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1.  Detachable Coil Embolization for Saccular Posterior Inferior Cerebellar Artery Aneurysms 
Objective
Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging due to limited surgical accessibility. Endovascular approach has a benefit of avoiding direct injury to the brainstem or lower cranial nerves. Therefore, it has recently been considered an alternative or primary modality for PICA aneurysms. We retrospectively assessed outcomes following detachable coil embolization of saccular PICA aneurysms.
Methods
From February 1997 to December 2007, we performed endovascular procedures to treat 15 patients with 15 PICA aneurysms. Fourteen patients with 14 PICA aneurysms morphology of which was saccular were reviewed retrospectively. Twelve patients had ruptured aneurysms. The aneurysms arose from the PICA origin site (n = 12), the PICA lateral medullary segment (n = 1), or the PICA tonsilomedullary segment (n = 1).
Results
Complete aneurysm occlusion was achieved in 10 patients, residual neck in 3, and residual sac in one. Radiological follow-up was performed in 7 patients with mean duration of 34.7 months (range, 1-97 months) and showed stable or complete occlusion in 6 patients. There were no rebleeding or retreatment after endovascular treatment. Thromboembolism was the only procedure-related complication (n = 4 ; 28.6%). Asymptomatic PICA infarction occurred in two patients and symptomatic PICA infarction in two elderly patients with poor clinical grade. Of these procedural PICA infarction cases, 1 symptomatic PICA infarction patient developed ventriculitis and septic shock leading to death. The clinical outcome was good in 10 patients (71.4%).
Conclusions
In the present study, detachable coil embolization has shown as an efficient modality for PICA saccular aneurysms challenging indications of microsurgery. However, thromboembolic complications should be considered, especially in poor clinical elderly patients with ruptured aneurysms.
doi:10.3340/jkns.2009.46.3.221
PMCID: PMC2764020  PMID: 19844622
Posterior inferior cerebellar artery; Endovascular; Microsurgery; Thromboembolism
2.  Anal Pain Secondary to Swallowed Bone 
Ghana Medical Journal  2006;40(1):31-32.
Summary
Swallowed foreign bodies can be a source of morbidity or rarely mortality since they can impact in the pharynx and the oesophagus and cause discomfort or even perforate to cause mediastinitis. Most (80% to 90%)1 foreign bodies including swallowed bone pass into the stomach, proceed through the intestines and are passed in stool without problems. Swallowed bone has been documented to cause intestinal perforation2, enterovesical fistula3 and perianal abscesses4. Two cases of swallowed bones, which passed through the alimentary tract to finally cause anal pain and anal fistula, are presented. Doctors should be aware of the possibility of sharp objects being the cause of anal pain and must therefore be careful when performing digital rectal examinations to prevent injuries from these foreign objects.
PMCID: PMC1790837  PMID: 17299562
Swallowed bone; fistula-in-ano; foreign objects
3.  The hazards of vinyl glove ingestion in the mentally retarded patient with pica: new implications for surgical management 
Canadian Journal of Surgery  1999;42(3):201-204.
Objective
To report experience with the treatment of complications of vinyl glove ingestion in mentally retarded patients with pica.
Design
A retrospective case series.
Setting
Two university-affiliated hospitals.
Patients
Five mentally retarded patients, 4 with a history of pica, who were admitted for the management of complications resulting from the ingestion of vinyl gloves.
Main outcome measures
Type of complication, treatment and operative outcome.
Findings
The patients ranged in age from 26 to 46 years. One patient died while awaiting surgical consultation of massive gastrointestinal bleeding from a large gastric ulcer caused by a vinyl glove bezoar (VGB). Four VGBs were removed surgically. Endoscopic removal was difficult or impossible because the gloves had become hardened and matted.
Conclusions
VGB should be considered in institutionalized mentally retarded people with a history of pica when they present with gastrointestinal symptoms. VGBs should be removed directly by laparotomy, gastrotomy or enterotomy. Endoscopic removal is not recommended.
PMCID: PMC3788950  PMID: 10372016
4.  Extraction of swallowed toothbrush in stomach by pneumatic insufflation and gastrotomy under local anesthesia: A rare occurrence 
Most of the ingested foreign bodies pass uneventfully through the gastrointestinal tract. However, long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation, and bleeding. Spontaneous passage of a toothbrush has not been reported till date and the technique of its removal is a curiosity for surgeons. Endoscopy is a recommended technique for the removal of such complex foreign bodies. However, if it fails, the foreign body can be removed successfully with a laparoscopic gastrotomy. We devised an innovative technique by using pneumatic gastric insufflation and extracted the toothbrush by a tiny gastrotomy under local anesthesia.
PMCID: PMC4116581  PMID: 25097632
Gastrotomy; local anesthesia; toothbrush; upper gastrointestinal endoscopy
5.  Management of rectal foreign bodies 
Background
Entrapped anorectal foreign bodies are being encountered more frequently in clinical practice. Although entrapped foreign bodies are most often related to sexual behavior, they can also result from ingestion or sexual assault.
Methods
Between 1999 and 2009, 15 patients with foreign bodies in the rectum were diagnosed and treated, at Izmir Training and Research Hospital, in Izmir. Information regarding the foreign body, clinical presentation, treatment strategies, and outcomes were documented. We retrospectively reviewed the medical records of these unusual patients.
Results
All patients were males, and their mean age was 48 years (range, 33–68 years). The objects in the rectum of these 15 patients were an impulse body spray can (4 patients), a bottle (4 patients), a dildo (2 patient), an eggplant (1 patient), a brush (1 patient), a tea glass (1 patient), a ball point pen (1 patient) and a wishbone (1 patient, after oral ingestion). Twelve objects were removed transanally by anal dilatation under general anesthesia. Three patients required laparotomy. Routine rectosigmoidoscopic examination was performed after removal. One patient had perforation of the rectosigmoid and 4 had lacerations of the mucosa. None of the patients died.
Conclusions
Foreign bodies in the rectum should be managed in a well-organized manner. The diagnosis is confirmed by plain abdominal radiographs and rectal examination. Manual extraction without anaesthesia is only possible for very low-lying objects. Patients with high- lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction. Open surgery should be reserved only for patients with perforation, peritonitis, or impaction of the foreign body.
doi:10.1186/1749-7922-8-11
PMCID: PMC3601006  PMID: 23497492
Foreign body; Rectum; Anorectal trauma
6.  Dental root canal treatment complicated by foreign body ingestion: a case report 
Cases Journal  2009;2:117.
Introduction
Most foreign bodies pass through the gastrointestinal tract uneventfully. The majority of the reported literature describes the management of ingested blunt objects. However, ingestion of sharp objects can still occur with a higher rate of perforation corresponding to treatment dilemmas.
Case Presentation
We report the conservative management of an inadvertently ingested sharp foreign body during a routine dental procedure and describe a management strategy for the treatment of both blunt and sharp foreign bodies.
Conclusion
Urgent endoscopic assessment and retrieval is indicated when there is a history of a recently ingested sharp foreign body or if clinical suspicion suggests that the object is located within the oesophagus. Conservative management is advocated if the object has passed through the pylorus with serial clinical assessments including daily radiographs. Surgical intervention is warranted in the presence of obstruction, perforation or peritonitis.
doi:10.1186/1757-1626-2-117
PMCID: PMC2642789  PMID: 19192270
7.  A bizarre foreign body in the appendix: A case report 
Foreign bodies are rare causes of appendicitis and, in most cases, ingested foreign bodies pass through the alimentary tract asymptomatically. However, ingested foreign bodies may sometimes remain silent within the appendix for many years without an inflammatory response. Despite the fact that cases of foreign-body-induced appendicitis have been documented, sharp and pointed objects are more likely to cause perforations and abscesses, and present more rapidly after ingestion. Various materials, such as needles and drill bits, as well as organic matter, such as seeds, have been implicated as causes of acute appendicitis. Clinical presentation can vary from hours to years. Blunt foreign bodies are more likely to remain dormant for longer periods and cause appendicitis through obstruction of the appendiceal lumen. We herein describe a patient presenting with a foreign body in his appendix which had been swallowed 15 years previously. The contrast between the large size of the foreign body, the long clinical history without symptoms and the total absence of any histological inflammation was notable. We suggest that an elective laparoscopic appendectomy should be offered to such patients as a possible management option.
doi:10.4240/wjgs.v5.i6.195
PMCID: PMC3692956  PMID: 23805364
Foreign body; Appendectomy; Laparoscopy; Acute appendicitis; Calcified fecaloma; Abdominal pain
8.  Endoscopic removal of multiple duodenum foreign bodies: An unusual occurrence 
Deliberate single foreign body ingestion is a scenario that many gastroenterologists commonly see in psychiatric units and prisons. However, multiple foreign body ingestions, especially located in the duodenum, provide the endoscopist with unique challenges for management and treatment. Although most foreign objects pass spontaneously, one should have a low threshold of intervention for multiple objects, especially those that are wide, sharp and at risk of perforation. Diagnosis is typically made when there is a history of ingestion coupled with corresponding radiographic verification. The symptoms tend to be non-specific although some patients are able to delineate where the discomfort level is, correlating with the site of impaction. Most foreign bodies pass spontaneously; however when multiple sharp objects are ingested, the gastroenterologist should perform endoscopic procedures to minimize the risks of bowel perforation. We describe here a successful case of multiple ingested foreign bodies retrieved across the C-loop of the duodenum and the pharynges-esophageal curve via endoscopy and review the literature of multiple foreign body ingestion.
doi:10.4253/wjge.v2.i5.186
PMCID: PMC2999126  PMID: 21160746
Foreign bodies; Multiple; Duodenum; Management; Foreign body ingestions
9.  Surgical Relief of Small Bowel Obstruction by Migrated Biliary Stent: Extraction Without Enterotomy 
Small bowel obstruction caused by biliary stent migration may be managed without enterotomy by using a combination of laparoscopy, endoscopy, and fluoroscopy.
Background:
Distal stent migration is a well-known complication following insertion of biliary stents. Most such cases can be managed expectantly, because the stents pass through the gastrointestinal tract. However, small bowel obstruction as a result of the stent mandates surgical intervention.
Methods:
We report the case of a patient who had distal stent migration causing a small bowel obstruction. We successfully retrieved the stent without an enterotomy, by using a combination of laparoscopy, endoscopy, and fluoroscopy. Our unique technique greatly decreased the risk of bacterial peritonitis in this patient with decompensated cirrhosis and associated ascites, which in this patient population results in a high mortality.
Results:
Management of small bowel obstruction secondary to biliary stent migration necessitates operative intervention. Retrieval of a dislodged stent can be performed safely without subjecting the patient to an enterotomy or a small bowel resection. Postoperative morbidity should be significantly reduced by this approach.
Conclusion:
Retrieval of biliary stents in cases of small bowel obstruction without perforation may be successfully performed without enterotomy or bowel resection. A similar approach may be applied to other foreign bodies dislodged in the small bowel.
doi:10.4293/108680811X13071180406998
PMCID: PMC3148878  PMID: 21902982
Biliary stent migration; Surgical management of small bowel obstruction from biliary stent migration
10.  Google Glass for Documentation of Medical Findings: Evaluation in Forensic Medicine 
Background
Google Glass is a promising premarket device that includes an optical head-mounted display. Several proof of concept reports exist, but there is little scientific evidence regarding its use in a medical setting.
Objective
The objective of this study was to empirically determine the feasibility of deploying Glass in a forensics setting.
Methods
Glass was used in combination with a self-developed app that allowed for hands-free operation during autopsy and postmortem examinations of 4 decedents performed by 2 physicians. A digital single-lens reflex (DSLR) camera was used for image comparison. In addition, 6 forensic examiners (3 male, 3 female; age range 23-48 years, age mean 32.8 years, SD 9.6; mean work experience 6.2 years, SD 8.5) were asked to evaluate 159 images for image quality on a 5-point Likert scale, specifically color discrimination, brightness, sharpness, and their satisfaction with the acquired region of interest. Statistical evaluations were performed to determine how Glass compares with conventionally acquired digital images.
Results
All images received good (median 4) and very good ratings (median 5) for all 4 categories. Autopsy images taken by Glass (n=32) received significantly lower ratings than those acquired by DSLR camera (n=17) (region of interest: z=–5.154, P<.001; sharpness: z=–7.898, P<.001; color: z=–4.407, P<.001, brightness: z=–3.187, P=.001). For 110 images of postmortem examinations (Glass: n=54, DSLR camera: n=56), ratings for region of interest (z=–8.390, P<.001) and brightness (z=–540, P=.007) were significantly lower. For interrater reliability, intraclass correlation (ICC) values were good for autopsy (ICC=.723, 95% CI .667-.771, P<.001) and postmortem examination (ICC=.758, 95% CI .727-.787, P<.001). Postmortem examinations performed using Glass took 42.6 seconds longer than those done with the DSLR camera (z=–2.100, P=.04 using Wilcoxon signed rank test). The battery charge of Glass quickly decreased; an average 5.5% (SD 1.85) of its battery capacity was spent per postmortem examination (0.81% per minute or 0.79% per picture).
Conclusions
Glass was efficient for acquiring images for documentation in forensic medicine, but the image quality was inferior compared to a DSLR camera. Images taken with Glass received significantly lower ratings for all 4 categories in an autopsy setting and for region of interest and brightness in postmortem examination. The effort necessary for achieving the objectives was higher when using the device compared to the DSLR camera thus extending the postmortem examination duration. Its relative high power consumption and low battery capacity is also a disadvantage. At the current stage of development, Glass may be an adequate tool for education. For deployment in clinical care, issues such as hygiene, data protection, and privacy need to be addressed and are currently limiting chances for professional use.
doi:10.2196/jmir.3225
PMCID: PMC3936278  PMID: 24521935
Google Glass; forensic medicine; autopsy, postmortem examination; documentation
11.  Laparoscopic removal of a needle from the pancreas 
Foreign bodies inside the pancreas are rare and usually occur after the ingestion of sharp objects like fish bone, sewing needle and toothpick. Most of the ingested foreign bodies pass spontaneously through the anus without being noticed but about 1% of them can perforate through the wall of stomach or duodenum to reach solid organs like pancreas or liver. Once inside the pancreas they can produce complications like abscess, pseudoaneurysm or pancreatits. Foreign bodies of pancreas should be removed by endoscopic or surgical methods. We hereby report our experience of successful removal one a sewing needle from pancreas.
doi:10.4103/0972-9941.110968
PMCID: PMC3673579  PMID: 23741114
Foreign body; laparoscopy; pancreas; sewing needle
12.  Successful Laparoscopic Removal of an Ingested Toothbrush 
Most ingested foreign bodies will pass through the gastrointestinal tract without any problems. On the other hand long, slender objects such as a toothbrush will rarely be able to negotiate the angulated and fixed retroperitoneal duodenal loop. Spontaneous toothbrush passage has never been described and therefore endoscopic or surgical removal is always required. Here we describe an asymptomatic young female presenting to out-patient clinic with a history of unintentional toothbrush ingestion 4 years prior. Endoscopic removal was unsuccessful because the toothbrush was partially embedded in to the gastric mucosa. We describe the second case to date of laparoscopic removal of a toothbrush via a gastrotomy with subsequent intra-corporeal repair of the defect.
doi:10.4103/2006-8808.128751
PMCID: PMC3977335  PMID: 24741430
Foreign body; gastronintestinal; laparoscopic; surgery; toothbrush
13.  Sources of Potential Lead Exposure Among Pregnant Women in New Mexico 
Maternal and child health journal  2013;17(1):172-179.
The objectives of this study were to ascertain the prevalence and potential sources of lead exposure among pregnant women residing in a socially-disadvantaged immigrant community in Albuquerque, New Mexico. Pregnant women (n = 140) receiving prenatal care through a community clinic participated in a structured interview and screening to measure their blood lead levels (BLLs). Potential sources of lead exposure were ascertained by the CDC and New Mexico Department of Health questionnaires. Self-reported risk factors were examined as predictors of BLLs using multiple linear regression and partial least squares discriminant analysis. Most patients were Spanish-speaking (88.6%), Latina (95%), foreign-born (87.1%), lacked health insurance (86.4%), and had a high school education or lower (84.3%). While risk factors were prevalent in this population, only three women (2.1%) had BLLs ≥3 μg/dL. Results of multivariate analyses demonstrated that pica symptoms in pregnancy, history of elevated BLLs before pregnancy, use of non-commercial pottery, and living in older houses were important predictors of elevated BLLs. Although the prevalence of other risk factors relevant to immigrant communities (i.e., use of traditional/folk remedies and cosmetics, seasonings and food products from Mexico) was high, they were not predictive of elevated BLLs. Clinics providing prenatal care to immigrant Hispanic communities should carefully assess patients’ pica symptoms, use of non-commercial pottery, and a history of elevated BLLs. Moreover, additional efforts need to focus on the development of screening questionnaires which better reflect exposures of concern in this population.
doi:10.1007/s10995-012-0963-5
PMCID: PMC3564678  PMID: 22362260
Lead; Pregnancy; Hispanics; Immigrants; Environmental exposure; Screening; Questionnaires
14.  Pica patient, status post gastric bypass, improves with change in medication regimen 
The causes and origins of pica remain unknown and are the source of speculation and heated debate. Bariatric surgery patients are increasingly being observed in eating disorders treatment programs. Often associated with pregnancy, iron deficiency anemia, early development and mental retardation, pica has only recently been noted in post bariatric surgery patients, all of whom presented with pagophagia (eating of ice). Although there is literature detailing the presence of bezoars in gastric bypass patients, the association of pica, bezoars and abnormal eating behavior after bariatric surgery is still not understood completely. We present the case of a patient diagnosed with pica who underwent bariatric surgery due to a specific bezoar causing obstruction, followed by a treatment plan aimed at curbing the impulses. The patient was diagnosed to have a cardboard and paper bezoar causing gastric obstruction, which was removed endoscopically. After incomplete improvement of pica symptoms with treatment including ziprasidone, lorazepam and behavioral therapy, Saphris (asenapine) was introduced resulting in significant and complete resolution.
doi:10.1177/2045125314561221
PMCID: PMC4315675  PMID: 25653830
asenapine; bariatric surgery; eating disorder; impulse control; Saphris
15.  A Unique Case of Pica of Adult Onset with Interesting Psychosexual Aspects 
Pica has been considered as the ingestion of inedible substances or atypical food combinations. Pica has been reported widely in pediatric age group and often found to be co existing with obsessive compulsive or major depressive disorder. Reports of pica in elderly age group are relatively uncommon and rarely does it have an adult onset. In this article we present a case of adult onset pica. A young lady with unusual sensation in her abdomen was found to consume iron nails over years and there was history of dyspareunia since her marriage three months back. On query it was known that the lady is having same sex relationship over years. There unique conglomeration of cultural, psychodynamic and physiological determinants which together is responsible for this unusual habit of this lady. Moreover the onset of the disease at a late age and different psychodynamic issues make the case all the more interesting. Whether the pica is an eating disorder or obsessive compulsive disorder is still controversial. Pica has been mentioned in Diagnostic and Statistical Manual IV TR. The present case report warrants the need to look into this entity more closely with regards to its occurrence and etiology.
doi:10.4103/0253-7176.85405
PMCID: PMC3195165  PMID: 22021963
Adult onset; ingestion of nails; pica
16.  Pica associated with iron deficiency or depletion: clinical and laboratory correlates in 262 non-pregnant adult outpatients 
BMC Blood Disorders  2010;10:9.
Background
There are many descriptions of the association of pica with iron deficiency in adults, but there are few reports in which observations available at diagnosis of iron deficiency were analyzed using multivariable techniques to identify significant predictors of pica. We sought to identify clinical and laboratory correlates of pica in adults with iron deficiency or depletion using univariable and stepwise forward logistic regression analyses.
Methods
We reviewed charts of 262 non-pregnant adult outpatients (ages ≥18 y) who required treatment with intravenous iron dextran. We tabulated their sex, age, race/ethnicity, body mass index, symptoms and causes of iron deficiency or depletion, serum iron and complete blood count measures, and other conditions at diagnosis before intravenous iron dextran was administered. We excluded patients with serum creatinine >133 μmol/L or disorders that could affect erythrocyte or iron measures. Iron deficiency was defined as both SF <45 pmol/L and TS <10%. Iron depletion was defined as serum ferritin (SF) <112 pmol/L. We performed univariable comparisons and stepwise forward logistic regression analyses to identify significant correlates of pica.
Results
There were 230 women (184 white, 46 black; ages 19-91 y) and 32 men (31 white, 1 black; ages 24-81 y). 118 patients (45.0%) reported pica; of these, 87.3% reported ice pica (pagophagia). In univariable analyses, patients with pica had lower mean age, black race/ethnicity, and higher prevalences of cardiopulmonary and epithelial manifestations. The prevalence of iron deficiency, with or without anemia, did not differ significantly between patients with and without pica reports. Mean hemoglobin and mean corpuscular volume (MCV) were lower and mean red blood cell distribution width (RDW) and platelet count were higher in patients with pica. Thrombocytosis occurred only in women and was more prevalent in those with pica (20.4% vs. 8.3%; p = 0.0050). Mean total iron-binding capacity was higher and mean serum ferritin was lower in patients with pica. Nineteen patients developed a second episode of iron deficiency or depletion; concordance of recurrent pica (or absence of pica) was 95%. Predictors of pica in logistic regression analyses were age and MCV (negative associations; p = 0.0250 and 0.0018, respectively) and RDW and platelet count (positive associations; p = 0.0009 and 0.02215, respectively); the odds ratios of these predictors were low.
Conclusions
In non-pregnant adult patients with iron deficiency or depletion, lower age is a significant predictor of pica. Patients with pica have lower MCV, higher RDW, and higher platelet counts than patients without pica.
doi:10.1186/1471-2326-10-9
PMCID: PMC3022645  PMID: 21176208
17.  Clinical Utility of Serologic Testing for Celiac Disease in Asymptomatic Patients 
Executive Summary
Objective
The objective of this evidence-based analysis was to evaluate the clinical utility of serologic testing for celiac disease in asymptomatic individuals presenting with one of the non-gastrointestinal conditions evaluated in this report. The clinical utility was based on the effects of a gluten-free diet (GFD) on outcomes specific to each of these conditions. The prevalence of celiac disease in asymptomatic individuals and one of these non-gastrointestinal conditions was also evaluated.
Clinical Need and Target Population
Celiac Disease
Celiac disease is an autoimmune disease characterized by a chronic inflammatory state of the proximal small bowel mucosa accompanied by structural and functional changes.
Technology Under Evaluation
Serologic Tests for Celiac Disease
There are a number of serologic tests for celiac disease available. Serologic tests are automated with the exception of the anti-endomysial antibody test, which is more time-consuming and operator-dependent than the other tests.
Research Questions
What is the prevalence of asymptomatic celiac disease in patients presenting with one of the non-gastrointestinal conditions evaluated?
What is the effect of the gluten-free diet on condition-specific outcomes in patients with asymptomatic celiac disease presenting with one of the non-gastrointestinal conditions evaluated?
What is the clinical utility of serologic testing for celiac disease in asymptomatic patients presenting with one of the non-gastrointestinal conditions evaluated? The clinical utility was defined as the impact of the GFD on disease specific outcomes.
What is the risk of all-cause mortality and lymphoma in individuals with asymptomatic celiac disease?
What is the budget impact of serologic testing for celiac disease in asymptomatic subjects presenting with one of the non-gastrointestinal conditions evaluated?
Research Methods
Study Population
The study population consisted of individuals with newly diagnosed celiac disease without any symptoms consistent with the disease presenting with one of the non-gastrointestinal conditions evaluated. When evaluating the risk of lymphoma and all-cause mortality, the study population consisted of asymptomatic individuals with a positive celiac disease serologic test and/or small bowel biopsy.
Literature Search
Search Strategy
Literature searches were performed for each disease/condition evaluated between December 2010 and March 2011 using OVID MEDLINE, the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA). No restrictions for start date of search were used.
Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with an unknown eligibility were reviewed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established.
Inclusion Criteria
Studies, systematic reviews, and meta-analyses that assessed the effects of a GFD in patients with newly diagnosed asymptomatic celiac disease presenting with one of the non-gastrointestinal conditions evaluated. If symptoms were not reported in the study but subjects were identified through screening for celiac disease the study was included.
Studies, systematic reviews, and meta-analyses that assessed the prevalence of newly diagnosed asymptomatic celiac disease in patients with one of the non-gastrointestinal conditions evaluated. If symptoms were not reported in the study but subjects were identified through screening for celiac disease the study was included.
Studies, systematic reviews, and meta-analyses that evaluated the risk of all-cause mortality or lymphoma in individuals with asymptomatic celiac disease.
Sample size ≥ 10.
Publications in English.
Exclusion Criteria
Studies that retrospectively assessed the prevalence of asymptomatic celiac disease.
Studies that reported the prevalence of one of the non-gastrointestinal conditions evaluated in subjects already diagnosed with celiac disease.
Studies in individuals with one of the non-gastrointestinal conditions evaluated if the condition could be explained by other causes.
Studies in subjects with celiac disease and symptoms consistent with the disease. If the study included individuals with and without symptoms consistent with celiac disease and their results were analysed separately, the results in individuals without symptoms were included in the analysis.
Studies in which individuals did not report any symptoms consistent with celiac disease at study start but that either retrospectively reported the presence of such symptoms after following a GFD, or that previously presented with symptoms consistent with celiac disease.
Study results published in letters to the editor or comments about other studies.
Studies with a sample size ≥ 10, however, in which less than 10 patients were included in the analysis.
Outcomes of Interest
The effects of a GFD on disease-specific outcomes for each condition evaluated in patients with asymptomatic celiac disease was assessed. The prevalence of asymptomatic celiac disease in patients presenting with one of the conditions evaluated was also assessed.
Results of Evidence-Based Analysis
Three eligible observational studies evaluated the effects of GFD on growth parameters in subjects with asymptomatic celiac disease and idiopathic short stature. Four eligible observational studies evaluated the effects of GFD on metabolic control in subjects with asymptomatic celiac disease and type 1 diabetes. Five eligible observational studies evaluated the risk of all-cause mortality and five eligible observational studies evaluated the risk of lymphoma in subjects with asymptomatic celiac disease. No eligible studies on the effects of the GFD for the other conditions evaluated were identified. Twenty-three eligible studies measured the prevalence of asymptomatic celiac disease in subjects presenting with one of the conditions evaluated.
Prevalence of Celiac Disease in Asymptomatic Patients
The prevalence of celiac disease in asymptomatic patients presenting with one of the conditions evaluated was analysed. Most studies also included a control group that generally consisted of individuals randomly selected from the general population.
Although there was a trend to a higher prevalence of asymptomatic celiac disease in individuals with the conditions evaluated compared to the controls, it only reached statistical significance in type 1 diabetes. No eligible prevalence studies were identified in patients with amenorrhea, delayed puberty, alopecia, and depression.
The Effects of a Gluten-Free Diet on Disease-Specific Outcomes in Patients with Asymptomatic Celiac Disease
The effects of GFD on metabolic control in patients with asymptomatic celiac disease and Type 1 Diabetes
The effects of a GFD on metabolic control (HbA1c, number of hypoglycemic episodes, and changes in insulin dosage) in subjects with asymptomatic celiac disease and type 1 diabetes were evaluated.
One prospective case-control study reported an increase in HbA1c levels in cases with type 1 diabetes and asymptomatic celiac disease after the introduction of a GFD, however, the clinical significance of this change is unclear.
Only one eligible retrospective case-control study evaluated the effects of a GFD on hypoglycemia episodes and since there were inadequate details in the study about both the ascertainment and severity of hypoglycemia episodes in both cases and controls, it is not possible to draw conclusions regarding the effects of a GFD on hypoglycemia episodes based on this study.
One prospective case-control study did not show a statistically significant change in insulin dosage between cases with type 1 diabetes and asymptomatic celiac disease and controls with type 1 diabetes either before or after the introduction of a GFD.
No eligible studies that evaluated the effects of a GFD on the long-term outcomes of type 1 diabetes such as cardiovascular or renal events in patients with asymptomatic celiac disease were identified.
The effects of a Gluten-Free Diet in Patients with Idiopathic Short Stature and Asymptomatic Celiac Disease
A total of 3 eligible studies were identified. All studies consisted of case series that compared growth parameters in subjects with asymptomatic celiac disease and idiopathic short stature before and after the celiac disease was diagnosed and the GFD was instituted.
Most subjects included in the studies demonstrated an improvement in growth parameters. Compliance with the GFD was not reported in the studies. The results of the studies suggest an increase in growth velocity in pediatric patients with asymptomatic celiac disease and idiopathic short stature once a GFD is introduced.
Risk of lymphoma in patients with asymptomatic celiac disease
One retrospective cohort study evaluated the risk of lymphoma in patients with asymptomatic celiac disease. The authors concluded that the number of events identified was low during the long follow-up period and that the risk of overall malignancies was not increased among patients with asymptomatic celiac disease.
Risk of Asymptomatic Celiac Disease in Patients with Lymphoma
Four case-control studies, one of which retrospective, evaluated the risk of asymptomatic celiac disease in patients newly diagnosed with lymphoma. One retrospective cohort study did not show an increase in the risk of lymphoma among subjects with asymptomatic celiac disease. Three prospective case-control studies did not find a statistically significant risk of asymptomatic celiac disease in patients with newly diagnosed lymphoma.
Risk of All-Cause Mortality in Patients with Asymptomatic Celiac Disease
A total of 5 studies that evaluated the risk of all-cause mortality in asymptomatic patients with celiac disease were identified. There were 5 cohort studies, 2 prospective and 3 retrospective. The two prospective studies did not show an increased risk of all-cause mortality in subjects with asymptomatic celiac disease.
Grading of Evidence
The quality of the evidence for each serologic tests evaluated based on the GRADE Working Group criteria. Overall, the quality of the evidence ranged from low to very low depending on the outcome evaluated.
The Clinical Utility of Serologic Testing for Celiac Disease in Asymptomatic Subjects
Eligible studies that evaluated the effects of a GFD on disease-specific outcomes were only identified for two of the conditions evaluated, type 1 diabetes and idiopathic short stature.
The clinical utility of serologic testing for celiac disease in patients with type 1 diabetes without symptoms consistent with celiac disease was not demonstrated since the studies identified did not provide evidence of the impact of the GFD on either metabolic control or long-term outcomes in these patients.
The clinical utility of serologic testing for celiac disease in patients with idiopathic short stature without symptoms consistent with celiac disease was demonstrated since the studies identified showed an acceleration in growth once the diagnosis of celiac disease was made and a GFD was introduced.
The Budget Impact of Serologic Testing for Celiac Disease in Asymptomatic Patients
The budget impact of serologic testing for celiac disease in asymptomatic patients was calculated for the conditions for which clinical utility for serologic testing was demonstrated. The budget impact in patients with idiopathic short stature without symptoms consistent with celiac disease was estimated as C$552,000 as calculated by multiplying the number of individuals in Ontario with idiopathic short stature that may be eligible for the test by the cost of the serologic test for celiac disease.
Conclusions
Based on a review of the literature, there is an increased risk of asymptomatic celiac disease in patients with type 1 diabetes.
Based on low quality evidence, in patients with idiopathic short stature and asymptomatic celiac disease there is an acceleration in growth once a gluten-free diet is introduced.
With the exception of idiopathic short stature, there was no published evidence of clinical utility of celiac disease testing in asymptomatic patients with respect to a gluten-free diet intervention in the other conditions evaluated.
Based on low to very low quality evidence, asymptomatic celiac disease does not confer an increased risk of lymphoma or mortality.
Similarly, in patients with lymphoma there is no increased risk of asymptomatic celiac disease.
PMCID: PMC3377551  PMID: 23074415
18.  A Case of Endovascular Treatment for Followed by Side to Side Bypass for Vertebral Artery Dissecting Aneurysms Involved Posterior Inferior Cerebellar Artery 
Treatment of complex aneurysms usually entails not only direct clipping but also alternative treatment modality. We recently experienced a case of vertebral artery dissecting aneurysm and obtained good treatment outcomes. Our case suggests that the endovascular segmental occlusion with posterior inferior cerebellar artery (PICA) to PICA side anastomosis might be a good treatment option in patients with complex vertebral artery dissecting aneurysms. A 45-year-old woman has a left vertebral dissecting aneurysm with dizziness. Based on the aneurysmal morphology and the involvement of PICA, the patient underwent side to side anastomosis of the PICA. This was followed by the endovascular segmental coil occlusion. The aneurysmal sac was completely obliterated. At a 2-year follow-up, the patient achieved a good patency of both PICA. In conclusion our case suggests that the endovascular segmental occlusion of the parent artery followed by PICA to PICA bypass surgery through a midline suboccipital approach is a reasonable multimodal treatment option in patients with complex vertebral artery dissecting aneurysms.
doi:10.3340/jkns.2014.55.1.36
PMCID: PMC3928346  PMID: 24570816
PICA dissecting aneurysm; Segmental occlusion; Multimodal treatment; Complex aneurysm
19.  ‘IMPULSIVE PICA’: A NEW DIAGNOSTIC CATEGORY? 
Indian Journal of Psychiatry  2002;44(4):372-374.
Pica is an interesting psychiatric entity that merits special clinical attention. This report describes three cases of pica and calls for its separate nosological placement in clinical psychiatry. In the Diagnostic and statistical manual of mental disorders fourth edition (DSM-IV), pica is described as persistent eating of nonutritive substances for a period of at least 1 month which is inappropriate to the developmental level and not part of a culturally sanctioned practice (American Psychiatric Association, 1994). On the other hand, impulse-control disorders not elsewhere classified is defined as failure to resist an impulse, drive or temptation to perform an act that is harmful to the person or to others, feeling of an increasing sense of tension or arousal before committing the act and pleasure, gratification or relief at the time of committing the act or shortly thereafter (American Psychiatric Association, 1994). Regarding the aetiologies of Pica most contemporary literatures have cited various causative factors, e.g. normal exploratory orality of children, pregnancy, stress and conflicts, cultural beliefs, mental retardation, psychotic disorders and even nutritional deficiencies (Chatoor, 2000; Popper & West, 2001). Here, we report 3 atypical cases of Pica, attending outpatient department of the Institute of Psychiatry, Calcutta. These reported cases are unique in their time of onset, phenomenological progression and therapeutic responsiveness.
PMCID: PMC2955310  PMID: 21206603
Pica; Impulse-control disorder; Atypical obsession
20.  Less-healthy eating behaviors have a greater association with a high level of sugar-sweetened beverage consumption among rural adults than among urban adults 
Food & Nutrition Research  2011;55:10.3402/fnr.v55i0.5819.
Background
Sugar-sweetened beverage (SSB) consumption is associated with the increasing prevalence of overweight and obesity in the United States; however, little is known about how less-healthy eating behaviors influence high levels of SSB consumption among rural adults.
Objective
We assessed the frequency of SSB consumption among rural and urban adults, examined the correlates of frequent SSB consumption, and determined difference in correlates between rural and urban adults in a large region of Texas.
Design
A cross-sectional study using data on 1,878 adult participants (urban=734 and rural=1,144), who were recruited by random digit dialing to participate in the seven-county 2006 Brazos Valley Community Health Assessment. Data included demographic characteristics, eating behaviors (SSB consumption, frequency of fast-food meals, frequency of breakfast meals, and daily fruit and vegetable intake), and household food insecurity.
Results
The prevalence of any consumption of SSB and the prevalence of high consumption of SSB were significantly higher among rural adults compared with urban counterparts. The multivariable logistic regression models indicated that a high level of SSB consumption (≥3 cans or glasses SSB/day) was associated with demographic characteristics (poverty-level income and children in the home), frequent consumption of fast-food meals, infrequent breakfast meals, low fruit and vegetable intake, and household food insecurity especially among rural adults.
Conclusions
This study provides impetus for understanding associations among multiple eating behaviors, especially among economically and geographically disadvantaged adults. New strategies are needed for educating consumers, not only about how to moderate their SSB intake, but also how to simultaneously disrupt the co-occurrence of undesirable eating and promote healthful eating.
doi:10.3402/fnr.v55i0.5819
PMCID: PMC3153312  PMID: 21845142
sugar-sweetened beverages; household food insecurity; fast-food consumption; sugar drinks; rural
21.  A curious case of foreign body induced jejunal obstruction and perforation☆ 
INTRODUCTION
Accidental and unnoticed ingestion of foreign bodies are not very uncommon. Most of such foreign bodies pass through gastrointestinal tract uneventfully and only on rare instances cause obstruction and/or perforation.
PRESENTATION OF CASE
We are reporting a case in which a 45 yr old male presented to accident and emergency department of our institute with complaints of pain abdomen, greenish vomiting, abdominal distension, fever and non passage of flatus and stool following alcoholic binge 15 days back. On presentation tachycardia, hypotension, generalised abdominal tenderness and guarding were present. After initial resuscitation and investigation diagnosis of perforation peritonitis was made and emergency exploratory lapratomy was done and a single perforation with plastic foreign body protruding through it was found in jejunum 5 cm distal to duodeno-jejunal junction.
DISCUSSION
The majority of ingested FBs that reach the stomach pass uneventfully through the gastrointestinal tract. The majority of cases occur in children. Only 1% of patient of patients requires surgical intervention depending upon nature, size and shape of the foreign body.
CONCLUSION
Present case report intends to draw the attention towards possibility of intestinal obstruction and perforation by a single plastic foreign body. High index of suspicion is needed as this foreign body is not even radio-opaque and cannot be picked up in X-ray investigations. Also with increasing use of such plastic materials there are increased chances of such incidents.
doi:10.1016/j.ijscr.2013.12.028
PMCID: PMC4201021  PMID: 25105776
Foreign bodies; Jejunum; Intestinal obstruction; Intestinal perforation
22.  Nutrient Intakes of Men and Women Collegiate Athletes with Disordered Eating 
The objective of this study was to assess the macro- and micronutrient intakes of men and women collegiate athletes with disordered eating behaviors and to compare the nutrient intakes of athletes with restrictive- versus binge-eating behaviors. National Collegiate Athletic Association (NCAA) Division I University athletes (n = 232) were administered an anonymous, written questionnaire to compare nutrient intakes, desired weight change, and weight control behaviors in athletes with restrictive- (R) and binge- (B) eating behaviors to those in asymptomatic (A) athletes. T-tests, χ2 statistic, and ANOVA were used to test for differences among disordered eating groups within genders (p < 0.05). Data are means ± standard error of the mean. Among men athletes, those with disordered eating consumed a smaller percentage of energy from carbohydrate compared to controls (R = 49.7 ± 1.5; B = 48.7 ± 2.3; A = 53.4 ± 0.7%). Among female athletes, those with disordered eating wanted to lose a greater percentage of their current body weight than did asymptomatic athletes (B = -6.1 ± 1.4; R = -6.7 ± 1.1; A = -3.7 ± 0.4%). Women who were classified with binge eating consumed significantly more alcohol than did controls (B = 6.8 ± 1.3; A = 3.9 ± 0.4 g alcohol per day). Athletes with disordered eating were more likely to report restricting their intake of carbohydrate and fat and using supplements to control their weight than asymptomatic athletes. Disordered eating was not associated with greater frequencies of inadequate micronutrient intake in either gender. Athletes with disordered eating may be at significantly greater risk for nutritional inadequacies than athletes who are asymptomatic due to macronutrient restriction and greater alcohol consumption.
Key PointsAthletes with disordered eating were more likely to report restricting their intake of carbohydrate and fat and using supplements to control their weight than asymptomatic athletesAmong female athletes, those with disordered eating wanted to lose a greater percentage of their current body weight than did asymptomatic athletesDisordered eating was not associated with greater frequencies of inadequate micronutrient intake in either genderAthletes with disordered eating may be at significantly greater risk for nutritional inadequacies than athletes who are asymptomatic due to macronutrient restriction and greater alcohol consumption.
PMCID: PMC3887328  PMID: 24453529
Eating disorder; Female Athlete Triad
23.  Broadening the perspective of pica: literature review. 
Public Health Reports  1990;105(1):29-35.
Pica is an eating disorder that is manifested by a craving for oral ingestion of a given substance that is unusual in kind and or quantity. It is a long-standing practice that has far reaching implications for prevention and treatment--implications for public health as well as clinical personnel who work in settings where they have the potential for influencing health knowledge, attitudes, and behaviors of their patients. Pica practices also challenge researchers and social scientists whose work encompass development and refinement of models related to nutritional deficiencies. The body of literature on pica is so fragmented that it is difficult to find a precise summary of the knowns and unknowns about the condition. There is little consistency in defining pica, classifying substances ingested, identifying key characteristics of practicers, recommending treatment, or in projecting outcomes. This review presents a framework for understanding pica as a general practice, summarizes divergent reported hypotheses and conclusions, and illustrates that there is a need for more comprehensive studies of prevalence and incidence and use of deductive as well as inductive research processes.
PMCID: PMC1579989  PMID: 2106702
24.  Is lead a concern in Canadian autistic children? 
Paediatrics & Child Health  2010;15(1):17-22.
BACKGROUND:
The Centers for Disease Control and Prevention (CDC) threshold for intervention for blood lead level (BLL) is greater than 0.48 μmol/L, but new research suggests that there are adverse effects at any level of exposure. Children with autism are at increased risk for lead exposure and intoxication, and have later and more prolonged exposures because of exploratory oral behaviours and pica.
OBJECTIVE:
To estimate the mean BLL and prevalence of high BLL in a convenience sample of autistic children living in northern Alberta, based on the CDC threshold for intervention.
METHODS:
Children with autism were recruited from the clinics at the Glenrose Rehabilitation Hospital in Edmonton, Alberta. A complete blood count and differential, serum ferritin and BLL were requested after consent was obtained. Summary statistics were reported. For dichotomous outcomes, proportions were presented. Continuous outcomes for the two groups with a BLL of 0.1 μmol/L or greater, or less than 0.1 μmol/L were compared.
RESULTS:
None of the children tested had a BLL exceeding 0.48 μmol/L. Nine children (19%) had BLLs of 0.1 μmol/L or greater but less than 0.48 μmol/L, and 39 (81%) had BLLs of less than 0.1 μmol/L. Those with a BLL of 0.1 μmol/L or greater had significantly more pica or oral exploratory behaviours.
CONCLUSION:
Children with autism in northern Alberta may not be at risk for elevated BLLs that exceed the CDC threshold for intervention. They should be screened for lead exposure risk factors and tested if there are risks, especially behaviours relating to pica and oral exploration of objects. Clinicians may need to further explore the reasons for low-level exposures to lead in the autistic population.
PMCID: PMC2827318  PMID: 21197164
Autism; Development; Environment; Lead; Toxins
25.  Bacteremia Caused by a Swallowed Toothpick Impacted in the Gastric Mucosa 
Case Reports in Gastroenterology  2011;5(1):227-231.
Although most ingested foreign bodies usually pass through the gastrointestinal tract asymptomatically, toothpick injury to the gastrointestinal tract is often associated with significant morbidity and mortality. Toothpick perforation of the gastrointestinal tract is frequently reported but, to the best of our knowledge, bacteremia caused by an impacted toothpick within the gastric mucosa has not yet been described. Here, we report the case of bacteremia caused by an accidentally swallowed toothpick. The toothpick was impacted deeply in the gastric mucosa and was first seen and localized on contrast-enhanced computed tomography (CT). CT scan is a very useful imaging technique in such situations since we lack typical and relevant physical findings or laboratory studies that go with accidentally swallowed objects, in this case a toothpick. Flexible endoscopy was successful in extracting the whole toothpick. In cases without free perforation, flexible endoscopy is the treatment of choice in toothpick removal from the upper gastrointestinal tract.
doi:10.1159/000327974
PMCID: PMC3088754  PMID: 21552451
Bacteremia; Gastric mucosa; Toothpick; Computed tomography; Flexible endoscopy

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