Health literacy and gout characteristics in a primary care cohort.

Objectives: To examine the cross-sectional association between health literacy and gout characteristics. Methods: In a primary care cohort of adults living with gout, the prevalence of poor health literacy was defined using the Single-Item Literacy Screener (SILS). Multiple logistic regression was used to obtain adjusted odds ratios (ORs) for the cross-sectional associations between health literacy and individual gout characteristics (frequency of flares, age at gout onset, history of oligo-/polyarticular flares, allopurinol use, allopurinol dose and serum urate level) with 95% CIs and adjustment for age, sex, deprivation and further education. Results: Of 551 participants [mean age 54.4 years (s.d. 11.2), 498 (90.4%) male], 163 (30.1%) reported two or more flares in the previous 12 months. Fifty-one (9.4%) had poor health literacy. Poor health literacy was associated with having two or more flares in the preceding 12 months [adjusted OR 4.10 (95% CI 2.04, 8.19)] and a history of oligo-/polyarticular flares [OR 1.93 (95% CI 1.06, 3.55)]. No associations were identified between health literacy and age at gout onset [OR 0.99 (95% CI 0.96, 1.01)], allopurinol use [OR 0.88 (95% CI 0.46, 1.65)] or dose [OR 1.00 OR (95% CI 1.00, 1.00)] or serum urate [most recent serum urate OR 1.0 (95% CI 1.00, 1.00)]. Conclusions: Frequent flares and a history of oligo-/polyarticular flares were associated with poor health literacy. Since health literacy is an important determinant of health outcomes, it is important to consider health literacy when providing information and education to people with gout.

Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care.

OBJECTIVE: To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care. METHODS: In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years. RESULTS: A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05). CONCLUSION: Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

'It's just a great muddle when it comes to food': a qualitative exploration of patient decision-making around diet and gout.

OBJECTIVE: Our aim was to understand whether, why and how patients choose to modify their diets after developing gout. METHODS: We conducted an inductive thematic secondary analysis of qualitative data from 43 interviews and four focus groups with UK participants with gout (n = 61). RESULTS: Participants commonly initiated dietary changes as part of a self-management strategy for gout. Reasons for making such dietary changes included: desperation; a desire for control; and belief that it would be possible to achieve successful management through diet alone; but not weight loss. Participants who did not make changes or who reverted to previous dietary patterns did so because: they believed urate-lowering therapy was successfully managing their gout; medication allowed normal eating; they did not find 'proof' that diet would be an effective treatment; or the dietary advice they found was unrealistic, unmanageable or irrelevant. Dietary modification was patient led, but patients would have preferred the support of a health-care professional. Beliefs that diet could potentially explain and modify the timing of flares gave patients a sense of control over the condition. However, the belief that gout could be controlled through dietary modification appeared to be a barrier to acceptance of management with urate-lowering therapy. CONCLUSIONS: Perceptions about gout and diet play a large role in the way patients make decisions about how to manage gout in their everyday lives. Addressing the reasons why patients explore dietary solutions, promoting the value of urate-lowering therapy and weight loss and drawing on strong evidence to communicate clearly will be crucial in improving long-term clinical management and patient experience.

Onset of comorbidities and flare patterns within pre-existing morbidity clusters in people with gout: 5-year primary care cohort study.

OBJECTIVE: To investigate the onset of comorbidities and pattern of flares over 5 years according to baseline comorbidity clusters in people with gout. METHODS: In a prospective primary care-based cohort study, adults aged ≥18 years with gout were identified from primary care medical records in 20 general practices across the West Midlands, UK and followed up over 5 years. Four clusters of participants have been defined previously according to baseline comorbidity status. The associations of (i) incident comorbidities and (ii) gout flares with baseline cluster membership were estimated using age and sex-adjusted Poisson regression and mixed effects ordinal logistic regression, respectively. RESULTS: The comorbidity with the highest incidence was coronary artery disease (39.2%), followed by hypertension (36.7%), chronic kidney disease stage ≥3 (18.1%), obesity (16.0%), hyperlipidaemia (11.7%), diabetes (8.8%) and cancer (8.4%). There were statistically significant associations observed between cluster membership and incidence of coronary artery disease, hyperlipidaemia, heart failure and hypertension. In each cluster, nearly one-third of participants reported two or more gout flares at each time-point. History of oligo/polyarticular flares (odds ratio [OR]= 2.16, 95% confidence interval [CI]: 1.73, 2.70) and obesity (1.66, 95% CI: 1.21, 2.25) were associated with increasing flares whereas current use of allopurinol was associated with lower risk (0.42, 95% CI: 0.34-0.53). Cluster membership was not associated with flares. CONCLUSION: Substantial numbers of people in each cluster developed new comorbidities that varies by cluster membership. People also experienced multiple flares over time, but these did not differ between clusters. Clinicians should be vigilant for the development of new comorbidities in people with gout.

Latent Class Growth Analysis of Gout Flare Trajectories: A Three-Year Prospective Cohort Study in Primary Care.

OBJECTIVE: To investigate the existence of distinct classes of gout flare trajectories and compare their gout-specific, comorbid, and sociodemographic characteristics. METHODS: In a prospective cohort study, adults with gout who were registered with 20 general practices self-reported the number of gout flares experienced at baseline and after 6, 12, 24, and 36 months via postal questionnaires. Latent class growth analysis (LCGA) was used to identify distinct gout flare trajectory classes. Statistical criteria and clinical interpretability were used to decide the optimal number of classes. Baseline comorbidities, medications, and sociodemographic and gout-specific characteristics of members of each class were described. RESULTS: A total of 1,164 participants (mean ± SD age 65.6 ± 12.5 years; 972 [84%] male) were included. Six latent gout flare trajectory classes were identified: "frequent and persistent" (n = 95), "gradually worsening" (n = 276), "frequent then improving" (n = 14), "moderately frequent" (n = 287), "moderately frequent then improving" (n = 143), and "infrequent" (n = 349). The "frequent and persistent" trajectory had the most class members classified as obese and, along with the "gradually worsening" class, the highest proportion who were socioeconomically deprived. The "frequent and persistent," "gradually worsening," and "frequent then improving" classes had the highest proportions of class members with an estimated glomerular filtration rate <60 ml/minute/1.73 m2 . The "infrequent" gout flare class was associated with more frequent allopurinol use and lower urate levels. CONCLUSION: Six distinct gout flare trajectories were identified. Infrequent flares were associated with allopurinol use and lower serum urate levels, supporting the use of urate-lowering therapy to reduce flare frequency. The characteristics of flare trajectory classes could help to target interventions and improve patient care.

Dietary components and risk of cardiovascular disease and all-cause mortality: a review of evidence from meta-analyses.

AIMS: The optimal diet for cardiovascular health is controversial. The aim of this review is to summarize the highest level of evidence and rank the risk associated with each individual component of diet within its food group. METHODS AND RESULTS: A systematic search of PudMed was performed to identify the highest level of evidence available from systematic reviews or meta-analyses that evaluated different dietary components and their associated risk of all-cause mortality and cardiovascular disease. A total of 16 reviews were included for dietary food item and all-cause mortality and 17 reviews for cardiovascular disease. Carbohydrates were associated with a reduced risk of all-cause mortality (whole grain bread: relative risk (RR) 0.85, 95% confidence interval (CI) 0.82-0.89; breakfast cereal: RR 0.88, 95% CI 0.83-0.92; oats/oatmeal: RR 0.88, 95% CI 0.83-0.92). Fish consumption was associated with a small benefit (RR 0.98, 95% CI 0.97-1.00) and processed meat appeared to be harmful (RR 1.25, 95% CI 1.07-1.45). Root vegetables (RR 0.76, 95% CI 0.66-0.88), green leafy vegetables/salad (RR 0.78, 95% CI 0.71-0.86), cooked vegetables (RR 0.89, 95% CI 0.80-0.99) and cruciferous vegetables (RR 0.90, 95% CI 0.85-0.95) were associated with reductions in all-cause mortality. Increased mortality was associated with the consumption of tinned fruit (RR 1.14, 95% CI 1.07-1.21). Nuts were associated with a reduced risk of mortality in a dose-response relationship (all nuts: RR 0.78, 95% CI 0.72-0.84; tree nuts: RR 0.82, 95% CI 0.75-0.90; and peanuts: RR 0.77, 95% CI 0.69-0.86). For cardiovascular disease, similar associations for benefit were observed for carbohydrates, nuts and fish, but red meat and processed meat were associated with harm. CONCLUSIONS: Many dietary components appear to be beneficial for cardiovascular disease and mortality, including grains, fish, nuts and vegetables, but processed meat and tinned fruit appear to be harmful.

Management of bile acid malabsorption using low-fat dietary interventions: a useful strategy applicable to some patients with diarrhoea-predominant irritable bowel syndrome?

This study evaluates the efficacy of low-fat dietary interventions in the management of gastrointestinal (GI) symptoms due to bile acid malabsorption. In total, 40 patients with GI symptoms and a 7-day (75)selenium homocholic acid taurine (SeHCAT) scan result of <20%, were prospectively recruited and then advised regarding a low-fat dietary intervention. Before and after dietary intervention, patients rated their GI symptoms using a 10-point numerical scale, and recorded their intake in 7-day dietary diaries. After dietary intervention, the median scores for all GI symptoms decreased, with a significant reduction for urgency, bloating, lack of control, bowel frequency (p ≥: 0.01). Mean dietary fat intake reduced to 42 g fat after intervention (p ≥: 0.01). Low-fat dietary interventions in patients with a SeHCAT scan result of <20% leads to clinically important improvement in GI symptoms and should be widely used.

Outcomes from treating bile acid malabsorption using a multidisciplinary approach.

BACKGROUND & AIM: Despite bile acid malabsorption affecting >1 % of the population, the outcomes of treatment are largely unreported. This study evaluated the effectiveness of a structured intervention for this condition. METHOD: This was a retrospective evaluation of prospectively recorded patient reported outcome measures in a consecutive cohort of patients diagnosed with bile acid malabsorption seen in a cancer centre gastroenterology clinic. Every patient completed a 7-day food diary, a gastrointestinal symptom rating scale questionnaire and Bristol stool chart before the first clinic appointment and the symptom questionnaire and Bristol stool chart before all subsequent appointments. Patients who reported any episodes of type 6 or 7 stool were referred for a (75)Selenium (Se) homocholic acid taurine scan. Abnormal gastrointestinal symptoms were investigated and treated systematically using a peer reviewed management algorithm. RESULTS: Between 2011 and 2013, 136 men, 146 women, median age 66 years (range 19-89) underwent a scan. 143 (51 %) had 7-day isotope retention of ≤20 %. 105 (73 %) had previously undergone pelvic radiotherapy and 67 (47 %) GI surgery. 123 (86 %) were treated with low-fat diets, 79 (55 %) with a bile acid sequestrant, 73 (51 %) both. On discharge, 100 (70 %) patients reported an overall symptom improvement (mean -4.2 points, p < 0.0001). In patients who had only bile acid malabsorption and no other gastrointestinal diagnoses, 77 % (41/53) reported a mean improvement of -5.4 points (p < 0.0005). Patients reported a clinically significant improvement in urgency, faecal incontinence, wind, nocturnal defaecation, tiredness, abdominal pain, bloating, and steatorrhoea, (p = <0.0005). Stool frequency was reduced and stool consistency was improved. CONCLUSION: In this large cohort of complex patients, bile acid malabsorption is common and a multidisciplinary approach to managing gastrointestinal symptoms is effective.

Guidance: The practical management of the gastrointestinal symptoms of pelvic radiation disease.

BACKGROUND: A recent randomised trial suggested that an algorithmic approach to investigating and managing gastrointestinal symptoms of pelvic radiation disease (PRD) is beneficial and that specially trained nurses can manage patients as effectively as a gastroenterologist. AIMS: The aim of the development and peer review of the guide was to make the algorithm used in the trial accessible to all levels of clinician. METHODS: Experts who manage patients with PRD were asked to review the guide, rating each section for agreement with the recommended measures and suggesting amendments if necessary. Specific comments were discussed and incorporated as appropriate, and this process was repeated for a second round of review. RESULTS: 34 gastroenterologists, 10 nurses, 9 dietitians, 7 surgeons and 5 clinical oncologists participated in round one. Consensus (defined prospectively as 60% or more panellists selecting 'strongly agree' or 'agree') was reached for 27 of the original 28 sections in the guide, with a median of 75% of panellists agreeing with each section. 86% of panellists agreed that the guide was acceptable for publication or acceptable with minor revisions. 55 of the original 65 panellists participated in round two. 89% agreed it was acceptable for publication after the first revision. Further minor amendments were made in response to round two. CONCLUSIONS: Development of the guide in response to feedback included ▸ improvement of occasional algorithmic steps ▸ a more user-friendly layout ▸ clearer timeframes for referral to other teams ▸ expansion of reference list ▸ addition of procedures to the appendix.

Managing gastrointestinal symptoms after cancer treatment: a practical approach for gastroenterologists.

The percentage of the population living with a diagnosis of cancer is rising. By 2030, there will be 4 million cancer survivors in the UK. One quarter of cancer survivors are left with physical symptoms, which affect their quality of life. Gastrointestinal (GI) symptoms are the most common of all chronic physical side-effects of cancer treatment and have the greatest impact on daily activity. Cancer therapies induce long-term changes in bowel function due to alterations to specific GI physiological functions. In addition, the psychological effect of a cancer diagnosis, new GI disease or pre-existing underlying conditions, may also contribute to new symptoms. Twenty-three upper GI symptoms have been identified as occurring after pelvic radiotherapy. After upper GI cancer treatment, the most troublesome symptoms include reflux, abdominal pain, indigestion, diarrhoea and fatigue. Often, several symptoms are present simultaneously and women experience more symptoms than men. The symptoms which patients rate as most difficult are urgency, wind, diarrhoea, incontinence, abdominal pain and rectal bleeding. Recent UK Guidance on managing GI symptoms suggests that these symptoms can be treated especially if gastroenterological advice is combined with dietetic and nursing input to optimise investigations and management. However, as different pathological processes can result in identical symptoms; a systematic, 'algorithmic' approach to assess and treat these symptoms is required. This paper aims to illustrate the value of such an approach to investigate and treat the most common GI symptoms that trouble patients. The algorithm allows clinicians to institute a comprehensive medical management plan.

Development and psychometric testing of the nurses' attitudes toward obesity and obese patients (NATOOPS) scale.

This study was designed to develop and test an instrument to measure nurses' attitudes towards obesity and obese adult patients. Items were based on an earlier version of the instrument, obesity discrimination research, and clinical experience. After content validation of items, the instrument was sent to 1,400 randomly selected Registered Nurses. Factor analysis yielded a 5-factor solution, with 36 items reaching loadings of .4 or greater. Cronbach's alpha was .81 for the reduced scale, with a range of .45 to .79 on the five factors. Construct validity was supported by significant differences between contrast groups on three factors and consistency with underlying theory. Overall the instrument demonstrated acceptable psychometric properties and could be used in future research.

Establishing integrity and avoiding methodological misunderstanding.

In this article, the authors discuss their understanding of how the consistent use of language, reflective of the research method used, can deem a study scientifically adequate. Using a hermeneutic phenomenological study, as the basis for the discussion, integrity is posed as a suitable term to describe scientific adequacy. In addition, the authors ask readers to reflect on their beliefs about the language used to discuss other qualitative approaches.