Is Dietitian Use Associated with Celiac Disease Outcomes?

A gluten-free diet (GFD) is the treatment for celiac disease (CD), but due to its complexity, dietitian referral is uniformly recommended. We surveyed patients with CD to determine if dietitian use is associated with quality of life, symptom severity, or GFD adherence. The survey utilized three validated CD-specific instruments: the CD quality of life (CD-QOL), CD symptom index (CSI) and CD adherence test (CDAT). Four hundred and thirteen patients with biopsy-proven CD were eligible for inclusion. The majority (77%) were female and mean BMI was 24.1. Over three-quarters of patients (326, 79%) had seen a dietitian, however, 161 (39%) had seen a dietitian only once. Age, sex, and education level were not associated with dietitian use; nor was BMI (24.6 vs. 24.0, p = 0.45). On multivariate analysis, adjusting for age gender, education, duration of disease, and body mass index, dietitian use was not associated with CD-QOL, CSI, or CDAT scores. Our survey did not show an association between dietitian use and symptom severity, adherence, or quality of life. Delay in diagnosis was associated with poorer outcomes. This is a preliminary study with several limitations, and further prospective analysis is needed to evaluate the benefits and cost-effectiveness of dietitian-referral in the care of celiac disease patients.     

Risk of Drop-Out from Follow-Up Evaluations for Celiac Disease: Is It Similar for All Patients?

Background: Celiac disease (CD) follow-up is a relatively underevaluated topic. However, correct adherence to follow-up procedures is central to the early recognition of complicated CD and other conditions typically associated with CD. Establishing whether patients at increased risk of complications follow clinicians’ recommendations has multiple repercussions. Methods: We retrospectively analyzed the records of patients consecutively diagnosed with CD in our outpatient clinic between January 2004 and October 2017 to investigate the factors associated with drop-out from follow-up procedures. Results: Among the 578 patients analyzed, 40 (6.9%) dropped out during the first six months and 272 (50.6%) during the observation period. The median time to drop-out was 7.4 years (95% confidence interval: 6.8–8.0). No factors were associated with early drop-out. Instead, age at diagnosis >40 years (40–59 years, p < 0.001; ≥60 years, p = 0.048) and classical clinical presentation (p = 0.016) were significantly associated with a lower risk of later drop-out. Conclusions: Patients at increased risk of complicated CD are more compliant with follow-up procedures than patients at lower risk, despite being prescribed the same controls. These results indirectly support the hypothesis of tailored follow-up strategies, differentiated according to the risk of complications.     

Gallbladder Disease—An Interdisciplinary Problem

Despite their intrinsic limitations, the currently available radiologic techniques can demonstrate gallbladder and biliary tract disease with almost 100% accuracy—provided a team approach is taken and the radiologist given all available clinical and laboratory data. With the more complex procedures such as percutaneous cholangiography, moreover, the need for interdisciplinary collaboration is absolute.     

Is Myopia a Public Health Problem in India?

Myopia, a form of refractive error is a leading cause of visual disability throughout the world. In India uncorrected refractive errors are the most common cause of visual impairment and second major cause of avoidable blindness. Due to this the public health and economic impact of myopia is enormous. Although school vision screening programme is very successful in many states, still a significant number of school going children remain unidentified and the unmet need for correcting refractive errors in children appears to be significant.     

Life Events and the Onset of Celiac Disease from a Patient’s Perspective

Stressful events have been investigated in various immune-mediated diseases but not in celiac disease. Our aim was to examine the relationship of stressful events assessed by the standardized interview of Paykel with the diagnosis of celiac disease in comparison to patients, with a diagnosis of gastroesophageal reflux disease used as the control group. Adults with celiac disease (n = 186) reported more frequent and more severe life events in the years prior to the diagnosis than control patients (n = 96) (67.2% vs. 37.5%, p < 0.001, mean Paykel score 11.5 vs. 13.4, p = 0.001, respectively). Findings were not significantly different between celiac disease and control patients for the time lapse between the event and the diagnosis (mean 5.5 vs. 5.7 months). Pregnancy was defined as a negative event by 20.3% of celiac women, but never by control women. Findings were confirmed when analyses were repeated in the subgroup of patients of both groups with diagnosis made within one year of onset of symptoms. Data indicate that, before diagnosis, the number of stressful events in celiac disease was more frequent although less severe than in the control group suggesting that life events may favor the clinical appearance of celiac disease or accelerate its diagnosis.     

Obesity Among Chronically Homeless Adults: Is It a Problem?

Objective

We examined rates of obesity and associated characteristics in the chronically homeless population to explore how a range of factors, including sociodemographics, housing, food source, physical and mental health, and health service use, were related to being overweight or obese.

Methods

We conducted multivariate regression analyses on a community sample of 436 chronically homeless adults across 11 U.S. cities to examine the prevalence of obesity.

Results

The majority (57%) of chronically homeless adults were overweight or obese. Chronically homeless adults who were female or Hispanic appeared to be at particular risk for obesity. There were few differences on physical and mental health by weight group. Although overweight and obese chronically homeless adults were more likely to discuss exercise with a health-care provider, they reported engaging in less exercise than those who were underweight or normal weight.

Conclusion

These findings underscore the need for greater attention to obesity in chronically homeless adults and demonstrate a food insecurity-obesity paradox or poverty-obesity link.Obesity has become a worldwide epidemic.^1–3 In the United States, 34% of adults are obese and 34% are overweight, meaning 68% are either overweight or obese.⁴ Obesity has been linked to various health problems, many of which have high morbidity and mortality, including diabetes, musculoskeletal disorders, cardiovascular disease, pulmonary disorders, and cancer.^3,5 Thus, identifying and intervening with people who are overweight or obese has become important for primary and secondary prevention.^6–8There has been little study of obesity among chronically homeless adults. Homeless adults represent a marginalized, neglected segment of the population and are known to experience poorer physical health than the general population.^9,10 Because adults who are chronically homeless lack a stable, secure residence and often cannot afford regular, healthy meals,^11–13 they are presumed to be underweight. However, this assumption has not been empirically examined, and there is evidence to suggest there may be an obesity problem among the homeless.A nationally representative survey of 1,704 homeless adults and 400 soup kitchens and shelter providers in 20 cities found that 63% of homeless adults reported obtaining meals from soup kitchens and 51% from shelters in a one-week period.¹⁴ Only 17% of soup kitchens, food pantries, and shelters surveyed were working with a nutritionist or dietician. The nutritional value of food served in many soup kitchens and shelters has been found to be low in vitamins and to exceed fat, energy, and protein content recommendations.^15,16A growing literature in the past decade has reported on a food insecurity-obesity paradox, whereby food insecurity, which often results from inadequate economic resources to purchase food, is associated with obesity, which is a consequence of overconsumption of food.^17,18 Many theories have been proposed to explain this correlation, including the low cost of energy-dense foods, binge eating habits as an adaptive physiological response to food scarcity, and childhood poverty leading to obesity in adulthood.^17,19 Related literature has also suggested a poverty-obesity link, finding that populations with high poverty rates and low education levels have the highest obesity rates.^1,20–22Yet the question remains whether there is an obesity problem among chronically homeless adults, and no prior study could be found directly addressing this question. Thus, this study aimed to examine the prevalence of obesity in a multisite community sample of chronically homeless adults and explore how a range of variables known to be related to weight, including sociodemographics, income and insurance, housing, food source, physical and mental health, and health service use, may be related to being overweight or obese.     

Bones of Contention: Bone Mineral Density Recovery in Celiac Disease—A Systematic Review

Metabolic bone disease is a frequent co-morbidity in newly diagnosed adults with celiac disease (CD), an autoimmune disorder triggered by the ingestion of dietary gluten. This systematic review of studies looked at the efficacy of the gluten-free diet, physical activity, nutrient supplementation, and bisphosphonates for low bone density treatment. Case control and cohort designs were identified from PubMed and other academic databases (from 1996 to 2015) that observed newly diagnosed adults with CD for at least one year after diet treatment using the dual-energy x-ray absorptiometry (DXA) scan. Only 20 out of 207 studies met the inclusion criteria. Methodological quality was assessed using the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist. Gluten-free diet adherence resulted in partial recovery of bone density by one year in all studies, and full recovery by the fifth year. No treatment differences were observed between the gluten-free diet alone and diet plus bisphosphonates in one study. For malnourished patients, supplementation with vitamin D and calcium resulted in significant improvement. Evidence for the impact of physical activity on bone density was limited. Therapeutic strategies aimed at modifying lifestyle factors throughout the lifespan should be studied.     

Is contracting a form of privatization?

Contracting is often seen as a form of privatization, with contracts functioning as the tool that makes privatization possible. But contracting is also viewed by some as a means for the private sector to expand in a covert way its presence within the health sector. This article discusses the wider meaning of the term privatization in the health sector and the ways in which it is achieved. Privatization is seen here not simply as an action that leads to a new situation but also as one that leads to a change in behaviour. It is proposed that privatization may be assessed by looking at the ownership, management, and mission or objectives of the entity being privatized. Discussed also is the use of contracting by the state as a tool for state interventionism that is not based on authoritarian regulation.     

Intestinal Microbiota and Celiac Disease: Cause,Consequence or Co-Evolution?

It is widely recognized that the intestinal microbiota plays a role in the initiation and perpetuation of intestinal inflammation in numerous chronic conditions. Most studies report intestinal dysbiosis in celiac disease (CD) patients, untreated and treated with a gluten-free diet (GFD), compared to healthy controls. CD patients with gastrointestinal symptoms are also known to have a different microbiota compared to patients with dermatitis herpetiformis and controls, suggesting that the microbiota is involved in disease manifestation. Furthermore, a dysbiotic microbiota seems to be associated with persistent gastrointestinal symptoms in treated CD patients, suggesting its pathogenic implication in these particular cases. GFD per se influences gut microbiota composition, and thus constitutes an inevitable confounding factor in studies conducted in CD patients. To improve our understanding of whether intestinal dysbiosis is the cause or consequence of disease, prospective studies in healthy infants at family risk of CD are underway. These studies have revealed that the CD host genotype selects for the early colonizers of the infant’s gut, which together with environmental factors (e.g., breast-feeding, antibiotics, etc.) could influence the development of oral tolerance to gluten. Indeed, some CD genes and/or their altered expression play a role in bacterial colonization and sensing. In turn, intestinal dysbiosis could promote an abnormal response to gluten or other environmental CD-promoting factors (e.g., infections) in predisposed individuals. Here, we review the current knowledge of host-microbe interactions and how host genetics/epigenetics and environmental factors shape gut microbiota and may influence disease risk. We also summarize the current knowledge about the potential mechanisms of action of the intestinal microbiota and specific components that affect CD pathogenesis.     

Celiac artery compression syndrome--stepchild of abdominal angina?

BACKGROUND: Celiac trunk compression in few percentages of the cases can cause chronic abdominal pain that shows no connection with eating. CASE REPORT: Detailed preoperative examinations showed significant, segmental stenosis of the celiac trunk, caused by outer compression of a tendonous arc of diaphragm, in the background of abdominal pain and mesenteric ischemia of a 58-year-old woman. After preparation we have executed the surgery by removing a tight ring, located at around 8-10 mm from the origin of trifurcation, and a part of the celiac ganglion. The patient was dismissed from our hospital 6 days after surgery in good general condition. DISCUSSION: The abdominal pain can normally be the consequence of mesenteric ischemia. The root cause in most of the cases is the alteration of the particular artery. The outer compression is normally responsible only for a few percentages of the cases. In our case the problem was caused by a stronger tendonous part of the aortic hiatus. The first sign of this during the examination was a recognisable noise over the artery, which was caused by the poststenotic turbulent flow. Detailed radiological examinations executed based on this indeed proved this malfunction. CONCLUSION: In case of unidentified abdominal pain we have to consider the possibility of the stenosis of the celiac trunk. By our case study we would like to call the attention to the importance of the auscultation over the abdomen, which is a relevant part of the basic physical examinations. When getting to the final diagnosis, apart from the duplex doppler sonography, we also used the results of angiography. The essence of the surgery was to get rid of the outer compression of the artery, which has to be done as soon as possible in order to avoid that compression causes degeneration of the artery itself.