PTU-112 Incidence and predictors of buried bumper syndrome following gastrostomy insertion: a systematic review

Introduction Gastrostomies are widely used to provide enteral nutrition support. Buried Bumper Syndrome (BBS) is a recognised complication seen following gastrostomy insertion, describing the migration of the internal bumper along the stoma tract towards the skin. The consequences of BBS can be fatal. Currently, there is a paucity of knowledge about the incidence and predictors of BBS, which is addressed in this study by systematically reviewing the medical literature. Method A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines (PRISMA). Four databases (EMBASE, MEDLINE, CINHAL, Web of Science) were utilised, and studies identified by searching for key terms relating to gastrostomy and BBS (Jan 1980 -Dec 2016). Unpublished studies were identified from conference abstract booklets. Two independent reviewers screened studies to identify those that included description of adult patients with BBS. Data was extracted relating to patient demographics, incidence, time to presentation and factors associated with BBS. Results 434 studies were initially identified (database search and grey literature). Of these, 299 (68.9%) were excluded following screening review of title and abstract (Kappa coefficient of reviewers=0.753). Of the remaining 135 studies, 85 met inclusion criteria (35 case studies, 11 case series and 39 cohort studies). No controlled trials were retrieved. In total, 16 627 patients were described post gastrostomy placement. 473 cases of BBS were reported in the literature, giving a pooled estimate incidence of 2.8% (0.46%–8.80%). The median age of presentation was 66 years, with 59.1% being in males. BBS was most frequently associated with gastrostomy tubes with thinner internal bumpers (40.7% of all reported cases), however reporting bias may have heavily influenced this outcome. The time to BBS presentation ranged from 3 days to 7 years. Common predictors of BBS reported in the literature include tight external bumpers and increased external traction made directly by the patient or during gastrostomy care. Conclusion This is the first study to systematically review the incidence of Buried Bumper syndrome and assess factors predicting its development. The paucity of high quality studies identified in this systematic review, provides the impetus to develop a national gastrostomy registry accurately assessing gastrostomy outcomes. Healthcare professionals, patients and their caregivers need to be appropriately educated about BBS, considering factors such as tightness of external bumpers and minimising external traction

Efficient Implementation of a Synchronous Parallel Push-Relabel Algorithm

Motivated by the observation that FIFO-based push-relabel algorithms are able to outperform highest label-based variants on modern, large maximum flow problem instances, we introduce an efficient implementation of the algorithm that uses coarse-grained parallelism to avoid the problems of existing parallel approaches. We demonstrate good relative and absolute speedups of our algorithm on a set of large graph instances taken from real-world applications. On a modern 40-core machine, our parallel implementation outperforms existing sequential implementations by up to a factor of 12 and other parallel implementations by factors of up to 3

High Prevalence of Microvascular Complications in Adults With Type 1 Diabetes and Newly Diagnosed Celiac Disease

Objective: The implications of celiac disease (CD) in adult patients with type 1 diabetes are unknown, with respect to diabetes-related outcomes including glycemic control, lipids, microvascular complications, quality of life, and the effect of a gluten-free diet (GFD). We identified CD in adults with type 1 diabetes and investigated the effect of a GFD on diabetes-related complications. Research design and methods: This was a case-control study conducted at a U.K. teaching hospital. Patients with type 1 diabetes aged >16 years (n = 1,000) were assessed for CD. HbA1c, lipid profile, quality of life, retinopathy stage, nephropathy stage, and degree of neuropathy before and after 1 year on a GFD were assessed. Results: The prevalence of CD was 33 per 1,000 subjects (3.3% [95% CI 2.3–4.6]). At diagnosis of CD, adult type 1 diabetic patients had worse glycemic control (8.2 vs. 7.5%, P = 0.05), lower total cholesterol (4.1 vs. 4.9, P = 0.014), lower HDL cholesterol (1.1 vs. 1.6, P = 0.017), and a higher prevalence of retinopathy (58.3 vs. 25%, P = 0.02), nephropathy (41.6 vs. 4.2%, P = 0.009), and peripheral neuropathy (41.6 vs. 16.6%, P = 0.11). There was no difference in quality of life (P > 0.1). After 1 year on a GFD, only the lipid profile improved overall, but in adherent individuals HbA1c and markers for nephropathy improved. Conclusions: Adults with undetected CD and type 1 diabetes have worse glycemic control and a higher prevalence of retinopathy and nephropathy. Treatment with a GFD for 1 year is safe in adults with type 1 diabetes and does not have a negative impact on the quality of life. Long-term microvascular and neurologic complications are responsible for major morbidity and mortality in type 1 diabetes (1). Intensive glycemic control reduces these complications and improves quality of life (1). Even patients with good glycemic control have complications, suggesting that other factors increase the risk (2). Coexisting medical problems may be a confounding factor when managing glycemic control (2). The association between celiac disease (CD) and type 1 diabetes was recognized over 30 years ago, particularly by pediatricians. The prevalence of CD in patients with adult type 1 diabetes has been reported as 1.8–8.4% (3–6). Despite a large number of prevalence studies, other important clinical factors have not been well investigated, including glycemic control, quality of life, microvascular complications, cardiac risk factors, and bone mineral density. Investigations of the effect of CD on glycemic control have been conflicting, with some studies showing improvement (7) and some deterioration (4,8) and others showing no effect (9). The difficulty in interpreting these studies is that most involve pediatric populations and are small, retrospective, and uncontrolled, leaving this question unanswered. There have been no quality-of-life assessments before and after the diagnosis of CD to assess the impact of the diagnosis and a subsequent gluten-free diet (GFD) (3). Adapting to a GFD with the restrictions of a diabetic diet may negatively impact quality of life. Peripheral neuropathy affects up to 30% of patients with adult type 1 diabetes and is a major cause of morbidity (1). Neuropathy is associated with both type 1 diabetes and CD; therefore, patients with both conditions may have a higher prevalence (10,11). In gluten-sensitive neuropathy, the pathophysiological changes lie in the humoral immune response, and a GFD seems to be beneficial (12,13). There are no studies examining neuropathy in patients with type 1 diabetes and CD or the effect of a GFD. One study examined whether CD may contribute to autonomic neuropathy in a cohort of patients with type 1 diabetes. They found no difference in the prevalence of positive antibodies in patients with and without autonomic neuropathy (14). Two previous studies have examined the effect of CD on diabetic nephropathy but were conflicting (15,16). There are currently no studies examining the prevalence of retinopathy in individuals with both type 1 diabetes and CD. Recent data in nondiabetic CD cohorts have shown a reduced risk of ischemic heart disease, possibly attributed to lower cholesterol levels and a lower prevalence of hypertension (17). Reduced bone mineral density has been associated with both CD and type 1 diabetes, but there are little data on people with both conditions (18). The aim of our study was to identify undetected CD in adult patients with type 1 diabetes and investigate the effect on diabetes-related complications before and after a GFD

Criticality Potential of Waste Packages Containing DOE SNF Affected by Igneous Intrusion

The Department of Energy (DOE) is currently preparing an application to submit to the U.S. Nuclear Regulatory Commission for a construction authorization for a monitored geologic repository. The repository will contain spent nuclear fuel (SNF) and defense high-level waste (DHLW) in waste packages placed in underground tunnels, or drifts. The primary objective of this paper is to perform a criticality analysis for waste packages containing DOE SNF affected by a disruptive igneous intrusion event in the emplacement drifts. The waste packages feature one DOE SNF canister placed in the center and surrounded by five High-Level Waste (HLW) glass canisters. The effective neutron multiplication factor (k{sub eff}) is determined for potential configurations of the waste package during and after an intrusive igneous event. Due to the complexity of the potential scenarios following an igneous intrusion, finding conservative and bounding configurations with respect to criticality requires some additional considerations. In particular, the geometry of a slumped and damaged waste package must be examined, drift conditions must be modeled over a range of parameters, and the chemical degradation of DOE SNF and waste package materials must be considered for the expected high temperatures. The secondary intent of this calculation is to present a method for selecting conservative and bounding configurations for a wide range of end conditions

On the averaging principle for one-frequency systems. Seminorm estimates for the error

We extend some previous results of our work [1] on the error of the averaging method, in the one-frequency case. The new error estimates apply to any separating family of seminorms on the space of the actions; they generalize our previous estimates in terms of the Euclidean norm. For example, one can use the new approach to get separate error estimates for each action coordinate. An application to rigid body under damping is presented. In a companion paper [2], the same method will be applied to the motion of a satellite around an oblate planet.Comment: LaTeX, 23 pages, 4 figures. The final version published in Nonlinear Dynamic

Brain fog and non-coeliac gluten sensitivity: Proof of concept brain MRI pilot study

Aims Non-Coeliac Gluten Sensitivity (NCGS) is poorly understood, particularly in terms of its neurological outcomes. We initially conducted a prospective postal survey to investigate its neurological presentation and symptom course. Results from this then motivated a follow-up pilot study utilising brain MRI to characterise potential diagnostic biomarkers for future research. Methods Patients with NCGS were recruited from a specialist centre and completed a prospective postal questionnaire (N = 125). This summarised symptoms experienced, their severity and their course. Onset time was compared by Chi-squared analysis to data from the same centre concerning coeliac disease patients (N = 224). Five respondents on a strict gluten-free diet who self-reported brain fog then attended a pilot study, completing MR brain imaging/questionnaires before/after a gluten challenge. “Baseline” data were assessed for abnormalities, while symptom severity and cerebral blood flow (CBF) were compared before/after challenge. Results Survey participants were aged 47 (85% female). Prevalence of neurological symptoms were: headaches (51%), brain fog (48%), balance issues (31%), tingling (19%). Median symptom resolution time was 48 hours, while onset was 90 minutes; onset pattern was not significantly different compared to CD patients (p = 0.322). Extra-intestinal symptoms worsened by 37%(±28) during a typical reaction. Predominantly non-statistical observations from the brain imaging study are discussed. Conclusions Neurological symptoms in NCGS are common, and onset time is comparable to that in CD. Brain imaging may be a useful future means of investigating physiological injury and responses to gluten in further study

Non-responsive coeliac disease : a comprehensive review from the NHS England national centre for refractory coeliac disease

Coeliac disease is a common small intestinal enteropathy which manifests following ingestion of gluten in genetically susceptible individuals. Since gluten was identified as the driving factor in coeliac disease, the gluten-free diet (GFD) has remained the mainstay of treatment. While most individuals will display improvement in symptoms and signs of coeliac disease following institution of the GFD, up to 30% will continue to experience symptoms and/or have persisting intestinal inflammation. These individuals can be classified as having non-responsive coeliac disease (NRCD), which may be associated with dietary indiscretion, slow healing, refractory coeliac disease, and/or an alternative condition. The purpose of this review is to provide an overview of the causes of NRCD in adults, highlight a systematic approach to investigate these patients, and appraise the latest management aspects of this subset of coeliac disease