Who gets an annual review for coeliac disease? Patients with lower health literacy and lower dietary adherence consider them important.

BACKGROUND: A lifelong gluten-free (GF) diet to manage coeliac disease is recognised to be challenging. This paper comprises two studies: study one aimed to report the opinions of adults with coeliac disease on review provision and explore factors influencing dietary adherence. Study two aimed to report dietetic provision for adults with coeliac disease. METHODS: A cross-sectional online survey was completed by 722 adults with coeliac disease, including validated dietary adherence, health literacy and quality-of-life questionnaires. An online and paper survey designed to capture the provision of dietetic services to adults with coeliac disease was completed by 88 dietetic departments within the United Kingdom. RESULTS: Only 26% of adults with coeliac disease were offered annual reviews. In contrast, 85% considered reviews important, with 62% preferring dietetic provision. Those who considered reviews important had lower health literacy, greater dietary burden, poorer GF dietary adherence and lower GF food knowledge (all p < 0.05) compared with those who did not consider reviews important. GF dietary adherence was associated with health literacy, self-regulatory behaviours, dietary burden and GF food knowledge; 53% agreed with the 'cost of GF food restricts what I eat'; they had poorer GF dietary adherence compared with those who disagreed (p < 0.001). More than 72% of dietetic coeliac review provision provided content on improving access to GF foods and eating out of the home. CONCLUSIONS: A subpopulation of adults with coeliac disease have a greater need for support and guidance, which supports the viewpoint that limited resources should be targeted towards patients with the most need for support to enable successful disease management.

Understanding vegetable farmers' adoption, dis-adoption, and non-adoption decisions of pest management by pheromone trapping.

The use of pheromone traps can minimize the excess application of synthetic insecticides, while can also benefit the environment. The use of pheromone traps has been promoted and suggested to vegetable farmers of Bangladesh for widespread adoption. However, the majority of farmers have continued to spray insecticides instead of using pheromone traps. The present study investigated the factors influencing farmers' adoption, dis-adoption, and non-adoption behavior of pheromone traps for managing insect pests. Primary data were collected from 438 vegetable growers. Data were analyzed using descriptive statistics and multinomial logistic regression. About 27% of the farmers abandoned the technique shortly after it was adopted as it was time-consuming to manage insect pests. Marginal effect analysis revealed that the likelihood of continued adoption was 34.6% higher for farmers who perceived that pheromone traps were useful in controlling insect pests. In contrast, the likelihood of dis-adoption was 16.5% and 10.4% higher for farmers who maintained communication with private pesticide company agents and neighbor farmers, respectively. Extension services by government extension personnel might be encouraged and maintained as a key component in increasing farmer awareness regarding the use of pheromone trap. Strategies to promote pheromone traps in vegetable production should highlight the positive impacts to farmers and the environment, as this would most likely lead to their continued and widespread use after initial adoption.

One bite or two? A comparison of single bite and double bite biopsy techniques in gastrointestinal endoscopy (BITES).

BACKGROUND AND AIM: Endoscopic biopsies can be taken using either single or double bite technique. In the single bite method, intubation time may be proportionately prolonged depending upon the number of biopsies taken. In contrast to this, double bite, though a greater number of biopsies may be taken per unit time, it may influence the quality of the biopsy specimen. The aim of the study was to compare these methods and to see if taking double bite has significant effect on the histological quality of the endoscopic biopsies. METHODS: A prospective, randomised and partly blind study (n = 135, M: 54%, age 21-91 years) divided into two equal arms to compare 144 procedures was conducted. Specimen were compared for time taken to size, depth, crush artefacts, necrosis, fragmentation, distortion, and epithelial stripping. Time taken to collect specimens was also recorded in the upper GI procedures. RESULTS: No significant difference was observed in the histological quality of single and double bite specimens (p < 0.05). However, DB took significantly less time (M = 88.5, SD ± 28.5) as compared to SB (M = 180, SD ± 55.9) (p < 0.05). CONCLUSIONS: There is no difference between the histological quality of DB and SB and the former technique takes less time, hence reducing intubation time.

Telephone clinic improves gluten-free dietary adherence in adults with coeliac disease: sustained at 6 months.

BACKGROUND: A gluten-free (GF) diet is the only treatment for coeliac disease (CD), non-adherence to the diet is associated with greater morbidity. The study aimed to examine the effect of a telephone clinic, designed to increase GF dietary knowledge and adherence, in adults with CD. METHODS: A prospective study of 125 patients with histologically confirmed CD. Patients, not adhering to a GF diet (n=30), engaged in a personalised telephone clinic. Validated questionnaires were used to assess GF dietary adherence (Coeliac Disease Adherence Test; CDAT), knowledge of GF foods and CD-related quality of life (QoL). GF dietary adherence was assessed up to 12 months post telephone clinic. The control group completed the questionnaires only. RESULTS: GF dietary adherence (CDAT) median scores significantly improved at 3 and 6 months after the telephone clinic compared with baseline (16, 13 and 13, respectively, p<0.01). Reassuringly, the dietary burden QoL score remained similar to baseline values. No change in CDAT scores were observed in the control group. Change in GF dietary knowledge score was associated with improved GF dietary adherence CDAT score (r=-0.22; p=0.039). At 9 and 12 months, CDAT scores were similar to baseline values. CONCLUSIONS: Telephone clinics have a positive impact on dietary knowledge and GF dietary adherence in adults with CD, promoting health-benefitting behaviours in those previously not adhering to a GF diet. The study highlights the need for patients to have regular follow-up, with targeted reviews for those not adhering to a GF diet.

Experiences of Outpatient Clinics and Opinions of Telehealth by Caucasian and South Asian Patients' With Celiac Disease.

Outpatient clinics are an important part of chronic disease management, including that of celiac disease. During the coronavirus disease 2019 (COVID-19) global pandemic, telephone and online video consultations with health care professionals have substantially increased. This study aimed to explore the experience and opinions of adults, with celiac disease, toward face-to-face clinic appointments and alternatives, such as telehealth. Semistructured qualitative interviews with 37 patients were undertaken (75% White Caucasians, 25% South Asians; 29 patients were not adhering to the gluten-free diet). Interviews were recorded, transcribed, and analyzed by NVivo. Frequently reported issues with face-to-face appointments included travel and car parking costs, needing to take time off work, and frequent changes to appointment time. In addition, South Asian patients highlighted issues with linguistics barriers. Telephone consultations were considered acceptable and practical by the majority of patients based on ease and convenience. Online video consultations were favored by just 9 patients, however it is acknowledged that since the COVID-19 pandemic, there has been a greater exposure to this type of technology. These patient experiences can inform health care service development and are not biased by external health concerns connected with in-person visits during the pandemic.

Neurological manifestation of coeliac disease with particular emphasis on gluten ataxia and immunological injury: a review article.

Coeliac disease (CD) is a gluten-induced enteropathy affecting 1% of the population and has extra intestinal manifestations. One such expression involves nervous system, and CD may present as gluten ataxia (GA), peripheral neuropathy and epileptiform disorder among others. Considerable controversy exists on the exact pathophysiological mechanism of gluten leading to ataxia. It is, however, clear that in intestinal axis tissue transglutaminase 2 (tTG2) is the primary target but in the nervous system, tTG6 may be the causative antigen although its exact role is not clear. Furthermore, it has also been postulated that anti-gangliodise antibodies may play a role in the emergence of central pathology if not the key contender. Moreover, the association of neurological injury with non-coeliac gluten sensitivity (NCGS), a related but pathologically different condition implies an independent mechanism of neuronal injury by gluten in the absence of CD. This review will touch on the salient features of CD and the nervous system and will highlight current controversies in relation to gluten and GA.

Polymer Networks Synthesized from Poly(Sorbitol Adipate) and Functionalized Poly(Ethylene Glycol).

Polymer networks were prepared by Steglich esterification using poly(sorbitol adipate) (PSA) and poly(sorbitol adipate)-graft-poly(ethylene glycol) mono methyl ether (PSA-g-mPEG12) copolymer. Utilizing multi-hydroxyl functionalities of PSA, poly(ethylene glycol) (PEG) was first grafted onto a PSA backbone. Then the cross-linking of PSA or PSA-g-mPEG12 was carried out with disuccinyl PEG of different molar masses (Suc-PEGn-Suc). Polymers were characterized through nuclear magnetic resonance (NMR) spectroscopy, gel permeation chromatography (GPC), and differential scanning calorimetry (DSC). The degree of swelling of networks was investigated through water (D2O) uptake studies, while for detailed examination of their structural dynamics, networks were studied using 13C magic angle spinning NMR (13C MAS NMR) spectroscopy, 1H double quantum NMR (1H DQ NMR) spectroscopy, and 1H pulsed field gradient NMR (1H PFG NMR) spectroscopy. These solid state NMR results revealed that the networks were composed of a two component structure, having different dipolar coupling constants. The diffusion of solvent molecules depended on the degree of swelling that was imparted to the network by the varying chain length of the PEG based cross-linking agent.

Zenker's Diverticulum: Can Protocolised Measurements with Barium SWALLOW Predict Severity and Treatment Outcomes? The "Zen-Rad" Study.

Although barium swallow imaging is established in the investigation of Zenker's diverticulum (ZD), no agreed measurement protocol exists. We developed a protocol for measuring ZD dimensions and aimed to correlate measurements with symptoms and post-operative outcomes. This prospective study included patients with confirmed ZD who underwent flexible endoscopic septal division (FESD) between 2014 and 2018. ZD was confirmed on barium radiology with measurements reviewed by two consultant radiologists. Symptom severity pre- and post-FESD was measured using the Dysphagia, Regurgitation, Complications (DRC) scale. Regression analyses were conducted to identify dimensions associated with therapeutic success, defined as remission (DRC score ≤ 1) 6 months after index FESD. In total, 67 patients (mean age 74.3) were included. Interobserver reliability (intraclass correlation coefficients-ICCs) was greatest for pouch width (0.981) and pouch depth (0.934), but not oesophageal depth (0.018). Male gender (60.9%) was associated with larger pouch height (P = 0.008) and width (P = 0.004). A positive correlation was identified between baseline DRC score and pouch depth (ρ 0.326, P = 0.011), particularly the regurgitation subset score (ρ 0.330, P = 0.020). The index pouch depth was associated with FESD procedure time (rho 0.358, P = 0.041). Therapeutic success was achieved in 64.2% and was associated with shorter pouch height (median 14.5 mm vs. 19.0 mm, P = 0.030), pouch width (median 19.9 mm vs. 28.8 mm, P = 0.34) and cricopharyngeal length (median 20.2 mm vs. 26.3 mm, P = 0.036). ZD dimensions may be feasible and were evaluated using Barium radiology. Specific parameters appear to correlate with severity and post-FESD outcomes, which aid with pre-procedural planning.

Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations.

BACKGROUND AND AIMS: Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS: Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS: In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS: The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

Multiple grafting to enzymatically synthesized polyesters.

Enzymatic polymerization is an environmentally benign process for the synthesis of biodegradable and biocompatible polymers. The regioselectivity of lipase B from Candida Antarctica (CAL-B) produces linear functional polyesters without protection-deprotection steps. In this work, two different methods for the enzymatic synthesis of functional polyesters based on renewable resources, as, e.g., glycerol, using CAL-B are outlined. Poly(glycerol adipate) was synthesized by enzymatic transesterification between glycerol and divinyl adipate or dimethyl adipate. Methods are also reported to graft poly(glycerol adipate) with different amounts of hydrophobic side chains (lauric, stearic, behenic, and oleic acids) and hydrophilic poly(ethylene glycol) side chains, respectively. The hydrophilicity or lipophilicity of grafted polyesters is well controlled by changing the degree of grafting of hydrophilic and hydrophobic side chains. The multiple grafted polyesters are characterized by NMR spectroscopy, differential scanning calorimetry, gel permeation chromatography, and X-ray diffraction. Furthermore, the self-assembly of the graft copolymers in water and their use as steric stabilizers for cubosomes are discussed. For this purpose mainly dynamic light scattering and small angle X-ray scattering have been employed.

Battle of the punches: Comparison of transection rates of different punches during FUE.

OBJECTIVES: To know the transection rate using three different kinds of punches of the same size (0.9 mm). MATERIALS AND METHODS: The study was conducted in 10 patients undergoing FUE. Informed consent was obtained from all the patients. In each patient, five areas of 1 cm2 were selected in three rows (each row having five areas of 1 cm2 ). For each row, one kind of punch (sharp, serrated, and blunt) was used. The rows were selected randomly (single-blind). The machine was set at a constant speed of 1200-1500 g. The grafts were harvested with the patient in lying position, the surgeon sitting on head side, and the harvesting started from the right side of the patient to left side. For each box, the FUs and hair were calculated. The harvested FUs were checked under microscope. Any transection (complete or incomplete) was calculated. All the data were collected and analyzed. RESULTS: The total hair yield was maximum with blunt punch (268.4) followed by serrated (247.2) and sharp (207.6). Similarly, the maximum FU yield was 155 using serrated punch followed by 154.4 by blunt and 147.2 in sharp punch. The hair:FUs was highest in blunt punch (1:1.738) vs serrated punch (1:1.595) vs sharp punch (1:1.410). The transection rate was highest with sharp punch (23.9%) followed by serrated (18.8%) and blunt punch (14.5%). CONCLUSION: The graft:hair ratio was maximum using blunt punch. Sharp punch resulted in maximum transection rate with lowest graft:hair ratio.

Adherence to a Gluten Free Diet Is Associated with Receiving Gluten Free Foods on Prescription and Understanding Food Labelling.

Treatment of coeliac disease requires a strict gluten-free (GF) diet, however, a high proportion of patients do not adhere to a GF diet. The study explores the practical challenges of a GF diet and dietary adherence in Caucasian and South Asian adults with coeliac disease. Patients with biopsy- and serology-proven coeliac disease were recruited from a hospital database. Participants completed a postal survey (n = 375), including a validated questionnaire designed to measure GF dietary adherence. Half of Caucasians (53%) and South Asians (53%) were adhering to a GF diet. The quarter of patients (n = 97) not receiving GF foods on prescription had a lower GF dietary adherence score compared with those receiving GF foods on prescription (12.5 versus 16.0; p < 0.001). Not understanding food labelling and non-membership of Coeliac UK were also associated with lower GF dietary adherence scores. A higher proportion of South Asian patients, compared with Caucasians, reported difficulties understanding what they can eat (76% versus 5%; p < 0.001) and understanding of food labels (53% versus 4%; p < 0.001). We recommend retaining GF foods on prescription, membership of a coeliac society, and regular consultations with a dietitian to enable better understanding of food labels. Robust studies are urgently needed to evaluate the impact of reducing the amount of GF foods prescribed on adherence to a GF diet in all population groups.

Diagnosis and Surveillance of Barrett's Esophagus: Addressing the Transatlantic Divide.

BACKGROUND: Barrett's esophagus is a premalignant condition of the esophagus leading to esophageal adenocarcinoma. No consensus exists between the UK and USA concerning the diagnosis of Barrett's esophagus. Although the diagnostic procedure is common, the required findings and diagnostic criteria vary. Both guidelines require endoscopy showing columnar epithelia lining the esophagus, but the US guidelines require the additional finding of intestinal metaplasia on biopsy to confirm diagnosis. Achievement of a consensus is of particular importance due to the established progression from Barrett's esophagus to esophageal adenocarcinoma. Of further importance is the increasing incidence of esophageal adenocarcinoma, a condition with poor overall survival, leading to various opinions on the utility of surveillance in patients. DISCUSSION: A review of the vast array of literature revealed that substantial evidence exists in favor of both diagnostic criteria; hence, there is no easy way to identify the "correct" method of diagnosing Barrett's esophagus. USA recommends surveillance of Barrett's esophagus, whereas UK does not advocate it unless dysplasia is present. Surveillance was found to be effective, but this varied as did cost-effectiveness. Further research into diagnostic methods for Barrett's esophagus is needed to address areas of limited understanding, such that agreement can be reached and practice standardized. Surveillance was generally advocated, but with different criteria and time intervals, and new methods are being evaluated.

Enzymatic Synthesis and Characterization of Hydrophilic Sugar Based Polyesters and Their Modification with Stearic Acid.

Biodegradable and hydrophilic functional polyesters were synthesized enzymatically using xylitol or d-sorbitol together with divinyl adipate and lipase B from Candida antartica (CAL-B). The resulting polyesters had pendant OH-groups from their sugar units which were esterified to different degrees with stearic acid chloride. The structure and the degrees of polymerization of the resulting graft copolymers based on poly(xylitol adipate) and poly(d-sorbitol adipate) were characterized by ¹H NMR spectroscopy and SEC. DSC, WAXS and SAXS measurements indicated that a phase separation between polymer backbone and stearoyl side chains occurred in the graft copolymers, and, additionally, the side chains were able to crystallize which resulted in the formation of a lamellar morphology. Additionally, nanoparticles of the graft copolymers in an aqueous environment were studied by DLS and negative stain TEM.

Component rhinoplasty.

BACKGROUND: According to statistics of American Society of Plastic Surgeons, cosmetic rhinoplasty was the second most frequently performed cosmetic surgery. This study shares the experiences with component rhinoplasty. METHODS: From 2004 to 2010, all patients underwent aesthetic nasal surgery were enrolled. The patients requiring only correction of septal deviation and those presenting with cleft lip nasal deformity were excluded. All procedures were performed under general anaesthesia with open technique using transcolumellar and infra-cartilageous incisions. The transculomelalr incision was closed with 6-0 polypropylene and infra-cartilagenous incisions by 5-0 absorbable sutures. Non-absorbable sutures were removed on the fifth postoperative day. The septum was fixed by 'quilting sutures'. Both nostrils were packed with antibiotic ointment containing paraffin gauzes which were removed after 24-48 hours. External nasal splint was applied to be removed on the fifth postoperative day. RESULTS: A total of 191 patients were enrolled (male:female ratio=1:1.47). The mean age of female patients was 25.3 years and 29.4 years in males. Among 50.8% of patients, the cause of deformity was not known. Only 21.5% patients had a positive history of trauma. Majority of patients (90.6%) underwent septoplasty. Twenty percent of surgeries were secondary. Spreader grafts were used in 85% of patients. In 11% of patients, conchal grafts were used. For none of patients, the inferior turbinectomy was performed. No case of costal cartilage graft or silicone implant was used. Only 5.6% of patients had redo-surgeries. No abnormal scarring was noted during follow-up. CONCLUSIONS: Dorsal hump reduction can be recommended with accuracy and safety without compromising the nasal airway.

Periareolar extra-glandular breast augmentation.

BACKGROUND: Breast augmentation is the most frequent procedure performed according to the 2009 Quick Facts report of the American Society of Plastic Surgeons. This study presents the periareolar extra-glandular breast augmentation. METHODS: From 2004 to 2010 among 32 female patients, peri-areolar incision was performed for breast augmentation. Dissection was performed in subcutaneous plane towards the inferior pole to reach the inframammary fold and was continued in the upwards direction in the subglandular plane to create a pocket. Once the implant of desired size was in place, three sutures fixed the inframammary fold. The skin incision was closed using 4-0 non-absorbable suture. RESULTS: The mean age of patients was 30.7 years and the average incision length was 5.8 cm. 59.4% of patients had an implant size of more than 305 ml and less than 10% of patients had drains which were removed the next morning. All patients were followed regularly and no case of implant infection or removal was seen and only 2 patients had slight stretched scars. In one patient, the implant was high riding and no case of the capsular contracture was noticed. Changes in sensation were noted in 21.9% patients at 3 month interval which was reduced to 6.3% at 6 months interval. Similarly no case of rippling or other visible deformity was noted. CONCLUSION: The extra-glandular periareolar approach for the breast augmentation can be a good option with few side-effects even it is associated with a higher level of surgical expertise.

2-(3-Methyl-but-2-en-1-yl)-1,2-benziso-thia-zol-3(2H)-one 1,1-dioxide.

In the title compound, C(12)H(13)NO(3)S, a saccharin derivative, the dihedral angle between the aromatic and isothia-zole rings is 2.91 (12)°. The planar 3,3-dimethyl-allyl group [maximum deviation = 0.0086 (16) Å] is oriented at dihedral angles of 71.86 (7) and 74.35 (7)° with respect to the aromatic and isothia-zole rings, respectively. In the crystal structure, weak inter-molecular C-H⋯O inter-actions link the mol-ecules into chains along the c axis. A weak C-H⋯π inter-action is also present.