Quality of life in people with ongoing symptoms of coeliac disease despite adherence to a strict gluten-free diet

People with Coeliac disease who suffer persistent symptoms despite adherence to a gluten-free diet are at a greater risk of a reduced health related quality of life. The purpose of this paper is to report the quality of life experienced by this specific group of patients in Australia. A Coeliac Disease Specific Questionnaire (CDQ) was administered to 45 people who were enrolled in a clinical trial and reported persistent symptoms of Coeliac disease despite adherence to a strict gluten free diet. The clinical trial was based in New South Wales, Australia. The instrument used was a subscale and total scores of a CDQ measuring health related quality of life. At baseline the overall mean CDQ score was 147 ± 3.31 (optimum 196) consisting of 4 subscales; gastrointestinal 33 ± 0.88, emotional 32.9 ± 0.99, worries 39.8 ± 0.79 and social 41 ± 6.12 each with a potential score of 49. The health related quality of life of people reporting persistent symptoms of Coeliac disease despite adherence to a gluten free diet is sub-optimal with concerningly low scores for emotional quality

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Towards consensus: defining and supporting a professional role for pharmacists associated with traditional and complementary medicines – a protocol of implementing an international e-survey

Introduction Traditional and complementary medicines (T&CM) are predominantly self-selected from retail outlets including pharmacies as part of self-care practices. Concerns about the appropriate and safe use of T&CM products raises questions about ‘should’ and ‘how’ pharmacists could adopt professional responsibilities. There lacks a consensus about the scope of these responsibilities, or the initiatives required to execute them. The aim of this study is to identify an international set of core responsibilities that support pharmacists’ contribution to ensuring the quality and safe use of T&CMs to promote public health.Methods and analysis An international cross-sectional e-survey of pharmacists representing the six WHO regions will be conducted over a 12-month period. Pharmacists will be invited via representative organisations and professional networks within their respective country. Survey responses to statements about the relevance of T&CM to day-to-day practice; opinions about the bioethical and practice responsibilities; and support required to build their scope of practice associated with T&CM will be collected centrally via the online survey platform Survey Monkey and analysed using the Statistical Package for Social Sciences V.27 software for Windows. Bivariate statistical analysis will be conducted to examine the associations between agreement to statements within each section with key demographic variables, country of practice, pharmacy type, age, gender, qualification and years in practice. Cronbach’s alpha will be used to test the internal consistency of items from certain sections of the survey and evince their clarity to respondents of the questionnaire.Ethics and dissemination Ethics approval has been obtained from the University of Macau (approval number SSHRE21-APP068-ICMS-01). The results of this survey will be used to inform key discussion points in a consensus process and a step towards developing an agreed and defined professional role for pharmacists in T&CMs

Hydrogen–methane breath testing results influenced by oral hygiene

Abstract The measurement of hydrogen–methane breath gases is widely used in gastroenterology to evaluate malabsorption syndromes and bacterial overgrowth. Laboratories offering breath testing provide variable guidance regarding oral hygiene practices prior to testing. Given that oral dysbiosis has the potential to cause changes in breath gases, it raises concerns that oral hygiene is not a standard inclusion in current breath testing guidelines. The aim of this study was to determine how a pre-test mouthwash may impact hydrogen–methane breath test results. Participants presenting for breath testing who had elevated baseline gases were given a chlorhexidine mouthwash. If a substantial reduction in expired hydrogen or methane occurred after the mouthwash, breath samples were collected before and after a mouthwash at all breath sample collection points for the duration of testing. Data were evaluated to determine how the mouthwash might influence test results and diagnostic status. In 388 consecutive hydrogen–methane breath tests, modifiable elevations occurred in 24.7%. Administration of a chlorhexidine mouthwash resulted in significantly (p ≤ 0.05) reduced breath hydrogen in 67% and/or methane gas in 93% of those consenting to inclusion. In some cases, this modified the diagnosis. Mean total gas concentrations pre- and post-mouthwash were 221.0 ppm and 152.1 ppm (p < 0.0001) for hydrogen, and 368.9 ppm and 249.8 ppm (p < 0.0001) for methane. Data suggest that a single mouthwash at baseline has a high probability of returning a false positive diagnosis. Variations in gas production due to oral hygiene practices has significant impacts on test interpretation and the subsequent diagnosis. The role of oral dysbiosis in causing gastrointestinal symptoms also demands exploration as it may be an underlying factor in the presenting condition that was the basis for the referral

Can We All Speak the Same ‘Language’ for Our Patients’ Sake? Feedback on Interprofessional Communication and Related Resources

Background The Australasian Integrative Medicine Association (AIMA) established a working group to develop the AIMA Guiding Principles for Letter Writing and Letter Writing Templates. The guiding principles were developed to promote effective communication between the diverse range of healthcare practitioners (HCPs) that patients choose to consult. Following the development of the Interprofessional Communication (IPC) resources, AIMA undertook a public consultation as part of a quality assurance process to evaluate the relevance and utility of the resource. Aim This study reports stakeholder feedback on AIMA’s draft guiding principles document. It explores stakeholder attitudes towards IPC and HCPs letter-writing, and interest in ongoing continuing professional development (CPD). Methods A cross-sectional survey involving 1) an online public consultation survey and 2) a paper survey collected following IPC CPD activities. Quantitative data were analysed using Chi square and Fisher-Freeman-Halton Test. Responses to open ended questions were coded and subject to a thematic analysis. Results The 64 survey participants and 55 CPD participants represented the Australian healthcare sectors and lay community. Most thought IPC is important (n = 112/117; 96%) and the resources were informative (n = 112/119; 94%), understandable (n = 111/119; 93%), and clinically relevant (n = 105/117; 90%). HCP reported wide variations in their frequency of correspondence with other practitioner types, with rates often concerningly low. Key IPC themes identified were the importance of continuity of care, clarity of communication, and professional practice. CPD participants were most interested in further IPC training (p = 0.001). Conclusions The IPC resources affirm the role of formal communication pathways, such as letters of correspondence to support coordinated, patient-centred and multidisciplinary care. Challenges with letter writing and IPC signal the need for more student and professional education on the subject to promote continuity of patient care and the delivery of high quality, integrative medicine and health care services