Celiac Disease: Common Questions and Answers.

Celiac disease is an immune-mediated, multisystem disorder that affects genetically susceptible individuals who are exposed to gluten-containing grains such as wheat, barley, and rye. The condition can develop at any age. Celiac disease presents with a variety of manifestations such as diarrhea, weight loss, abdominal pain, bloating, malabsorption, and failure to thrive. Most adult patients will present with nonclassic symptoms, including less specific gastrointestinal symptoms or extraintestinal manifestations such as anemia, osteoporosis, transaminitis, and recurrent miscarriage. Immunoglobulin A tissue transglutaminase serologic testing is the recommended initial screening for all age groups. Esophagogastroduodenoscopy with small bowel biopsy is recommended to confirm the diagnosis in most patients, including those with a negative serologic test for whom clinical suspicion of celiac disease persists. Biopsies may be avoided in children with high immunoglobulin A tissue transglutaminase (i.e., 10 times the upper limit of normal or more) and a positive test for immunoglobulin A endomysial antibodies in a second serum sample. Genetic testing for human leukocyte antigen alleles DQ2 or DQ8 may be performed in select cases. A gluten-free diet for life is the primary treatment, and patients may benefit from support groups and education on common and hidden sources of gluten, gluten-free substitutes, food labeling, balanced meal planning, dining out, dining during travel, and avoiding cross-contamination. Patients with celiac disease who do not respond to a gluten-free diet should have the accuracy of the diagnosis confirmed, have their diet reassessed, and be evaluated for coexisting conditions. Patients with refractory celiac disease should be treated by a gastroenterologist.

Comparison of MRI and neurosonogram 1- and 2-dimensional morphological measurements of the newborn corpus callosum.

BACKGROUND: Developmental abnormalities of the corpus callosum (CC) are linked to multiple neuro-developmental disorders, for which neonatal neuroimaging may allow earlier diagnosis and intervention. MRI is often considered the most sensitive imaging modality to white matter changes, while neurosonogram (NS) remains the clinical staple. This study assesses the correlation between MRI and US measurements of the neonatal CC using a protocol derived from established methodologies. METHODS: MR and NS images from an existing cohort of term infants (≥37 weeks gestational age) were studied. Length and area measurements of the CC made with linear (LUS) and phased array US (PUS) data were compared to those from MRI. Intra-observer reliabilities were estimated. RESULTS: Moderate-to-strong correlation strengths were observed for length measurements and the total area of the CC. Sectional area measurements showed poorer correlations. Bland-Altman plots support improved correspondence of length and total area measurements. LUS data appeared to correspond closer to MRI. All three modalities showed comparable repeatability. CONCLUSION: NS correlates well with some MRI measurements of the CC and shows similar levels of repeatability, making them possibly interchangeable. Use of LUS, a technique rarely used for NS, may be preferable to the standard approach for morphological studies.

Prospective multicentre evaluation and refinement of an analysis tool for magnetic resonance spectroscopy of childhood cerebellar tumours.

BACKGROUND: A tool for diagnosing childhood cerebellar tumours using magnetic resonance (MR) spectroscopy peak height measurement has been developed based on retrospective analysis of single-centre data. OBJECTIVE: To determine the diagnostic accuracy of the peak height measurement tool in a multicentre prospective study, and optimise it by adding new prospective data to the original dataset. MATERIALS AND METHODS: Magnetic resonance imaging (MRI) and single-voxel MR spectroscopy were performed on children with cerebellar tumours at three centres. Spectra were processed using standard scanner software and peak heights for N-acetyl aspartate, creatine, total choline and myo-inositol were measured. The original diagnostic tool was used to classify 26 new tumours as pilocytic astrocytoma, medulloblastoma or ependymoma. These spectra were subsequently combined with the original dataset to develop an optimised scheme from 53 tumours in total. RESULTS: Of the pilocytic astrocytomas, medulloblastomas and ependymomas, 65.4% were correctly assigned using the original tool. An optimized scheme was produced from the combined dataset correctly assigning 90.6%. Rare tumour types showed distinctive MR spectroscopy features. CONCLUSION: The original diagnostic tool gave modest accuracy when tested prospectively on multicentre data. Increasing the dataset provided a diagnostic tool based on MR spectroscopy peak height measurement with high levels of accuracy for multicentre data.

The Reactivity of Germanium Phosphanides with Chalcogens.

The reactivity of germanium phosphanido complexes with elemental chalcogens is reported. Addition of sulfur to [(BDI)GePCy2] (BDI = CH{(CH3)CN-2,6-iPr2C6H3}2) results in oxidation at germanium to form germanium(IV) sulfide [(BDI)Ge(S)PCy2] and oxidation at both germanium and phosphorus to form germanium(IV) sulfide dicylohexylphosphinodithioate complex [(BDI)Ge(S)SP(S)Cy2], whereas addition of tellurium to [(BDI)GePCy2] only gives the chalcogen inserted product, [(BDI)GeTePCy2]. This reactivity is different from that observed between [(BDI)GePCy2] and selenium. Addition of selenium to the diphenylphosphanido germanium complex, [(BDI)GePPh2], results in insertion of selenium into the Ge-P bond to form [(BDI)GeSePCy2] as well as the oxidation at phosphorus to give [(BDI)GeSeP(Se)Ph2]. In contrast, addition of selenium to the bis(trimethylsilyl)phosphanido germanium complex, [(BDI)GeP(SiMe3)2], yields the germanium(IV) selenide [(BDI)Ge(Se)P(SiMe3)2].

Cross-Cultural Mentorship in Military Family Medicine: Defining the Problem.

BACKGROUND AND OBJECTIVES: Mentorship is critical to physician recruitment, career development, and retention. Many underrepresented in medicine (URiM) physicians experience minority taxes that can undermine their professional objectives. Use of cross-cultural mentoring skills to navigate differences between non-URiM and URiM physicians can make mentorship relationships with URiM physicians more effective. This survey examined military family physician demographics and mentorship practices. METHODS: Design and Setting: Cross-sectional study using voluntary, anonymous data from the 2021 Uniformed Services Academy of Family Physicians (USAFP) Annual Meeting Omnibus Survey. STUDY POPULATION: USAFP Members attending 2021 Virtual Annual Meeting. INTERVENTION: None. STATISTICAL ANALYSIS: Descriptive statistics and χ2 tests. RESULTS: The response rate to the omnibus survey was 52.9%, n=258. More than half of respondents did not have a URiM mentee and had not collaborated with a URiM colleague on a scholarly activity within the last 3 years. Only 54.7% of respondents could recognize and address minority taxes. URiM physicians were more likely to have a URiM mentee (65.4% vs 44.4%, P=.042) and to recognize and address minority taxes (84.6% vs 51.3%, P=.001). They also were more confident (84.6% vs 60.3%, P=.015) and more skilled in discussing racism (80.8% vs 58.2%, P=.026). CONCLUSIONS: Structured programs are needed to improve knowledge and skills to support cross-cultural mentorship. Additional studies are needed to further evaluate and identify implementation strategies.

Procedural Benzodiazepine and Post-Vasectomy Opioid and Nonopioid Prescribing Variation in a Large Health Care System.

INTRODUCTION: Our goal was to describe variation in procedural benzodiazepine and post-vasectomy nonopioid pain and opioid prescription dispense events, and multilevel factors associated with the probability of an opioid refill. METHODS: Patients (40,584) undergoing vasectomies in the U.S. Military Health System between January 2016-January 2020 were included in this observational retrospective study. The main outcome was the probability of being dispensed an opioid prescription refill within 30 days post-vasectomy. Bivariate analyses examined the relationships between patient- and care-level characteristics, prescription dispense and 30-day opioid prescription refill. A generalized additive mixed-effects model and sensitivity analyses examined factors associated with opioid refill. RESULTS: There was wide variation in procedural benzodiazepine (32%) and post-vasectomy nonopioid (71%) and opioid (73%) prescription dispense patterns across facilities. Only 5% of the patients dispensed opioids received a refill. Probability of an opioid refill was associated with race (White), younger age, opioid dispense history, documented mental health or pain condition, lack of post-vasectomy nonopioid pain medication dispense events and higher dispensed post-vasectomy opioid prescription dose; albeit the effect of dose did not replicate in sensitivity analyses. CONCLUSIONS: Despite the wide variation in vasectomy-related pharmacological pathways across a large health care system, most patients do not require an opioid refill. Significant variation in prescribing practices indicated racial inequities. Given the low rates of opioid prescription refill, combined with the wide variation in opioid prescription dispense events and American Urological Association recommendations for conservative opioid prescribing after vasectomy, intervention to address excessive opioid prescribing is warranted.

Short echo time single voxel 1H magnetic resonance spectroscopy in the diagnosis and characterisation of pineal tumours in children.

BACKGROUND: Magnetic resonance spectroscopy (MRS) has been successful in characterising a range of brain tumours and is a useful aid to non-invasive diagnosis. The pineal region poses considerable surgical challenges and a major surgical resection is not required in the management of all tumours. Improved non-invasive assessment of pineal region tumours would be of considerable benefit. METHODS: Single voxel MRS (TE 30 ms, TR 1500, 1.5 T) was performed on 15 pineal tumours: 5 germinomas, 1 non-germinomatous secreting germ cell tumour (GCT), 2 teratomas, 5 pineoblastomas, 1 pineal parenchymal tumour (PPT) of intermediate differentiation and 1 pineocytoma. Two germinomas outside the pineal gland were also studied. Metabolite, lipid and macromolecule concentrations were determined with LCModel™. RESULTS: Germ cell tumours had significantly higher lipid and macromolecule concentrations than other tumours (t-test; P < 0.05). The teratomas had significantly lower total choline and creatine levels than germinomas (z test; P < 0.05). Taurine was convincingly detected in germinomas as well as PPTs. CONCLUSIONS: Magnetic resonance spectroscopy is useful for characterising pineal region tumours, aiding the non-invasive diagnosis and giving additional biological insight.

Clinical Inquiries: Can mobile technology improve weight loss in overweight and obese patients?

Yes, this technology can help in the short term. Mobile technology compared with minimal or no intervention increases short-term (⟨6 months) weight loss (1.4 to 2.7 kg) in overweight and obese patients. Interventions that combine nonelectronic measures with mobile technology increase weight loss more effectively (3.7 kg) than no intervention.

Why compete when you can share? Competitive reactivity of germanium and phosphorus with selenium.

Addition of one equivalent of selenium to a germanium-phosphanide complex results in insertion of selenium into the Ge-P bond, not oxidation at germanium or phosphorus. Addition of excess selenium results in oxidation at phosphorus, although of germanium oxidation is still observed.

Monitoring long-term effects of mild traumatic brain injury with magnetic resonance spectroscopy: a pilot study.

This pilot study explores the metabolic changes associated with persistent postconcussion syndrome (PCS) after mild traumatic brain injury (mTBI; >12 months after injury) using magnetic resonance spectroscopy. We hypothesized that those mTBI participants with PCS will have larger metabolic differences than those without. Data were collected from mTBI participants with PCS, mTBI participants without PCS and non-head-injured participants (all groups: n=8). Magnetic resonance spectroscopy metabolite profiles within the dorsolateral prefrontal cortex showed a reduced creatine/choline ratio in mTBI patients compared with control participants. This data provides initial evidence for residual metabolic changes in chronic mTBI patients, but there was no conclusive relationship between these metabolic changes and PCS symptom report. Creatine is involved in maintaining energy levels in cells with high or fluctuating energy demand, suggesting that there may be some residual energy impairment in chronic mTBI.

Linked metabolites: a tool for the construction of directed metabolic graphs.

Metabolic pathway diagrams provide a wealth of information on how reactions combine to perform biological functions. While pathway diagrams are arranged in a way that allows a specific area of metabolism to be visualised, the inherent complexity of each pathway makes it difficult to identify the sets of reactions linking groups of compounds; a common task for researchers attempting to explain observed correlations or looking for further compounds of potential interest to use in validation work. Here we introduce Linked Metabolites, a tool that identifies sets of reactions linking groups of compounds in the context of the KEGG pathway diagrams.

Magnetic resonance spectroscopy in the assessment of pilocytic astrocytomas.

BACKGROUND: Pilocytic astrocytomas (PA) are common childhood brain tumours whose management and prognosis vary widely depending on location. (1)H magnetic resonance spectroscopy (MRS) measures biochemistry in vivo and shows promise for characterising brain tumours and aiding management. METHODS: Single voxel MRS (1.5 Tesla, TE 30 ms, TR 1500 ms) was performed on 27 children with PAs. Cases were designated 'progressors' if tumour progression led to their clinical management plan being altered. RESULTS: Prior to treatment, supratentorial tumours had significantly higher myo-inositol (p<0.01, t-test) and glutamate plus glutamine (p=0.02, t-test) than cerebellar tumours. Optic pathway or thalamic tumours that progressed had a significantly (p=0.04, t-test) lower myo-inositol at initial MRS than those with stable disease. Myo-inositol levels decreased significantly in progressors between the initial and subsequent MRS (p=0.03, paired t-test). Changes in myo-inositol occurred before clinical and radiological progression. CONCLUSIONS: MRS identifies differences with anatomical location in PAs and yields potential non-invasive biomarkers of prognosis.

The use of short-echo-time 1H MRS for childhood cerebellar tumours prior to histopathological diagnosis.

BACKGROUND: Proton magnetic resonance spectroscopy (MRS) measures concentrations of metabolites in vivo and provides a powerful method for identifying tumours. MRS has not entered routine clinical use partly due to the difficulty of analysing the spectra. OBJECTIVE: To create a straightforward method for interpreting short-echo-time MRS of childhood cerebellar tumours. MATERIALS AND METHODS: Single-voxel MRS (1.5-T Siemens Symphony NUM4, TR/TE 1,500/30 ms) was performed at presentation in 30 children with cerebellar tumours. The MRS results were analysed for comparison with histological diagnosis. Peak heights for N-acetyl aspartate (NAA), creatine (Cr), choline (Cho) and myo-inositol (mIns) were determined and receiver operator characteristic curves used to select ratios that best discriminated between the tumour types. The method was implemented by a group of clinicians and scientists, blinded to the results. RESULTS: A total of 27 MRS studies met the quality control criteria. NAA/Cr >4.0 distinguished all but one of the astrocytomas from the other tumours. A combination of Cr/Cho <0.75 and mIns/NAA <2.1 separated all the medulloblastomas from the ependymomas. CONCLUSION: Peak height ratios from short-echo-time MRS can accurately predict the histopathology of childhood cerebellar tumours.