Celiac Disease: An Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guideline.

Celiac disease is an autoimmune disorder in which the immune system of genetically susceptible individuals elicits a reaction to gluten causing small intestine damage. If left undiagnosed and untreated, the resulting nutrition malabsorption can lead to anemia, bone disease, growth faltering, or other consequences. The condition is lifelong and lacks a cure; the only treatment is lifelong adherence to a gluten-free diet (GFD). This diet is challenging to follow and adversely influences quality of life; however, it is essential to ensure intestinal recovery and prevent future negative health consequences. The Academy of Nutrition and Dietetics convened an expert panel complemented by a celiac disease patient advocate to evaluate evidence for six topics, including medical nutrition therapy; the GFD; oat consumption; micronutrients; pro-/prebiotics; and the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. This publication outlines the Academy of Nutrition and Dietetics Evidence Analysis Library methods used to complete the systematic review and guideline development, and summarizes the recommendations and supporting evidence. The guidelines affirm that all individuals with celiac disease should follow a GFD (1C, Imperative) that may include gluten-free oats in adults (2D, Conditional). Children should follow a nutritionally adequate GFD that supports healthy growth and development (Consensus, Imperative) and does not unnecessarily restrict gluten-free oats (Consensus, Conditional). The guidelines indicate nutritional care should include routine nutritional assessment (Consensus, Imperative) and medical nutrition therapy (Consensus, Imperative). At this time, the guidelines do not support a recommendation for the addition of the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (2C, Conditional); prebiotic or probiotic supplementation (2D, Conditional); or micronutrient supplementation (in the absence of nutritional deficiency) (Consensus, Conditional). The 2021 Celiac Disease Evidence-Based Nutrition Guideline will assist registered dietitian nutritionists in providing appropriate evidence-based medical nutrition therapy to support people with celiac disease in achieving and maintaining nutritional health and avoiding adverse celiac disease consequences throughout their lives.

Trans-Atlantic aeromedical repatriation of multiple COVID-19 patients: a hybrid military-civilian model.

Here, we report the first known transcontinental aeromedical evacuation of a large number (55) of patients with known and suspected positive COVID-19. These patients were evacuated from Havana, Cuba, to the UK through MOD Boscombe Down as part of Operation BROADSHARE, the British military's overseas response to COVID-19. We describe the safe transfer of patients with COVID-19 using a combined military-civilian model. In our view, we have demonstrated that patients with COVID-19 can be aeromedically transferred while ensuring the safety of patients and crew using a hybrid military-civilian model; this report contains lessons for future aeromedical evacuation of patients with COVID-19.

Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort.

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

Prognostic implications of histological organ involvement in retroperitoneal sarcoma.

BACKGROUND: The prognostic significance of histological organ involvement by retroperitoneal sarcoma subtype is unknown. The present study aimed to describe organ involvement across the subtypes, and the implications for survival. METHODS: Patients undergoing surgery for primary retroperitoneal sarcoma at the Queen Elizabeth Hospital, Birmingham from April 2005 to September 2018 were identified retrospectively. Histological organ involvement was classed as pushing, infiltrative or neither. Univariable and multivariable Cox regression models were produced to analyse the association between histological organ involvement and both overall (OS) and recurrence-free (RFS) survival for the cohort as a whole, and by histological subtype. RESULTS: Data were available for a total of 197 patients, of whom 171 (86.8 per cent) had at least one organ resected. Infiltrative organ behaviour was seen in 37 patients (18.8 per cent), and pushing behaviour in 67 (34.0 per cent). For the cohort as a whole, infiltration (hazard ratio (HR) 4.32, 95 per cent c.i. 2.35 to 7.93; P < 0.001), but not pushing (HR 1.62, 0.90 to 2.92; P = 0.106), was associated with significantly shorter OS, in comparisons with a group with neither of these behaviours. However, this effect was found to differ significantly by histological subtype (P = 0.009). For patients with dedifferentiated liposarcoma, there was no significant association between tumour behaviour and either OS (P = 0.508) or RFS (P = 0.313). However, in leiomyosarcoma, infiltrative behaviour was associated with shorter OS (P = 0.002), and both infiltrative (P < 0.001) and pushing (P = 0.010) behaviours were associated with shorter RFS, compared with tumours with neither behaviour. Multivariable analyses of both OS and RFS returned similar results. CONCLUSION: The prognostic implications of organ involvement in retroperitoneal sarcoma vary by histological subtype.

Aeromedical evacuation: experiences from the UK military level 2 hospital in Bentiu, South Sudan, during Op TRENTON.

INTRODUCTION: Aeromedical Evacuation (AE) is a vital role of the Defence Medical Services (DMS). With a far-reaching defence global footprint, an AE capability is crucial to enable movement of patients in the fastest, safest and least stressful way that meets or exceeds the level of care an injured or ill person may expect to receive in the UK. Operation (Op) TRENTON is a UK military humanitarian operation in support of the United Nations (UN) Mission in South Sudan. METHODS: A retrospective analysis was carried out of all patients who underwent AE from the UK level 2 hospital at Bentiu during Op TRENTON over a 17-month period from June 2017 to October 2018. RESULTS: 14 patients underwent AE. The median age was 36 (22-64) years and all patients were male. 21% of AEs were for UK personnel and 79% were for UN personnel. 29% of AEs were due to non-battle injury with the remainder due to disease. Musculoskeletal was the largest diagnostic group (n=4) followed by respiratory (n=3), cardiovascular (n=2), undifferentiated febrile illness (n=2), neurology (n=1), renal medicine (n=1) and psychiatry (n=1). CONCLUSIONS: Patients requiring AE from the level 2 hospital at Bentiu mostly had musculoskeletal and medical pathology, a stark contrast to the trauma patient cohort from operations in the past. The majority of patients had definitive care under the medical team highlighting the requirement for DMS physicians and the AE team, to be trained in acute, general and aviation medicine. The majority of AE moves were for UN personnel and on UN airframes, highlighting the importance of a sound understanding of the nations we are working with.

Practice Pattern Variation in Pediatric Eosinophilic Esophagitis in the Carolinas EoE Collaborative: A Research Model in Community and Academic Practices.

OBJECTIVES: Differences in the initial management of pediatric eosinophilic esophagitis (EoE) by practice setting have not been well characterized. We aimed to characterize these differences for sites in the Carolinas EoE Collaborative (CEoEC), a multicenter network of academic and community practices. METHODS: We performed a retrospective cohort study of pediatric EoE patients at five CEoEC sites: University of North Carolina (UNC) Hospital, Charlotte Asthma and Allergy Specialists, Greenville Health Systems, Wake Forest Baptist Medical Center, and the Medical University of South Carolina Hospital. Cases of EoE were defined by consensus guidelines. Data were extracted from electronic medical records. We tested for differences among sites and used a multinomial model (polytomous regression) to assess associations between treatment and site, adjusting on patient factors. RESULTS: We identified 464 children with EoE across the CEoEC sites. The median age was highest at Wake Forest (11.4 years), the median eosinophil count was highest at UNC (69 eos/hpf), and UNC had the most male patients (82%). UNC used topical steroids for initial treatment in 86% of cases, compared with <1% in Greenville (P < 0.01). Greenville used dietary elimination more frequently than UNC (81% vs 2%, P < 0.01). Differences in treatment approach held after adjusting for potential baseline confounders. There was no significant association between patient factors and initial treatment approach. CONCLUSIONS: Significant differences in EoE patient factors and treatment approaches were identified across CEoEC sites and were not explained by patient or practice factors. This suggests that institutional or provider preferences drive initial treatment approaches, and that more data are needed to drive best practice decisions.

Combined and Alternating Topical Steroids and Food Elimination Diet for the Treatment of Eosinophilic Esophagitis.

BACKGROUND: Few studies have examined combined or alternating treatment algorithms in eosinophilic esophagitis. AIMS: We conducted a retrospective cohort study to ascertain the efficacy and adherence to a combined and alternating treatment approach with topical corticosteroids and 2-food elimination diet for pediatric EoE. METHODS: Patients were prescribed a 2-food elimination diet (milk and soy) and topical corticosteroid (fluticasone or oral viscous budesonide) for 3 months, after which the steroid was discontinued and 2-food elimination diet continued for 3 months. An EGD was performed at baseline, 3 and 6 months. Clinical, endoscopic, and histologic data were extracted from electronic medical records. Nonparametric tests assessed adherence and outcomes. RESULTS: Twenty-nine eosinophilic esophagitis cases were included (mean age 11.5 years, 61% male). Complete adherence to combined therapy and 2-food elimination diet alone was 75 and 79%, respectively. Median eosinophil counts decreased from 51 to 2 eosinophils/hpf (p < 0.001) after combined treatment and rebounded to 31 (p = 0.07) after 2FED alone. Dysphagia improved after both the combined and 2-food elimination diet alone treatment approaches (52 vs. 11% and 10%; p = 0.001, 0.005). Nonsignificant improvements in endoscopic findings were documented across the length of follow-up. CONCLUSIONS: An initial combined treatment approach resulted in significant improvements in symptoms and histologic findings. While symptomatic improvements continued with 2-food elimination diet alone, the histologic improvement was not maintained. While loss to follow-up may obscure the efficacy of 2-food elimination diet alone, a combined/alternating treatment approach merits assessment in a larger prospective study.

Factors affecting school physical education provision in England: a cross-sectional analysis.

BACKGROUND: Attitudes towards physical activity are largely developed during childhood meaning that school physical education classes can have a strong influence. METHODS: National level data of school pupils (n = 21 515) in England were analysed to examine the association between school provision of physical education with sex, age, geographic and socioeconomic factors. RESULTS: Children attending independent schools had more scheduled physical education time (P < 0.001; 95% confidence interval (CI) 18 to 30 extra min per week). This association was true for males (P = 0.024); schools located in the South (P < 0.001; 95% CI 2 to 3) and rural areas (P < 0.001; 95% CI 3 to 5); or with a higher percentage of pupils eligible for free school meals (P < 0.001; 95% CI 3 to 4). Schools in more affluent areas (P < 0.001; 95% CI -1 to -2) and those with lower percentages of pupils from ethnic minorities (P < 0.001; 95% CI -1 to -2) also had higher minutes of physical education provision per week. Regarding age, 93% of schools met the guidelines in Years 1-9; only 45% did in Years 10-13. CONCLUSION: Differences in physical education were found in relation to school type, socioeconomic status and geographical factors. Age-related differences in compliance with guidelines are of concern; ways to increase provision for older children should be investigated.

Renal replacement in the deployed setting.

We present a case of a UK soldier suffering multiple injuries in Afghanistan including a lacerated liver, complicated by acute anuric renal failure. His condition was stabilised prior to transfer to the UK using continuous venovenous haemofiltration. This is the first deployed use of renal replacement therapy by UK forces for several decades, and raises questions regarding the provision of this high level capability in the deployed setting.

Pigment dispersion and chronic intraocular pressure elevation after sulcus placement of 3-piece acrylic intraocular lens.

A 55-year-old man had phacoemulsification and implantation of a 3-piece acrylic intraocular lens (IOL) (AcrySof MA60AC) in the right eye. One month postoperatively, the intraocular pressure (IOP) was 48 mm Hg and peripheral transillumination defects were noted in the iris circumferentially, with the IOL optic edge visible as a silhouette. Gonioscopy showed dense pigmentation of the trabecular meshwork in the right eye, but in the left eye, only mild trabecular meshwork pigment was seen, along with a concave peripheral iris insertion. At 21 months, the right eye required 3 medications for IOP control. While pigment dispersion has been widely reported after placement of 1-piece acrylic IOLs in the ciliary sulcus, we conclude that in susceptible individuals with a concave peripheral iris insertion, pigment dispersion can occur with sulcus placement of a 3-piece acrylic model despite its thinner optic and angulated haptics.

Decompression of the orbital apex: an alternate approach to surgical excision for radiographically benign orbital apex tumors.

OBJECTIVE: To study the outcome of patients with orbital apex lesions treated with endoscopic decompression alone. DESIGN: Retrospective medical chart review with a mean follow-up of 25.6 months. SETTING: Departments of Ophthalmology and Otolaryngology, University of Washington, Seattle. PATIENTS: Five individuals seen at the University of Washington Medical Center from November 2003 through December 2005 with visual disturbance caused by orbital apex lesions as documented by preoperative magnetic resonance imaging or computed tomographic scan. INTERVENTION: All patients underwent endoscopic decompression of the medial wall of the orbital apex with incision of the periorbita. MAIN OUTCOME MEASURES: Postoperative visual acuity, presence or absence of a relative afferent pupillary defect, color vision, and visual field were recorded. RESULTS: All 5 patients presented with visual field deficits, 4 of whom improved postoperatively. Three patients had dyschromatopsia preoperatively, 2 of whom improved postoperatively. Visual acuity improved or stabilized in 4 of 5 patients postoperatively. One patient had progressive visual loss during the course of her follow-up, which, after obtaining postoperative imaging, was attributed to inadequate decompression of the apex at its most posterior aspect. This same patient also developed postoperative sinusitis that resolved with antibiotic treatment. Two patients developed diplopia, 1 in primary gaze requiring treatment with prismatic lenses. All patients presented with and maintained normal intraocular pressures. CONCLUSION: Orbital apex lesions can often be effectively and relatively safely treated by endoscopic decompression alone.

Reduced hypothalamic neuropeptide Y expression in growth hormone- and prolactin-deficient Ames and Snell dwarf mice.

Neuropeptide Y (NPY)-producing neurons in the hypothalamic arcuate nucleus (ARC) have been implicated in GH feedback in several studies in rats. Ames (df/df) and Snell (dw/dw) dwarf mice carry mutations in transcription factors Prop-1 and Pit-1, respectively, that abrogate detectable expression of GH, prolactin, and TSH. The present study was undertaken to determine whether and to what extent hypothalamic NPY neurons are affected by the lifelong absence of pituitary hormone feedback in hypopituitary Ames and Snell dwarf mice. Total ARC NPY mRNA levels were quantified using in situ hybridization, and numbers of ARC NPY-producing cells were quantified using immunocytochemistry. For in situ hybridization, dwarf and normal coronal brain sections were hybridized with 35S-labeled riboprobe complementary to rat NPY cDNA, and then analyzed for total signal intensity from the entire ARC for each animal as well as for mRNA per neuron. NPY-containing perikarya in ARC were counted in sections of colchicine-treated (intracerebroventricular) dwarf and normal mice. Total ARC NPY mRNA was reduced in df/df mice to 33.6% (P < 0.01) of that in normal littermates, and reduced in dw/dw mice to 46.3% (P < 0.05) of normals, but there was no difference in expression per neuron as determined by reduced silver-grain counting. The decrement in dwarf mice of total ARC NPY mRNA without reduction in mRNA per cell suggested a reduction in NPY-containing neuron number, which was the case as shown by immunocytochemistry. NPY neuronal number in adult Ames dwarf mice (1048 +/- 104) was significantly (P < 0.01) reduced to 68% of that in DF/df littermates (1536 +/- 73), and significantly (P < 0.05) reduced in Snell dwarf mice to 63% of normals (1138 +/- 137 vs. 1726 +/- 205). This study represents the first enumeration of NPY-producing neurons in mouse hypothalamus and the first demonstration of lower NPY neuron number in a hypopituitary model. The reduction in total NPY mRNA was greater than that reported in studies of GH-deficient rats, suggesting that NPY expression may be affected by the lifelong absence of prolactin or TSH or both, as well as GH.

Azithromycin: an assessment of its pharmacokinetics and therapeutic potential in CAPD.

BACKGROUND: Azithromycin is an azalide antibiotic with a similar antibacterial spectrum to erythromycin but with greater gram-negative activity. Azithromycin displays a favorable pharmacokinetic profile, with improved absorption and higher sustained tissue concentrations compared with erythromycin. This results in a prolonged elimination half-life, suggesting a potential for treating continuous ambulatory peritoneal dialysis (CAPD) peritonitis. OBJECTIVE: This study aimed to define the potential role of azithromycin in treating CAPD peritonitis. DESIGN: The pharmacokinetics and peritoneal dialysis (PD) clearance of azithromycin were studied following a single 500-mg oral dose of azithromycin. Blood and dialysate samples were taken over a 10-day period and assayed using high-pressure liquid chromatography. SETTING: The study took place within the Renal Unit at Southend Hospital NHS Trust, a district general hospital in the United Kingdom. PATIENTS: Eight patients with oliguric end-stage renal failure without peritonitis maintained on CAPD (3 x 2 L/day). RESULTS: Peak plasma concentrations occurred at 2-3 hours with 0.35-1.35 microg/mL (mean 0.75). The mean elimination half-life was 84.55 hrs, and plasma clearance was 21.93 L/hour. This compares with values of greater than 40 hours and 40.8 L/hour reported in healthy volunteers. After 8 hours, the mean dialysate concentration was 0.07 microg/mL; PD clearance was 0.06 L/hr. CONCLUSION: Azithromycin is not substantially removed by CAPD in the absence of peritonitis and cannot be recommended for widespread use in this setting at present. However, the successful use of azithromycin in CAPD peritonitis, due possibly to an intracellular drug transport mechanism, has been reported. Future research should address this possibility.

Reactions of hydroxyl radicals with alkenes in low-temperature matrices.

The reactions of hydroxyl radicals with a number of stable alkenes have been studied in low-temperature matrices. The reactions were initiated by broad band UV-visible irradiation of matrices containing H2O2, and the alkene under investigation. The hydroxyalkyl radical products were identified principally by comparison of their spectra with the spectra of corresponding stable alcohols. Accordingly, IR spectra were recorded for the following series of alcohols isolated in argon matrices--methanol, ethanol, ethanol-d6, propan-1-ol, propan-2-ol, butan-2-ol, 2-methylpropan-1-ol (iso-butyl alcohol), 2-methylpropan-2-ol (tert-butyl alcohol), 2-methylbutan-2-ol (tert-amyl alcohol), 3-methylbutan-2-ol and 2,3-dimethylbutan-2-ol. The hydroxyalkyl radicals, which appear to be formed from the alkenes studied were as follows--from ethene, 2-hydroxyethyl radical: from cis- or trans-but-2-ene. 1-methyl-2-hydroxypropyl radical; from propene, 1-methyl-2-hydroxyethyl and 2-hydroxypropyl radicals; from but-1-ene. 1-hydroxymethylpropyl and 2-hydroxybutyl radicals; from 2-methylpropene (iso-butene), 1,1-dimethyl-2-hydroxyethyl and 2-methyl-2-hydroxypropyl radicals; the radical products from buta-1,3-diene and isoprene could not be identified. In the cases, where two radical products were possible, i.e. when propene, but-1-ene or 2-methylpropene were the substrates, it was found that the concentration of the secondary or tertiary radical always exceeded that of the primary radical. However, the relative concentration of these radicals appears to be determined by subsequent photolysis to give carbonyl compounds. There seems, therefore, to be little preference for the secondary and tertiary radicals over the primary radicals in the primary addition process. Comments on the mechanism of the transformation from radical to carbonyl compound based upon identification of intermediates within the matrix and isotopic substitution experiments are made. The characterisation of the 2-hydroxyethyl radical has been backed up by experiments utilising isotopic substitution with 13C and D (2H). The other radicals have been identified with varying degrees of certainty. Those radicals, which are observed at the highest concentration and which are, therefore, characterised more certainly are--2-hydroxyethyl (1), from ethene: 1-methyl-2-hydroxypropyl (2), from cis- and trans-but-2-ene; 1-methyl-2-hydroxyethyl (3), from propene; 1-hydroxymethylpropyl (5), from but-1-ene; and 1,1- dimethyl-2-hydroxyethyl (8), from 2-methylpropene.

Reactions of alkenes with ozone in the gas phase: a matrix-isolation study of secondary ozonides and carbonyl-containing reaction products.

Gas phase ozonolysis reactions of the alkenes ethene, cis- and trans-but-2-ene, isoprene and the monoterpenes alpha-pinene, beta-pinene, beta-carene, limonene and beta-myrcene have been carried out and the reaction products have been trapped in O2-doped-argon matrices onto a Csl window held at 12 K. Products have been identified by IR spectroscopy. Comparison with previous matrix spectra, where secondary ozonides have been generated either in situ by annealing or in solution reactions allows a positive identification of the secondary ozonides of ethene and of cis- and trans-but-2-ene to be made. These observations are backed up by experiments utilising the isotopes 13C and 2H (D). It appears that secondary ozonides have also been formed from isoprene and the range of monoterpenes studied; this hypothesis is based upon the similarity of spectral features seen in the products of these reactions within those of the simpler alkenes. A number of other primary and secondary products are also identified from these reactions. Ethene gives formaldehyde as a primary product and acetaldehyde as a secondary product; it is found that the yield of acetaldehyde compared to formaldehyde increases as the reaction times are increased. Formaldehyde, one of the expected primary products, is formed by ozonolysis of beta-pinene, although the other expected primary product, nopinone, is not seen. A range of secondary reaction products have been identified from the ozonolysis of the monoterpenes studied.

The photodimerisation of trans-cinnamic acid and its derivatives: a study by vibrational microspectroscopy.

Infrared and Raman spectroscopies have been used to monitor the [2 + 2] photodimerisation reactions of alpha-trans-cinnamic acid and of a number of its derivatives. The principal changes observed in the spectra upon dimerisation are decay of a band around 1637 cm(-1), which is assigned to v(C=C) of the ethene bond of the monomer, and growth of bands just above 3000 cm(-1), which result from v(C-H) of saturated carbon atoms of the dimer. The use of microscope attachments has allowed us to follow the reactions of single crystals and we conclude that the reactions are topotactic in nature. We have carried out preliminary kinetic experiments in which spectra of one single crystal are recorded after sequential periods of photolysis. We find that the rates of dimerisation of differently substituted cinnamic acids are similar, with physical effects, such as the thickness of an individual crystal, outweighing any observed electronic effects (inductive or mesomeric).