Inaccuracy of patient-reported descriptions of and satisfaction with bowel actions in irritable bowel syndrome.

BACKGROUND: Perception of diarrhea and constipation differs greatly. This study aimed to correlate subjective and objective assessment of fecal characteristics in irritable bowel syndrome (IBS) patients. METHODS: Data from two interventional dietary trials with varying FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) or gluten content were interrogated. Subjects rated their dissatisfaction with stool consistency daily using a visual analog scale during the interventions. Subjects collected stools at the end of each intervention. Each stool was scored according to the King's Stool Chart (KSC). Fecal water content (FWC) was measured on pooled feces by freeze drying, with diarrhea defined as ≥78%. KEY RESULTS: Seventy IBS (Rome III) and eight healthy subjects were studied. Each subject's self-rating of stool consistency during the most symptomatic diet was approximately double that of their least. Degree of dissatisfaction with stool consistency correlated poorly with changes in FWC and KSC. IBS subtype related poorly to objective measures of stool consistency. Sixty percent of IBS-D subjects had diarrhea on objective measures. Eighty-five percent with IBS-C had hard and formed stools but three patients met the criteria for diarrhea. One healthy subject had diarrhea on FWC and KSC, and six had hard, formed stools. No differences in FWC was observed when subjects consumed differing amounts of FODMAPs or gluten (all P > .200). CONCLUSIONS AND INFERENCES: There are major disparities between patients' stool descriptions and objective features of constipation and diarrhea. Patient-reported bowel habits require more interrogation for accurate IBS subtyping. Varying FODMAP or gluten content of the diet is not associated with consistent change in FWC.

A 7-day team-based model of care in general medicine: implementation and outcomes at 12 months.

BACKGROUND: Demand for inpatient beds is increasing whilst supply is diminishing. General medical services are feeling this demand as the ageing population presents more patients with undifferentiated illness traditionally cared for by this service. Redesign efforts need to focus on improving the quality and speed of decision-making to utilise resources efficiently. AIMS: The aim of this study was to improve patient flow through general medical services by undertaking a comprehensive redesign process targeting each stage of the patient journey. METHODS: We utilised a rapid improvement event to identify waste and design a new model of care (MOC) that eliminated as much waste as possible. The model had three main elements: (i) ward-based teams; (ii) 7-day per week standard work; and (iii) pull systems to operate for all transfers and referrals. Here, we analyse the first 12 months of the new MOC with regard to key outcomes: length of stay, occupancy, weekend discharges, clinical incidents and Medical Emergency Team (MET) calls, emergency department length of stay and National Emergency Access Target (NEAT) performance and elective surgical throughput. RESULTS: The new MOC resulted in a 0.88-day reduction in length of stay. This resulted in reduced general medical bed occupancy of 19 beds. Weekend discharges improved by 54.6%. There were no significant increases in serious clinical incidents or MET calls. Emergency department admitted NEAT performance improved also. CONCLUSION: Redesign of the general medicine model of care eliminating waste has resulted in a significant improvement in patient flow and reduced length of stay without compromising quality of care.

Appropriate clinical use of human leukocyte antigen typing for coeliac disease: an Australasian perspective.

The past decade has seen human leukocyte antigen (HLA) typing emerge as a remarkably popular test for the diagnostic work-up of coeliac disease with high patient acceptance. Although limited in its positive predictive value for coeliac disease, the strong disease association with specific HLA genes imparts exceptional negative predictive value to HLA typing, enabling a negative result to exclude coeliac disease confidently. In response to mounting evidence that the clinical use and interpretation of HLA typing often deviates from best practice, this article outlines an evidence-based approach to guide clinically appropriate use of HLA typing, and establishes a reporting template for pathology providers to improve communication of results.

Cognitive impairment in coeliac disease improves on a gluten-free diet and correlates with histological and serological indices of disease severity.

BACKGROUND: Mild impairments of cognition or 'Brain fog' are often reported by patients with coeliac disease but the nature of these impairments has not been systematically investigated. AIM: This longitudinal pilot study investigated relationships between cognitive function and mucosal healing in people with newly diagnosed coeliac disease commencing a gluten-free diet. METHODS: Eleven patients (8 females, 3 males), mean age 30 (range 22-39) years, were tested with a battery of cognitive tests at weeks 0, 12 and 52. Information processing efficacy, memory, visuospatial ability, motoric function and attention were tested. Small bowel biopsies were collected via routine gastroscopy at weeks 12 and 52 and were compared to baseline Marsh scores. Cognitive performance was compared to serum concentrations of tissue transglutaminase antibodies, biopsy outcomes and other biological markers. RESULTS: All patients had excellent adherence to the diet. Marsh scores improved significantly (P = 0.001, Friedman's test) and tissue transglutaminase antibody concentrations decreased from a mean of 58.4 at baseline to 16.8 U/mL at week 52 (P = 0.025). Four of the cognitive tests assessing verbal fluency, attention and motoric function showed significant improvement over the 12 months and strongly correlated with the Marsh scores and tissue transglutaminase antibody levels (r = 0.377-0.735; all P < 0.05). However, no meaningful patterns of correlations were found for nutritional or biochemical markers, or markers of intestinal permeability. CONCLUSIONS: In newly diagnosed coeliac disease, cognitive performance improves with adherence to the gluten-free diet in parallel to mucosal healing. Suboptimal levels of cognition in untreated coeliac disease may affect the performance of everyday tasks.

Quantifying exposure to diagnostic medical radiation in patients with inflammatory bowel disease: are we contributing to malignancy?

BACKGROUND: While potential risks of diagnostic medical radiation are acknowledged, actual exposure of patients in routine clinical practice is poorly documented. AIM: To quantify such exposure to vulnerable abdominal organs in patients with inflammatory bowel disease who are already at risk of intestinal cancer. METHODS: All incidences of exposure to diagnostic medical radiation were documented in a consecutive series of 100 patients with inflammatory bowel disease (62 Crohn's disease, 37 ulcerative colitis, 1 indeterminate colitis) attending a hospital-based clinic. Total effective dose (mSv) was calculated using published tables. Predictors of high or no irradiation were evaluated by multivariate logistic regression analysis. RESULTS: Thirteen patients had no documented diagnostic irradiation. Twenty-three patients received an effective dose greater than 25 mSv. An at-risk effective dose >50 mSv was received by 11 patients. Dosage was higher in patients with Crohn's disease than ulcerative colitis (P = 0.02) and in patients undergoing surgery (P = 0.004). However, no predictive factors for high radiation dosage or for no exposure were identified. CONCLUSIONS: At-risk irradiation from diagnostic medical radiation is common in patients with inflammatory bowel disease, and might potentially contribute to the elevated risk of intra-abdominal and other cancers. The level of irradiation should be considered in clinical decisions regarding abdominal imaging.

Review article: fructose malabsorption and the bigger picture.

Fructose is found widely in the diet as a free hexose, as the disaccharide, sucrose and in a polymerized form (fructans). Free fructose has limited absorption in the small intestine, with up to one half of the population unable to completely absorb a load of 25 g. Average daily intake of fructose varies from 11 to 54 g around the world. Fructans are not hydrolysed or absorbed in the small intestine. The physiological consequences of their malabsorption include increasing osmotic load, providing substrate for rapid bacterial fermentation, changing gastrointestinal motility, promoting mucosal biofilm and altering the profile of bacteria. These effects are additive with other short-chain poorly absorbed carbohydrates such as sorbitol. The clinical significance of these events depends upon the response of the bowel to such changes; they have a higher chance of inducing symptoms in patients with functional gut disorders than asymptomatic subjects. Restricting dietary intake of free fructose and/or fructans may have durable symptomatic benefits in a high proportion of patients with functional gut disorders, but high quality evidence is lacking. It is proposed that confusion over the clinical relevance of fructose malabsorption may be reduced by regarding it not as an abnormality but as a physiological process offering an opportunity to improve functional gastrointestinal symptoms by dietary change.

Safety of iron polymaltose given as a total dose iron infusion.

An audit of the in-hospital safety and tolerability of 401 infusions of iron polymaltose in 386 patients has shown no cases of anaphylaxis or other cardiorespiratory compromise. The infusion was terminated prematurely because of adverse events in six patients (1.6%). No adverse events occurred within the first 15 min of the infusion. Premedication (in 24%) was not associated with fewer adverse events. Fear of anaphylaxis should not inhibit the use of total dose iron infusion and the practices of premedication and of medical supervision during the first 15 min of the infusion should be abandoned.

Expanded genomic map of Campylobacter jejuni UA580 and localization of 23S ribosomal rRNA genes by I-CeuI restriction endonuclease digestion.

The genomic map of Campylobacter jejuni UA580 was expanded and more precisely constructed using I-CeuI, Sal/I and SmaI restriction endonucleases in conjunction with pulsed-field gel electrophoresis (PFGE). The presence of three fragments after digestion with I-CeuI confirmed the presence of three copies of the 23S ribosomal rRNA (rrl) gene. The genome size of Campylobacter jejuni UA580 was determined to be 1725 +/- 5.9 kbp by I-CeuI with fragment sizes of 1053 +/- 4.4, 361 +/- 2.7 and 311 +/- 3.6 kbp. Analysis of a PCR product from C. jejuni UA580 23S rRNA gene showed that I-CeuI did cut within the gene. The precise locations of the three genes were determined using I-CeuI with two copies of the 23S and 5S rRNA genes located separately from the 16S rRNA gene whereas the third copy of the 23S and 5S rRNA genes had a closer linkage to a 16S rRNA gene copy. Homologous gene probes were used to map additional genes and allowed the realignment of a few previously mapped genes on the chromosome. Other strains of C. jejuni were also cut into three fragments with I-CeuI, which generated variable PFGE patterns.

Genome map of Campylobacter fetus subsp. fetus ATCC 27374.

A physical map of the chromosome of Campylobacter fetus subsp. fetus was constructed by using pulsed-field gel electrophoresis of restriction fragments generated by SalI, SmaI and NotI. Digestion of the type strain ATCC 27374 with these restriction endonucleases resulted in generating 4-14 fragments. The order of the fragments was deduced from hybridization of these restriction fragments to Southern blots of pulsed-field gel electrophoresis gels generated by the other two enzymes. The estimated genome size was 1160 kb. The position of several homologous and heterologous genes was determined on the circular map. These included the 2.8-kb sapA gene, encoding the 97-kDa surface array protein. Three copies of ribosomal RNA genes for which the 16S, 23S and 5S rRNA appeared to be located in close proximity in each of the three regions. The RNA polymerase genes rpoA, rpoB, and rpoD were mapped and appeared to be situated close together in one region. The flagellin genes (flaAB) of C. jejuni and the gyrase genes gyrA and gyrB of C. perfringens and Bacillus subtilis, respectively, were used to identify the locations of flaAB, the gyrA and the gyrB genes on the ATCC 27374 chromosome.