Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial

Background: Patients with irritable bowel syndrome (IBS) often feel they have some form of dietary intolerance and frequently try exclusion diets. Tests attempting to predict food sensitivity in IBS have been disappointing but none has utilised IgG antibodies. Aims: To assess the therapeutic potential of dietary elimination based on the presence of IgG antibodies to food. Patients: A total of 150 outpatients with IBS were randomised to receive, for three months, either a diet excluding all foods to which they had raised IgG antibodies ( enzyme linked immunosorbant assay test) or a sham diet excluding the same number of foods but not those to which they had antibodies. Methods: Primary outcome measures were change in IBS symptom severity and global rating scores. Non-colonic symptomatology, quality of life, and anxiety/depression were secondary outcomes. Intention to treat analysis was undertaken using a generalised linear model. Results: After 12 weeks, the true diet resulted in a 10% greater reduction in symptom score than the sham diet ( mean difference 39 (95% confidence intervals (CI) 5 - 72); p = 0.024) with this value increasing to 26% in fully compliant patients ( difference 98 ( 95% CI 52 - 144); p< 0.001). Global rating also significantly improved in the true diet group as a whole ( p = 0.048, NNT = 9) and even more in compliant patients ( p = 0.006, NNT = 2.5). All other outcomes showed trends favouring the true diet. Relaxing the diet led to a 24% greater deterioration in symptoms in those on the true diet ( difference 52 ( 95% CI 18 - 88); p = 0.003). Conclusion: Food elimination based on IgG antibodies may be effective in reducing IBS symptoms and is worthy of further biomedical research

Acute care nurses' perceptions of barriers to using research information in clinical decision-making

Aim. To examine the barriers that nurses feel prevent them from using research in the decisions they make. Background. A sizeable research literature focusing on research utilization in nursing has developed over the past 20 years. However, this literature is characterized by a number of weaknesses: self-reported utilization behaviour; poor response rates and small, nonrandom sampling strategies. Design. Cross-case analysis involving anonymised qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 h, and 122 nurses were involved in the Q modelling exercise (response rate of 64%). Results. Four perspectives were isolated that encompassed the characteristics associated with barriers to research use. These related to the individual, organization, nature of research information itself and environment. Nurses clustered around four main perspectives on the barriers to research use: (1) Problems in interpreting and using research products, which were seen as too complex, 'academic' and overly statistical; (2) Nurses who felt confident with research-based information perceived a lack of organizational support as a significant block; (3) Many nurses felt that researchers and research products lack clinical credibility and that they fail to offer the desired level of clinical direction; (4) Some nurses lacked the skills and, to a lesser degree, the motivation to use research themselves. These individuals liked research messages passed on to them by a third party and sought to foster others' involvement in research-based practice, rather than becoming directly involved themselves. Conclusions. Rejection of research knowledge is not a barrier to its application. Rather, the presentation and management of research knowledge in the workplace represent significant challenges for clinicians, policy-makers and the research community

Functional non-epileptic attacks: essential information for psychiatrists

Functional non-epileptic attacks (FNEA) are seizure-like events occurring in the absence of epilepsy. Having had many different names over the years including dissociative convulsions and pseudo-seizures, they now fall in the borderland between neurology and psychiatry, often not accepted by either specialty. However, there is evidence that there is a high rate of psychiatric comorbidity in these patients and therefore it is likely that psychiatrists will come across patients with FNEA and they should know the broad principles of assessment and management. We have provided a clinically based overview of the evidence regarding epidemiology, risk factors, clinical features, differentiation from epilepsy, prognosis, assessment and treatment. By the end of this article, readers should be able to understand the difference between epileptic seizures and FNEA, know how to manage acute FNEA, and understand the principles of neuropsychiatric assessment and management of these patients, based on knowledge of the evidence base

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings

Background. The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions. Aim. To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use. Design. Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals. Results. Three perspectives on accessibility were identified: (a) the humanist-in which human sources of information were the most accessible; (b) local information for local needs-in which locally produced resources were seen as the most accessible and (c) moving towards technology-in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses oil the wards had any explicit research base. These, and the remainder were Out of date (mean age of textbooks 11 years), and authorship hard to ascertain. Conclusion. A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles Could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced

Clinical effectiveness of a pain psychology service within an outpatient secondary care setting

Purpose Data gathered from routine clinical settings is complementary to evidence garnered from controlled efficacy trials. This paper presents individual-level analysis of changes in a group of patients discharged from psychological therapy within an outpatient pain service. The service had recently shifted from a traditional cognitive-behavioural approach to one underpinned by Acceptance and Commitment Therapy (ACT). Design/methodology/approach Reliable and clinically significant change methodology was applied to CORE-10 outcomes for 27 patients discharged during 2013-14. Outcomes were compared to 2012-13. A patient satisfaction questionnaire was administered and functional outcomes were collated. Findings Outcomes were not adversely affected by the shift in service focus as clients demonstrating reliably improvement increased from 2012-13; 81% reliably improved, 44% made a clinically significant improvement. Increases in returning to work/unpaid activities at post-treatment were noted. The service met a number of NICE quality standards concerning the “relational” aspects of care. Research limitations/implications Clinically effectiveness is evaluated through one outcome measure thereby limiting conclusions. The longer term effectiveness of the service remains unclear. Narrow demographic information limits an assessment of any systematic biases in findings. Little is known about treatment drop-outs. Practical implications A number of recommendations concerning data collection and future service evaluations are made. Originality/value This paper contributes towards the evidence-base for using psychological therapies with clients experiencing chronic pain and related distress. Importantly, the paper complements evidence for general efficacy (from large-scale controlled studies) through an evaluation of real-world effectiveness (i.e., practice-based evidence)

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P <0.002) and orlistat for obesity (P <0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer’s disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context

A new, temporarily confined population in the polar cap during the August 27, 1996 geomagnetic field distortion period

On August 27, 1996, a two-hour energetic heavy ion event (∼1 MeV) was detected at 8:25 UT at apogee (∼9 Re and an invariant latitude of ∼80°), by the Charge and Mass Magnetospheric Ion Composition Experiment onboard POLAR. The event, with a maximum spin averaged peak flux of ∼150 particles/(cm²-sr-s-MeV), showed three local peaks corresponding to three localized regions; the ion pitch angle distributions in the three regions were different from an isotropic distribution and different from each other. No comparable flux was observed by the WIND spacecraft. The appearance of lower energy He++ and O \u3e +2 during the event period indicates a solar source for these particles. From region 1 to 2 to 3, the helium energy spectra softened. A distorted magnetic field with three local minima corresponding to the three He peak fluxes was also observed by POLAR. A possible explanation is that the energetic He ions were energized from lower energy helium by a local acceleration mechanism that preferred smaller rigidity ions in the high altitude polar cusp region