The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: a systematic review of the qualitative literature

Objectives: The objective of this systematic review was to synthesize the available qualitative evidence on the knowledge, attitudes and beliefs of adult patients, healthcare professionals and carers about oral dosage form modification. Design: A systematic review and synthesis of qualitative studies was undertaken, utilising the thematic synthesis approach. Data sources: The following databases were searched from inception to September 2015: PubMed, Medline (EBSCO), EMBASE, CINAHL, PsycINFO, Web of Science, ProQuest Databases, Scopus, Turning Research Into Practice (TRIP), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Citation tracking and searching the references lists of included studies was also undertaken. Grey literature was searched using the OpenGrey database, internet searching and personal knowledge. An updated search was undertaken in June 2016. Review methods: Studies meeting the following criteria were eligible for inclusion; (i) used qualitative data collection and analysis methods; (ii) full-text was available in English; (iii) included adult patients who require oral dosage forms to be modified to meet their needs or; (iv) carers or healthcare professionals of patients who require oral dosage forms to be modified. Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme Checklist. A thematic synthesis was conducted and analytical themes were generated. Results: Of 5455 records screened, seven studies were eligible for inclusion; three involved healthcare professionals and the remaining four studies involved patients. Four analytical themes emerged from the thematic synthesis: (i) patient-centred individuality and variability; (ii) communication; (iii) knowledge and uncertainty and; (iv) complexity. The variability of individual patient’s requirements, poor communication practices and lack of knowledge about oral dosage form modification, when combined with the complex and multi-faceted healthcare environment complicate decision making regarding oral dosage form modification and administration. Conclusions: This systematic review has highlighted the key factors influencing the knowledge, attitudes and beliefs of patients and healthcare professionals about oral dosage form modifications. The findings suggest that in order to optimise oral medicine modification practices the needs of individual patients should be routinely and systematically assessed and decision-making should be supported by evidence based recommendations with multidisciplinary input. Further research is needed to optimise oral dosage form modification practices and the factors identified in this review should be considered in the development of future interventions.

Development of a toolbox for the reduction of hordeins in barley malt beers

Gluten sensitive consumers and people suffering from coeliac disease account for up to 6% of the general population (Catassi et al., 2013). These consumers must avoid foods which contain gluten and related proteins found in wheat, rye or barley. Beer is produced from barley malt and therefore contains hordeins, (gluten like proteins). Beers labelled as gluten-free must contain below 10 mg/kg hordeins (10 mg/kg hordeins = 20 mg/kg gluten under current regulations) to be considered safe for gluten sensitive consumers. Currently there are a limited number of methods available for reducing beer hordeins, the studies outlined in this thesis provide a range of tools for the beverage industry to reduce the hordein content of beer It is well known, that during malting and brewing hordeins are reduced, but they still remain in beer at levels above 10 mg/kg. During malting, hordeins are broken down to form new proteins in the growing plant. Model malting and brewing systems were developed and used to test, how the modification of the malting process could be used to reduce beer hordeins. It was shown, that by using a controlled malting and brewing regime, a range of barley cultivars produced beer with significant differences in levels of hordeins. Beer hordeins ranged from 10 mg/kg to 60 mg/kg. Another study revealed that when malting was prolonged, to maximise breakdown of proteins, beer hordeins can be reduced by up to 44%. The natural breakdown of hordein during malting enhanced in a further study, when a protease was added to support the hordein degradation during steeping and germination. The enzyme addition resulted in a 46% reduction in beer hordeins 2 when compared to the control. All of the malt treatments had little or no impact on malt quality. The hordein levels can also be reduced during the beer stabilisation process. Levels of beer hordein were tested after stabilisation using two different concentrations of silica gel and tannic acid. Silica gel was very effective in reducing beer hordeins, 90% of beer hordeins were removed compared to the control beer. Beer hordeins could be reduced to below 10 mg/kg and the beer qualities such as foam, colour and flavour were not affected. Tannic acid also reduced beer hordein by up to 90%, but it reduced foam stability and affected beer flavours. A further study described treatment of beer with microbial transglutaminase (mTG), to create bonds between hordein proteins, which increased particle size and allowed removal during filtration. The addition of the mTG led to a reduction of the beer hordein by up to 96% in beer, and the impact on the resulting beer quality was minimal. These studies provide the industry with a toolbox of methods leading to the reduction of hordein in the final beer without negatively affecting beer quality.