Is Gluten a Cause of Gastrointestinal Symptoms in People Without Celiac Disease?

The avoidance of wheat- and gluten-containing products is a worldwide phenomenon. While celiac disease is a well-established entity, the evidence base for gluten as a trigger of symptoms in patients without celiac disease (so-called ‘non-celiac gluten sensitivity’ or NCGS) is limited. The problems lie in the complexity of wheat and the ability of its carbohydrate as well as protein components to trigger gastrointestinal symptoms, the potentially false assumption that response to a gluten-free diet equates to an effect of gluten withdrawal, and diagnostic criteria for coeliac disease. Recent randomized controlled re-challenge trials have suggested that gluten may worsen gastrointestinal symptoms, but failed to confirm patients with self-perceived NCGS have specific gluten sensitivity. Furthermore, mechanisms by which gluten triggers symptoms have yet to be identified. This review discusses the most recent scientific evidence and our current understanding of NCGS.     

Is It Possible to Manage Hypertension and Evaluate Therapy Without Ambulatory Blood Pressure Monitoring?

In the management of patients with hypertension, blood pressure (BP) has been traditionally measured in the physician's office. The contribution of ambulatory BP monitoring (ABPM) to the management of hypertensive patients has been increasingly recognized through clinical and epidemiological research. Ambulatory BP monitoring can enhance the ability to detect white-coat or masked hypertension, determine the absence of nocturnal dipping status, and evaluate BP control in patients on antihypertensive therapy. Recently, the United Kingdom National Clinical Guideline Centre published guidelines for the clinical management of primary hypertension in adults, recommending the routine use of ABPM to make the initial diagnosis of hypertension. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to the cost of the equipment, data evaluation, and staff training as well as the possible inconvenience to the patient. In this review, we summarize the clinical importance of ABPM and discuss the current guidelines for establishing the diagnosis of hypertension.     

It Is Possible to Classify Non-erosive Reflux Disease (NERD) Patients into Endoscopically Normal Groups and Minimal Change Groups by Subjective Symptoms and Responsiveness to Rabeprazole—A Report from a Study with Japanese Patients

The hypothesis that non-erosive reflux disease (NERD) patients comprise various subgroups is gaining popularity. This study was conducted to investigate the possibility of categorizing NERD patients according to symptom types and response to acid-suppressive drug rabeprazole (RPZ) 10 mg/day. NERD patients were classified as grade N (endoscopically normal), M (minimal change), or erosive GERD, and answered a 51-item, yes-or-no questionnaire pre and post-treatment. Compared to erosive GERD, clear differences existed in pretreatment prevalence of symptoms and responsiveness to RPZ in grades N and M; the results suggested stomachaches (especially at night) were significant symptoms in grade N and dysmotility-like symptoms like bloated stomach were significant in grade M while gastroesophageal reflux symptoms were significant in erosive GERD. Clinical significance of classifying NERD was indicated from different symptoms and responsiveness to PPI. The authors of The Acid-Related Symptom (ARS) Research Group are given in Appendix I. An erratum to this article can be found at     

Is There a Benefit to Patients Using Wearable Devices Such as Fitbit or Health Apps on Mobiles? A Systematic Review

Wearable devices have become a standard health care intervention with emerging health care technologies. These devices are designed to promote healthy behaviors and decrease risk for chronic disease like cardiovascular disease and diabetes. The purpose of this study was to provide evidence of the benefit of wearable devices in chronic disease outcomes among adults. Systematic search of PubMed, Web of Science, World Health Organization international clinical trials registry platform, BMC ISRCTN registry, and the Institute of Electrical and Electronics Engineers was performed based upon the PRISMA guideline. Included articles were randomized controlled trials or quasi-experimental studies with health outcomes published in English up to October 2018. Studies focusing on adults were selected. Three investigators reviewed the selected publications and made agreement on final selection. Of a total of 550 publications extracted, 6 studies met the final criteria. There was little indication that wearable devices provide a benefit for health outcomes. Of the 6 studies examined, only one study showed a significant reduction for weight loss among participants who used wearable devices. No significant reduction was discovered in cholesterol or blood pressure. Among the 6 studies, only one study examined hemoglobin A1c, and it showed a significant reduction in older patients with type 2 diabetes. The current literature evaluating wearable devices indicates little benefit of the devices on chronic disease health outcomes. Wearable devices play a role as a facilitator in motivating and accelerating physical activity, but current data do not suggest other consistent health benefits.     

Can Peer Education Make a Difference? Evaluation of a South African Adolescent Peer Education Program to Promote Sexual and Reproductive Health

Peer education is popular both with governments and with young people. The purpose of this quasi-experimental study was to evaluate the effectiveness of a government-led peer education program on the self-reported sexual health behavior and related psychosocial outcomes of adolescent students in public high schools in the Western Cape of South Africa. Grade 10 students (n = 3934), at 30 public high schools (15 intervention, 15 comparison) were recruited to the study. In the intervention schools, peer educators were recruited and trained to provide information and support to their fellow students. Sexual health behaviors and related psychosocial outcomes of students were measured at baseline and at follow up 18 months later. Comparisons were made between those in the intervention and comparison group schools. We were unable to detect a significant difference in the age of sexual debut, use of condoms at last sex, goal orientation, decision-making or future orientation for students in the intervention group as compared to students in the comparison group. The findings suggest that the peer education program was not effective in reducing the age of sexual debut or condom use. Issues around the implementation of the program suggested that this was sub-optimal. Governments who advocate widespread use of peer education as an approach need to recognise barriers to implementation and ensure ongoing monitoring and evaluation of effectiveness and cost effectiveness.     

A Systematic Review of Provider Knowledge of Hepatitis C: Is it Enough for a Complex Disease?

As studies indicate that patients with hepatitis C face poor provider knowledge and even stigmatization, we conducted a systematic review of provider knowledge about and attitudes toward hepatitis C. We searched Medline for original studies between 1990 and 2005. Articles were abstracted to define target population, recruitment strategies, study design, and key findings. Twenty-six publications performed in nine countries were identified. Whereas studies demonstrated an understanding of the nature of hepatitis C, significant knowledge deficits existed related to natural history, diagnostic approaches, and treatment. The relevance of simple measures, such as vaccinations against hepatitis A and B, was underappreciated. While providers were aware of risk factors for the disease, there were substantial misperceptions, with 5%–20% of providers considering casual contact as a risk for disease acquisition. We conclude that while healthcare providers understand the nature of hepatitis C, important knowledge gaps persist, which may constitute barriers to appropriate therapy.     

Shear Wave Elastography: Is It a Valuable Additive Method to Conventional Ultrasound for the Diagnosis of Small (≤2?cm) Breast Cancer?

The aim of this study is to evaluate the diagnostic value of shear wave elastography (SWE) added to conventional ultrasound (US) in the diagnosis of small (≤2 cm) breast cancer.Among 410 patients who underwent SWE before US-guided biopsy from June 2012 to June 2013, 171 patients (mean age: 45.17 ± 9.37 years) with 177 small (≤2 cm) breast lesions were enrolled in this study. Diagnostic performances of each quantitative SWE parameters were calculated by receiver operating characteristic (ROC) curves. Performances of conventional US and US combined to SWE was also compared. Histologic diagnosis was used as a reference standard.Of the 177 lesions, 22 lesions (12.4%) were malignant and 155 (87.6%) were benign. With respect to conventional US, when a cutoff point between category 3 and 4a was used, the A_z value was 0.915 (100% sensitivity, 36.8% specificity, 18.3% positive predictive value (PPV), and 100% negative predictive value (NPV)). All average quantitative elastography values were significantly higher in malignant lesions compared to benign lesions (P = 0.001).The E_max value with a cutoff of 87.5 kPa had the highest A_z value of 0.796 (68.2% sensitivity and 87.1% specificity, 42.9% PPV, and 95.1% NPV). A_z value of combined data (0.861, 95% CI: 0.801, 0.909) was significantly lower than that of conventional US alone (P = 0.02). By using an E_max value for downgrading Breast Imaging Reporting and Data System (BI-RADS) category 4a lesions to category 3, 76/94 category 4a lesions (80.9%) were downgraded. After downgrading, 5 cancers were missed and the malignancy rate of category 3 lesions increased from 0% (0/55) to 3.8% (5/133) (P = 0.01).In conclusion, combined use of SWE and conventional US increased the specificity by reducing the number of unnecessary biopsies in differential diagnosis of small breast lesions. However, we propose that the application of conservative strategy for downgrading of soft category 4a lesions would be appropriate to minimize false-negative cases.     

The Color of Meth: Is It Related to Adverse Health Outcomes? An Exploratory Study in Tijuana,Mexico

In a study of injection drug users (IDUs) in Tijuana, Mexico, logistic regression identified factors associated with injection of colored vs. clear methamphetamine in the prior six months (N = 613). Colors injected most often were clear (50%), white (47%), yellow (2%), and pink (1%). IDUs injecting colored meth were more likely to experience recent abscesses (34%) compared to those injecting clear meth (24%; p = 0.008), an association that persisted after adjusting for confounders. Market characteristics, possibly relating to purity or adulterants, may be associated with abscesses among methamphetamine injectors. Further study is needed to confirm and determine the mechanism of this association to better inform prevention messages.