为CAD组,另50例CAG阴性的正常人为正常对照组。对所有受检者进行24h动态心电图、冠状动脉造影及心脏彩超检查,比较各组左室射血分数(LVEF)、心率变异性指标等参数的差异。结果:与正常对照组比较,CAD组震荡初始(TO)值明显升高[(-1.34±1.09)%比(2.32±0.60)%],震荡斜率(TS)值明显降低[(11.14±2.27)ms/RR比(3.44±0.60)ms/RR],P均0.01;在CAD组中随冠状动脉病变严重程度加重(单支、双支、多支病变),TO值显著升高[(1.35±0.52)%比(2.56±0.83)%比(3.01±1.62)%],TS值[(6.49±1.79)ms/RR比(3.33±1.02)ms/RR比(1.66±0.30)ms/RR]显著降低,组间两两比较差异均有统计学意义(P0.05或0.01);与无心脏事件CAD组比较,合并心脏事件CAD组TO值[(1.68±0.61)%比(2.24±0.24)%]明显升高、TS[(5.87±1.22)ms/RR比(1.65±0.23)ms/RR]、LVEF[(66.18±2.64)%比(56.36±3.34)%]显著降低(P均0.01)。结论:CAD患者存在HRT减弱现象,HRT可作为评估CAD患者病情严重程度的指标及预测CAD患者发生再发心脏事件的指标。     

心率变异性在ST-T改变时的鉴别诊断意义

目的探讨心率变异(HRV)性分析对于功能性与器质性ST-T改变的鉴别诊断意义。方法对40例单纯ST-T改变组、41例伴有ST-T改变的器质性心脏病患者和40例正常人群行24h动态心电图分析,观察心率变异性时域、频域10项指标24h、清醒期和睡眠期的改变。结果单纯ST-T改变组和器质性ST-T改变组均存在心率变异性异常。与正常对照组相比,单纯ST-T改变组心率变异性升高,总功率频谱密度为4227±1456ms2 vs 2893±677ms2(p<0.01),高频功率为440±254ms2 vs 242±109ms2(p<0.01);睡眠期与清醒期差值增大,高频功率为371±352ms2 vs 169±129ms2(p<0.017),pNN50为17±12% vs 4.1±6%(p<0.01)。器质性ST-T改变组心率变异性持续降低,高频功率为108±66ms2 vs 242±109ms2(p<0.01);睡眠期与清醒期差值减小,高频功率为59±79ms2 vs 169±129ms2(p<0.01),pNN50为1.44±5.18%vs4.1±6%(p<0.01)。结论心率变异性对于功能性和器质性ST-T改变的诊断和鉴别诊断具有重要意义。     

多发伤患者的心率变异性分析及其临床意义

目的 观察多发伤患者心率变异性变化及其临床意义.方法 50例多发伤患者分为轻伤和重伤两组.分析伤后第2、9天24h心电图心率变异性.结果 伤后第2天轻伤组SDNN(110.25±2050ms)、SDANN(72.35±28.33ms)、SDNN Index(51.37±17.37ms)较对照组显著降低(P＜0.05),而RMSSD及PNN50与对照组无显著差异(P＞0.05).重伤组SDNN(85.30±30.21ms)、SDANN(68.41±27.52ms)、SDNN Index(32.77±18.11ms)、RMSSD(20.81±10.31ms)及PNN50(5.41%±2.33%)均显著低于对照组(P＜0.05).伤后第9天,轻伤组与对照组无显著差异(P＞0.05);重伤组SDNN(89.91±30.33ms)、SDANN(70.35±29.31ms)、SDNN Index(43.88±20 31ms)、RMSSD(25.93±12.73ms)及PNNm(5.99%±3.55%)仍然显著低于对照组(P＜0.05).2周内心血管事件发生率重伤组(24.00%)显著高于轻伤组(4.00%)(P＜0.05).结论 对多发伤患者作心率变异性检测,有助于了解自主神经功能变化,判断病情发展和预后.     

甲状腺功能异常患者心率变异性临床分析

目的 分析甲状腺功能亢进症(简称甲亢)和甲状腺功能减退症(简称甲减)患者心率变异性,探讨两种疾病的自主神经功能状况.方法以哈尔滨市第二医院和哈尔滨医科大学第二临床医学院就诊的66例甲状腺疾病患者作为观察对象,分为甲亢组(36例)、甲减组(30例),同时选取26例健康体检人员作对照组,进行12导联同步24 h动态监测,指标包括24 h连续窦性R-R间期标准差(SDNN),24 h连续5 min节段的窦性R-R间期标准差(SDANN),24 h内两个相邻窦性R-R间期差＞50 ms心率数占所分析信息期内的心率数的百分比(PNN50),24 h连续窦性R-R间期差值的均方根(rMSSD),低频段功率(LF),高频段功率(HF),低频段功率与高频段功率比值(LF/HF).结果甲亢组心率变异性检测指标SDNN[(80.48±11.95)ms]、PNN50[(18.56±3.50)%]、rMSSD[(13.56±3.45)ms]均明显低于对照组[(128.06±12.8)ms、(32.84±7.21)%、(30.84±6.12)ms,P均＜0.05];LF/HF比值(3.78±1.63)与对照组(2.34±1.06)比较,明显增加(P＜0.05).甲减组SDNN[(65.65±15.55)ms]、SDANN[(80.2±15.72)ms]、PNN50[(16.34±3.56)%]、rMSSD[(15.77±3.58)ms]、LF[(279.03±91.49)ms2/Hz]也明显低于对照组[(128.06±12.87)ms、(132.40±21.95)ms、(32.84±7.21)%、(30.84±6.12)ms、(525.60±84.11)ms2/Hz],两组比较差异有统计学意义(P均＜0.05);LF/HF比值(1.08±0.73)与对照组比较,呈降低趋势,但差异无统计学意义(P＞0.05).结论甲状腺功能异常患者心率变异性总体表现为降低,甲亢患者以交感神经活性占优势,而甲减患者以迷走神经活性占优势.     

曲美他嗪对缺血性心力衰竭患者心率变异性的影响

目的评价曲美他嗪对缺血性心力衰竭患者心率变异性的影响。方法选择缺血性心肌病心衰患者30例,在常规抗心衰治疗(利尿剂、血管紧张素转换酶抑制剂/血管紧张素受体抑制剂、β受体组滞剂、醛固酮拮抗剂及洋地黄制剂)基础上加服曲美他嗪20mg,每日3次,连用3个月。以超声心动图和24h动态心电图分别观察治疗前、治疗后3月心脏功能和心率变异性的改变情况。结果曲美他嗪使用后左室射血分数由(33.5±5.1)%增加到(42.5±5.8)%(P<0.001)。心率变异性分析表明,使用曲美他嗪后,正常R-R间期标准差(SDNN,97.3ms±40.1ms vs 110.5ms±29.2ms,P=0.049)和连续5min正常R-R间期均值标准差(SDANN,80.5ms±29.0ms vs 98.3ms±30.5ms)均较使用前显著增加。结论曲美他嗪能够在一定程度上改善缺血性心肌病心衰患者心率变异性,改善心脏功能。     

516例不同疾病短程心率变异性对比分析

目的探讨不同疾病与正常人之间短程心率变异性的差异,评价短程心率变异性的临床应用价值。方法对337例分别患有糖尿病、冠心病、高血压、肿瘤、脑卒中、颈椎病、腰椎病患者和179例正常人进行短程心率变异性检查,对各病种患者之间及各病种患者与正常人之间的RR间期标准差(SDNN)及变异系数(CV)两项心率变异性指标进行对比分析。结果糖尿病组RR间期标准差和变异系数均较正常组显著降低(SDNN:18.1±8.4msvs26.2±14.2ms,p<0.05;CV:2.42±1.13%vs3.14±1.64%,p<0.05);冠心病、高血压、肿瘤及颈腰椎病组两项指标均较正常人降低,但无统计学差异;脑卒中组两项指标均较正常组显著增高(SDNN:35.2±37.1msvs26.2±10.2ms,p<0.05;CV:4.46±5.37%vs1.64±1.64%,p<0.05)。结论短程心率变异性检测能敏感地反映糖尿病心率变异性的改变,这一观察结果与长程心率变异性分析有相同趋势。     

心率变异性在儿童非器质性或病毒性心肌炎Ⅰ°AVB的诊断意义

目的分析心率变异性在儿童非器质性或病毒性心肌炎Ⅰ度房室传导阻滞(Ⅰ°AVB)的诊断意义。方法选取我院儿科82例Ⅰ°AVB患儿作为研究对象,根据患儿是否伴随器质性心脏病进行分组,其中非器质性心脏病42例患儿为A组,病毒性心肌炎40例患儿为B组,选用同期在我院进行体检的正常儿童31例作为C组;检测并比较三组儿童的心率变异性(HRV)时域、频域以及三组儿童清醒期和睡眠期的改变。结果 A、B两组患儿全部正常窦性心搏间期的标准差(SDNN)、全程相邻正常窦性心搏间隙之差的均方根值(RMSSD)、低频(LF)以及高频(HF)明显高于C组,B组患儿RMSSD明显高于A组患儿,A组患儿LF明显高于B组患儿,差异具有统计学意义(P 0. 05)。A、B两组患儿清醒期和睡眠期SDNN明显低于C组,而RMSSD、极低频(VLF)、LF、HF以及LF/HF明显高于C组,差异具有统计学意义(均P 0. 05),A组患儿清醒期SDNN、RMSSD以及全程记录相邻正常窦性心搏间期差值 50ms的数量与总正常窦性心搏间期数量的百分比(PNN50)明显高于B组,差异具有统计学意义(P 0. 05)。结论房室传导阻滞(AVB)可存在于正常儿童中,但不同情况具有不同AVB的HRV表现,其中HRV时域指标在Ⅰ°AVB儿童非器质性与病毒性心肌炎中存在差异,可用作进行临床鉴别。     

高分辨率超声技术评价病毒性心肌炎患者血管内皮功能的改变

目的:采用高分辨率超声技术探讨病毒性心肌炎患者血流介导的肱动脉舒张反应(FMD)和硝酸甘油介导的肱动脉舒张反应(NMD).方法:采用高分辨率超声技术检测30例病毒性心肌炎患者(心肌炎组)的内皮功能,并与20例非心肌炎患者(非心肌炎组)及20例健康体检者(正常对照组)做比较.结果:心肌炎组FMD(8.73±2.87)%和非心肌炎组FMD(13.00±2.79)%均低于正常对照组(19.32±2.67)%,且差异有统计学意义(P均＜0.01),心肌炎组FMD低于非心肌炎组,差异有统计学意义(P＜0.01).心肌炎组NMD(19.68±5.84)%、非心肌炎组NMD(23.18±4.28)%及正常对照组NMD(24.24±4.13)%3组比较差异无统计学意义(P＞0.05).结论:病毒性心肌炎患者血管内皮依赖性舒张功能受损明显,而非内皮依赖性舒张功能变化不明显.     

冠心病伴阻塞性睡眠呼吸暂停低通气综合征患者的心电变化

目的:研究冠心病(CHD)伴阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者与单纯CHD患者心电的变化。方法:选取行24h动态心电图检测的单纯CHD患者42例(Ⅰ组),CHD伴OSAHS患者47例(Ⅱ组),对比分析Ⅰ组和Ⅱ组发生心律失常情况及心率变异性时域、频域指标,对其中室性期前收缩患者比较其窦性心率震荡指标。结果:房性心律失常和室性心律失常发生率Ⅱ组均明显高于Ⅰ组;Ⅱ组心率变异性时域指标SDNN[(91.51±16.43)∶(128.12±13.78)ms,P<0.05],SDANNI[(83.44±16.21)∶(117.32±17.68)ms,P<0.05],SDNNI[(33.15±9.89)∶(48.17±11.69)ms,P<0.05],均显著低于Ⅰ组;2组窦性心率震荡指标TO、TS值差异均有统计学意义(P<0.05)。结论:CHD伴OSAHS患者心律失常发生率明显增高,心率变异性显著降低,窦性心率震荡减弱。     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.