A191 PERSISTENT BENEFIT OF DIETITIAN-LED GLUTEN-FREE DIET EDUCATION AT CD DIAGNOSIS ON DIETARY ADHERENCE IN CHILDREN AND ADULTS WITH TYPE 1 DIABETES AND CELIAC DISEASE

Background

Celiac disease (CD) is a common autoimmune comorbidity of type 1 diabetes (T1D) with a gluten-free diet (GFD) being the current gold standard treatment for this condition. Adherence to a GFD can be impacted by several factors including dietetic counselling, yet little is known about the impact of clinic-based interventions on long-term GFD adherence in this population.

Aims

To prospectively evaluate the impact of a dietitian-led GFD education intervention on adherence to a GFD in children and adults with T1D and CD over a 3-year period.

Methods

A cohort of N=62 pediatric and adult subjects who screened seropositive for CD as part of the CD-DIET clinical trial were followed over a 3-year period post-CD diagnosis and assessed on the basis of the GFD education regimen they received at initial CD diagnosis. This included 3 groups: 1) intensive dietitian training (IDT = 5 dietitian visits over 1 year while following GFD), 2) single dietitian training (SDT = 1 GFD training session after 1 year of following GCD) and 3) no dietitian training (NDT) at CD diagnosis. Annual visits included serologic testing of TTG-IgA titres, anthropometric assessments and the completion of questionnaires evaluating diet and adherence to a GFD. Data was analysed longitudinally using linear mixed effects and generalized estimating equations (GEE) regression modeling adjusting for the fixed effects of age, sex, duration of diabetes and time.

Results

At baseline, participants who received IDT (n=15), SDT (n=16) and NDT (n=31) represented 24.2%, 25.8%, and 50.0% of the cohort, respectively. Over the 3-year study period, participants in the IDT group had the greatest odds of self-reporting being a GFD, with odds 4.3 (95%CI: 1.1 to 16.4; P=0.033) and 9.5 (95%CI: 2.7 to 33.7; P<0.001) greater than the SDT and NDT groups, respectively. The assessment of daily gluten intakes less than 10mg, as recommended for a GFD, revealed a lack of differences between the IDT and SDT groups. In contrast, the NDT group had significantly lower odds of meeting this threshold relative to those who received IDT (OR=0.2; 95%CI: 0.04 to 0.56; P=0.004). No longitudinal differences in TTG-IgA levels were seen between groups over the 3-year period.

Conclusions

In diabetes patients greater contact with a dietitian at CD diagnosis was associated with higher levels of GFD adherence over time, which was not reflected in follow-up Serologic evaluation. These findings highlight the importance of nutritional support in patients with both diabetes and celiac disease at the time of CD diagnosis. In addition, following TTG-IgA alone does not fully inform dietary compliance to a GFD.

Diet teaching stratification

Funding Agencies

Juvenile Diabetes Research Foundation / PSI

Effect of donor pneumoperitoneum on early allograft perfusion following renal transplantation in pediatric patients: an intraoperative Doppler ultrasound study

Decreased perfusion and trauma during laparoscopic harvesting are proposed causative factors for DGF and rejection in children following renal transplantation with laparoscopic donor nephrectomy (LDN) allograft. We performed a retrospective review of 11 children who underwent LDN transplant and 11 preceding patients who underwent ODN transplant. Intraoperative DUS findings, creatinine values and clearance, time to nadir creatinine and AR episodes were compared. There were no significant differences in the BMI, vascular anatomy, side of nephrectomy, or warm ischemia time in the two groups. Mean follow-up duration was 11.4 and 30.4 months in LDN and ODN groups. DUS showed initial turbulent flow in five of the LDN and four of the ODN group with an average RI of 0.59 and 0.66 in the ODN and LDN groups, respectively (NS). Three patients in the ODN group had an abnormal RI compared to none in the LDN group (p = 0.034). The creatinine values, creatinine clearances (at 24 h, one, four wk and last follow-up) and AR episodes were similar in both groups. Pneumoperitoneum during LDN does not appear to have an adverse impact on early graft reperfusion.

A comparison of patient-controlled sedation using either remifentanil or remifentanil-propofol for shock wave lithotripsy

Patient-controlled sedation (PCS) has been used for extracorporeal shock wave lithotripsy (SWL) because it allows for rapid individualized titration of anesthetics. Because of its sedating effects, the addition of propofol to remifentanil may improve patient tolerance of SWL with PCS. One hundred twenty patients were randomly assigned to receive remifentanil 10 microg or remifentanil 10 microg plus propofol 5 mg for PCS with zero-lockout interval. Nine patients in the Remifentanil group and three patients in the Remifentanil-Propofol group required additional sedatives to complete their SWL (P = 0.128). Compared with the Remifentanil group, the Remifentanil-Propofol group required less remifentanil, had a decreased incidence of postoperative nausea and vomiting, and had a better overall satisfaction level. However, they had an increased incidence of transient apnea and oxygen desaturation. The incidence of apnea was 15% in the Remifentanil group and 52% in the Remifentanil-Propofol group (P < 0.001). All patients were able to move themselves to the stretcher at the end of SWL, and median time to home discharge was <70 min in both groups. Both remifentanil and remifentanil-propofol were useful for PCS during SWL.

IMPLICATIONS

The addition of propofol to remifentanil improves patient satisfaction and decreases postoperative nausea and vomiting. However, it causes more respiratory depression than remifentanil alone. When remifentanil-propofol is used with patient-controlled sedation, appropriate monitoring and a minimum 1-2 min lockout interval is required.

Profound natriuresis, extracellular fluid volume contraction, and hypernatremia with hypertonic losses following trauma

A young male sustained very serious head and soft tissue injuries in a motor vehicle accident (MVA). Three interesting problems developed in the sodium (Na) and water area in the second week in hospital. First, on day 11 after the MVA, his urine output increased to 3 liters per day; the urine osmolality was 1000 mOsm/kg H2O and Na and Cl were the principal urine osmoles. There appeared to be a salt wasting syndrome because he had a very large natriuresis (close to 900 mmol/24 hr) at a time when his central venous pressure was low. To help identify the nephron site responsible for a natriuresis with a high urine osmolality, additional studies were carried out in normal volunteers who took a loop or a thiazide diuretic on different occasions while ADH was acting. The pattern of natriuresis in the patient was similar to that after the thiazide but not the loop diuretic. The second problem concerned his hypernatremia (153 mM) because his urine was hypertonic and his intravenous therapy was isotonic saline. To explain hypernatremia while receiving more electrolyte-free water, we speculated that there was a water shift into cells resulting from particles generated and retained in his intracellular fluid. Given the large shift of water required, a lesion in muscle was suspected, a form of rhabdomyolysis. The third problem concerned the rate of catabolism of lean body mass. The metabolic consequences of generating these intracellular particles and the large amount of urea that was excreted could reflect a large degree of protein catabolism.

Communicating with cancer patients & families

Treating cancer comprehensively reaches far beyond physical needs. The home care setting may prove to be the most conducive to effective communication with cancer patients and families, a vital component of the holistic approach to cancer care--but it won't happen automatically.

An assessment of mast-cell deficient mice (W/Wv) as a model system to study the role of histamine in implantation and deciduoma formation

The ovaries from mast cell-normal (+/+) and mast cell-deficient (W/Wv) mice were examined with light and electron microscopy. In addition the effect of ovariectomy and subsequent steroid treatment on total uterine histamine content, total mast cell numbers and surface and glandular epithelial cell heights was measured. The ovaries of +/+ mice were normal, displaying various stages of follicular growth and atresia and numerous corpora lutea; the ovaries of W/Wv mice lacked follicles and corpora lutea but contained numerous hyperplastic interstitial cells which contained numerous lipid droplets, vesiculated mitochondria and abundant endoplasmic reticulum suggestive of steroid synthesis. Steroid treatment of ovariectomized +/+ and W/Wv mice caused a significant increase in uterine wet weight and endometrial surface and glandular epithelial cell heights. In +/+ mice, steroid treatment caused a concomitant increase in total mast cells per uterine horn while mast cells were totally absent in W/Wv mice. The increase in uterine histamine in +/+ mice is consistent with the increase in mast cell numbers. Measurable amounts of uterine histamine, which increases slightly after steroid treatment, were demonstrated in W/Wv mice. Since the uteri of +/+ and W/Wv mice respond to steroids in a similar manner with the sole exception being histamine content and mast cell numbers, our results demonstrate the potential of using these animals to investigate the role(s) of uterine mast cells and non-mast cell uterine histamine in the process of implantation and the formation of a decidual cell response.