BSACI guideline for the diagnosis and management of pollen food syndrome in the UK.

Pollen food syndrome (PFS) is a highly prevalent food allergy affecting pollen-sensitized children and adults. Sufferers experience allergic symptoms when consuming raw plant foods, due to the homology between the pollen allergens and unstable proteins in these foods. The triggers involved can vary depending on the pollen sensitization, which in turn is affected by geographical location. The British Society of Allergy and Clinical Immunology (BSACI) Standards of Care Committee (SOCC) identified a need to develop a guideline for the diagnosis and management of PFS in the United Kingdom (UK). Guidelines produced by the BSACI use either the GRADE or SIGN methodology; due to a lack of high-quality evidence these recommendations were formulated using the SIGN guidelines, which is acknowledged to be less robust than the GRADE approach. The correct diagnosis of PFS ensures the avoidance of a misdiagnosis of a primary peanut or tree nut allergy or confusion with another plant food allergy to non-specific lipid transfer proteins. The characteristic foods involved, and rapid-onset oropharyngeal symptoms, mean PFS can often be diagnosed from the clinical history alone. However, reactions involving tree nuts, peanuts and soya milk or severe/atypical reactions to fruits and vegetables may require additional diagnostic tests. Management is through the exclusion of known trigger foods, which may appear to be simple, but is highly problematic if coupled with a pre-existing food allergy or for individuals following a vegetarian/vegan diet. Immunotherapy to pollens is not an effective treatment for PFS, and although oral or sublingual immunotherapy to foods seems more promising, large, controlled studies are needed. The typically mild symptoms of PFS can lead to an erroneous perception that this condition is always easily managed, but severe reactions can occur, and anxiety about the onset of symptoms to new foods can have a profound effect on quality of life.

Context and the evidence-based paradigm: The potential for participatory research and systems thinking in oral health.

The implementation of research evidence to promote oral health is critical, given the intransigent and emerging challenges for policymakers at a population level. Despite this, little attention has been paid to implementation research within the evidence-based paradigm. This is important as getting research evidence into clinical practice is not a linear path that consists of simple sequential steps. In this article, we argue that we need to consider a broader range of conceptual and methodological approaches to increase the value of information generated. This should be undertaken either in parallel with empirical and experimental designs, or in some cases, instead of. This is important if we are going to understand the complexity and contextual knowledge of the 'system', within which interventions are implemented. Involving key stakeholders alongside empirical and experimental designs is one helpful approach. Examples of these approaches include Patient and Public Involvement and the development of Core Outcome Sets, where the views of those that will be potentially affected by the research, are included. The use of theoretical frameworks and process evaluations alongside trials are also important, if they are fully integrated into the approach taken to address the research question. A more radical approach is using participatory designs and 'systems thinking'. Participatory approaches include subject matter 'experts by experience'. These include patients, their families, carers, healthcare professionals, services managers, policymakers, commissioners and researchers. Participatory approaches raise important questions about who facilitates the process, when it should happen and how the diverse actors become meaningfully engaged so that their involvement is active, democratic and ongoing. We argue that the issues of control, power and language are central to this and represent a paradigmatic shift to conventional approaches. Systems thinking captures the idea that public health problems commonly involve multiple interdependent and interconnected factors, which interact with each other dynamically. This approach challenges the simplicity of the hierarchy of evidence and linear sequential logic, when it does not account for context. In contrast, systems thinking accepts complexity de novo and emphasizes the need to understand the whole system rather than its individual component parts. We conclude with the idea that participatory and systems thinking help to unpack the diverse agents that are often involved in the generation and translation of evidence into clinical dental practice. It moves our conception of research away from a simple exchange between 'knowledge producers' and 'knowledge users' and raises both methodological and epistemological challenges.

Ergogenic Effect of Nitrate Supplementation: A Systematic Review and Meta-analysis.

Although over 100 studies and reviews have examined the ergogenic effects of dietary nitrate (NO3) supplementation in young, healthy men and women, it is unclear if participant and environmental factors modulate the well-described ergogenic effects-particularly relevant factors include biological sex, aerobic fitness, and fraction of inspired oxygen (FiO2) during exercise. To address this limitation, the literature was systematically reviewed for randomized, crossover, placebo-controlled studies reporting exercise performance outcome metrics with NO3 supplementation in young, healthy adults. Of the 2033 articles identified, 80 were eligible for inclusion in the meta-analysis. Random-effects meta-analysis demonstrated that exercise performance improved with NO3 supplementation compared with placebo (d = 0.174; 95% confidence interval (CI), 0.120-0.229; P < 0.001). Subgroup analyses conducted on biological sex, aerobic fitness, and FiO2 demonstrated that the ergogenic effect of NO3 supplementation was as follows: 1) not observed in studies with only women (n = 6; d = 0.116; 95% CI, -0.126 to 0.358; P = 0.347), 2) not observed in well-trained endurance athletes (≥65 mL·kg·min; n = 26; d = 0.021; 95% CI, -0.103 to 0.144; P = 0.745), and 3) not modulated by FiO2 (hypoxia vs normoxia). Together, the meta-analyses demonstrated a clear ergogenic effect of NO3 supplementation in recreationally active, young, healthy men across different exercise paradigms and NO3 supplementation parameters; however, the effect size of NO3 supplementation was objectively small (d = 0.174). NO3 supplementation has more limited utility as an ergogenic aid in participants with excellent aerobic fitness that have optimized other training parameters. Mechanistic research and studies incorporating a wide variety of subjects (e.g., women) are needed to advance the study of NO3 supplementation; however, additional descriptive studies of young, healthy men may have limited utility.

Cancer and changes in facial appearance: A meta-ethnography of qualitative studies.

INTRODUCTION: Living with an altered facial appearance as a result of treatment for cancer requires considerable psychological adjustment. As such it is essential that health care professionals understand the lived experience of people affected. This systematic review provides a meta-ethnography of studies that have explored the experience of changed facial appearance as a result of cancer. METHODS: A search of four databases (Web of Science, CINAHL, PsycInfo, and Scopus) took place using terms relating to qualitative research, cancer, and changed facial appearance. Thirteen studies were identified, appraised, and included in the synthesis. The findings and interpretations within the studies were subject to meta-ethnography procedures so as to elicit novel cross-cutting themes. FINDINGS: The experience of changed facial appearance after cancer was clustered into three contexts. In the context of the disease, subthemes were the primacy of survival, the changing relationship with the disease, and the impact of the care team on the experience of changed appearance. In the context of the social world, subthemes were positive reactions, negative reactions, and coping strategies. In the context of the self, subthemes were the self under attack, self-to-self relating, the self in the world, and rebuilding the self. CONCLUSIONS: The findings indicate that health care professionals must conduct holistic assessments, so as to fully recognize and where necessary address the impact upon self. The meta-ethnography shows that the experience of facial appearance change following cancer is complex and requires awareness of a number of theoretical areas including identity construction, social support, stigmatization, and the specific literature on visible difference. Statement of contribution What is already known on this subject? Changed facial appearance after cancer can cause significant social difficulties and impact on the sense of self. The experience of managing the specific dual challenges of cancer and altered facial appearance is not clearly understood. Recent studies that have focused specifically on the experience of changes in appearance after cancer have been limited in scope and transferability. What does this study add? To our knowledge, this is the first meta-ethnography to bring together the literature on the impact of altered facial appearance following cancer. Patients may feel unable to talk about appearance with health care professionals because it is seen as a frivolous issue. Clinicians should facilitate open, person-centred opportunities for patients to discuss the impact of changed appearance and where necessary facilitate access to support.

Promoting co-production in the generation and use of research evidence to improve service provision in special care dentistry.

Special care dentistry (SCD) provides holistic oral service provision for people with complex health and care needs. These can include physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of these factors. The level of disability within these population groups can vary, and a proportion of people will have multiple and overlapping impairments and/or medical conditions. This paper explores a number of possible research methods that may better reflect the diversity and challenges of this population group, where the emphasis is placed on co-production and co-design.

Effects of exercise intensity compared to albuterol in individuals with cystic fibrosis.

BACKGROUND: Although exercise is a vital component of the therapy prescribed to individuals with cystic fibrosis (CF), it is not a priority due to a finite amount of treatment time and the view that exercise is not as beneficial as pharmacological treatments by many individuals with CF. We sought to compare the therapeutic benefits of exercise and their prescribed bronchodilator albuterol. METHODS: CF (n = 14) and healthy (n = 16) subjects completed three visits, a baseline screening with VO2 max test and two treatment visits. On the two treatment visits, subjects completed spirometry and diffusing capacity of the lungs for nitric oxide (DLNO) maneuvers either at baseline, 60, and 110 min post-albuterol administration, or at baseline and the midway point of three separate 15 min exercise bouts at low, moderate and vigorous intensity (25, 50 and 65% of the maximum workload, respectively). RESULTS: With moderate exercise the increase in DLNO was double (39 ± 8 vs 15  ± 6% change) and the level of bronchodilation similar (23% change) when compared to 110 min post-albuterol in individuals with CF. During exercise FVC became reduced (-309 ± 66 mL with moderate exercise) and the increase in FEV1 was attenuated (103 ± 39 vs 236 ± 58 mL, exercise vs. albuterol) when compared with the response to albuterol in individuals with CF. Epinephrine (EPI) release increased 39, 72 and 144% change with low, moderate and vigorous intensity exercise respectively for individuals with CF, but this increase was blunted when compared to healthy subjects. CONCLUSION: Our results suggest that moderate intensity exercise is the optimal intensity for individuals with CF, as low intensity exercise increases EPI less than 50% and vigorous intensity exercise is over taxing, such that airflow can be restricted. Although the duration of the beneficial effect is uncertain, exercise can promote greater improvements in gas diffusion and comparable bronchodilation when compared to albuterol.

Relaxation breathing improves human glycemic response.

OBJECTIVES: This study evaluated a simple relaxation breathing exercise for acute improvement of postprandial glycemic and insulinemic status. DESIGN: Healthy human subjects were randomized to control breathing (CB; n=13) or a relaxation breathing exercise (RB; n=13) that was repeated every 10 minutes for the 30 minutes before and 90 minutes after consuming a glucose challenge (oral glucose tolerance test; OGTT; 75 g/240 mL). Blood samples were collected before, and 30, 60, and 90 minutes post OGTT for glucose and insulin analysis. RESULTS: Blood glucose at 0 minutes (pre-OGTT), and 30, 60, and 90 minutes post-OGTT with continued RB was 93.7±1.9, 136.5±8.1, 165.7±8.1, and 130.2±6.9 mg/dL, and 97.1±2.4, 173.1±8.4, 158.7±11.1, and 137.1±10.1 with CB, respectively. RB blood glucose was significantly lower at 30 minutes than CB. Glucose area under the curve (AUC) for CB and RB were not significantly different. Plasma insulin for both CB and RB was significantly increased relative to baseline at 30, 60, and 90 minutes. Insulin values for RB tended to be higher than CB at 30 and 60 minutes, although the difference was not statistically significant. Insulin AUC for CB and RB was not significantly different. CONCLUSIONS: Relaxation breathing acutely improves the glycemic response of healthy subjects, and breathing pattern could be important for interpretation of glycemic index measurements.

Self-reported and actual physiological responses in social phobia.

OBJECTIVES: The aim of the current study was to compare physiological reactions and self-reports of bodily sensations for social phobics, clinically anxious and non-anxious controls across four tasks. DESIGN: A within-group design was used in which each participant took part in four tasks. Two were designed to be demanding, either physically (riding an exercise bicycle) or mentally (mental arithmetic task), while two, a mental imagery task (personally relevant situation) and a social conversation, were designed specifically to be anxiety provoking. METHODS: Of the 54 participants, 18 were generalized social phobics, 18 were clinically anxious but not socially phobic (8 with panic disorder, 6 with generalized anxiety disorder and 4 simple phobics), and 18 were non-anxious. Heart rate, skin conductance, and facial and neck temperatures were recorded continuously during four different tasks and rest periods with corresponding self-report ratings of bodily sensations taken to reflect 13 sampling points. RESULTS: There were no group differences on any of the physiological measures during any of the four tasks. However, there were a number of between-group differences with regard to ratings of bodily sensations. Both clinical groups had higher ratings of racing heart than the non-anxious control group during the imagery task. In addition, social phobics had significantly higher ratings of racing heart during the social conversation in relation to both comparison groups. With regard to ratings of body heat, the anxious group had greater ratings than the non-anxious controls during the imagery task. Finally with regard to ratings of sweaty hands, both clinical groups had higher ratings than the non-anxious controls during the social conversation. All three groups were generally inaccurate in their ratings of bodily sensations.