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Objectives Literature from stroke and cardiac hospital admissions demonstrate a higher prevalence of undiagnosed type 2 diabetes compared with the general population. Fewer diabetes screening studies exist in the general medicine population, none of which have been based in Canada. Our primary objective in this study was to determine the prevalence of probable undiagnosed diabetes (glycated hemoglobin [A1C]≥6.5%) in hospitalized medicine patients. Secondary objectives were to identify the prevalence of undiagnosed dysglycemia (A1C≥6.0%) and the subsequent management of emergent cases. Methods In this prospective cohort study, adult patients admitted to internal medicine at a tertiary hospital in Ontario were screened for diabetes using an A1C test over a 3-month period. Baseline demographics and outcomes were compared using t tests, chi-square tests and Fisher’s exact tests for normoglycemia, undiagnosed dysglycemia and probable undiagnosed diabetes. A regression analysis was performed to identify any relationships between various cardiovascular-related risk factors and A1C. Results A total of 53 adult patients were enrolled. The prevalence of probable undiagnosed diabetes and undiagnosed dysglycemia was 7.5% (n=4) and 30.2% (n=16), respectively. Implementation of diabetes management strategies and/or documentation of the finding occurred in 4 of 16 patients. Regression analysis showed no relationship between either cardiovascular-related risk factors or admission glucose with A1C. Conclusions A broader screening approach may capture previously undiagnosed cases of diabetes that do not belong to traditionally at-risk populations. Future studies should focus on identifying risk factors for undiagnosed dysglycemia in hospitalized patients, including ethnicity and barriers to community access, so that appropriate screening programs can be developed.

Individuals from South Asian communities are known to have a higher likelihood of developing type 2 diabetes (T2D), which is often attributed to individual lifestyle and behavioural factors. This focus on individual responsibility can position communities as complicit in their illness, compounding stigmatization and systemic discrimination. In this article, we explore the social determinants of health (SDOH) that influence health behaviours among South Asian adults with T2D from a service provider's perspective.Using a qualitative descriptive design, we conducted semistructured interviews with 12 community, social and health-care service providers. We used thematic analysis and the analytical concept of intersectionality to explore how different social locations and SDOH impact T2D management for South Asian adults.Three themes were identified: 1) managing challenges with settlement process, labour policies and job market disparities take priority over T2D management; 2) poor working conditions and low socioeconomic status reduce access to health care and medication; and 3) there are social, economic and cultural barriers to implementing diet and exercise recommendations.Service providers identified social, economic and systemic factors as influencing the higher prevalence of T2D among South Asian individuals. They also identified their important roles in providing culturally appropriate supports to address SDOH and described advocacy for changes to policies and practices that reinforce systemic racism. The providers further suggested that more equitable employment policies and practices are needed to address the systemic factors that contribute to the higher risk of T2D among South Asian adults in the Peel Region.

OBJECTIVE To determine if a structured transition program for young adults with type 1 diabetes improves clinic attendance, glycemic control, diabetes-related distress, quality of life, and satisfaction with care. RESEARCH DESIGN AND METHODS In this multicenter randomized controlled trial, young adults (17–20 years) with type 1 diabetes were randomly assigned to a transition program with a transition coordinator or to standard care. The intervention lasted 18 months (6 in pediatric and 12 in adult care). The primary outcome was the proportion of participants who failed to attend at least one adult diabetes clinic visit during the 12-month follow-up after completion of the intervention. RESULTS We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean [SD] number of visits 4.1 [1.1] vs. 3.6 [1.2], P = 0.002), and there was greater satisfaction with care (mean [SD] score 29.0 [2.7] vs. 27.9 [3.4], P = 0.032) and less diabetes-related distress (mean [SD] score 1.9 [0.8] vs. 2.1 [0.8], P = 0.049) reported than in standard care. There was a trend toward improvement in mean HbA1c (8.33% [68 mmol/mol] vs. 8.80% [73 mmol/mol], P = 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (P = 0.846), and the mean change in HbA1c did not differ between the groups (P = 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life. CONCLUSIONS Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.

Context Celiac disease (CD) is a common comorbidity seen in patients with type 1 diabetes (T1D) and is frequently asymptomatic. As chronic conditions requiring significant lifestyle changes, there are limited reports assessing changes in health-related quality of life (HRQoL) during transition to a gluten-free diet (GFD) in patients with T1D who are asymptomatic for CD. Objective This work aims to prospectively assess HRQoL and health perception in children and adults with T1D and asymptomatic CD after random assignment to GFD vs usual diet. Methods Patients with T1D aged 8 to 45 years without CD symptoms were serologically screened for CD, with positive results confirmed with intestinal biopsy. Participants were randomly assigned in an open-label fashion to a GFD or gluten-containing diet (GCD) for 12 months. Generic and diabetes-specific HRQoL and self-perceived wellness (SPW) were assessed longitudinally. Results A total of 2387 T1D patients were serologically screened. CD was biopsy-confirmed in 82 patients and 51 participants were randomly assigned to a GFD (N = 27) or GCD (N = 24). Excellent adherence to the assigned diets was observed. Overall, no changes in generic (P = .73) or diabetes-specific HRQoL (P = .30), or SPW (P = .41) were observed between groups over 12 months. Hemoglobin A1c (HbA1c) and gastrointestinal symptoms were consistent predictors of HRQoL and SPW. Conclusion HRQoL and SPW were not significantly affected by the adoption of a GFD over 12 months, but worsened with symptom onset and increased HbA1c. Our findings indicate that transition to a GFD can be made successfully in this population without adversely affecting quality of life.

OBJECTIVE To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD. RESEARCH DESIGN AND METHODS Asymptomatic patients (8–45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA1c and continuous glucose monitoring over 12 months. RESULTS Adults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9–8.2%, N = 1,298] vs. 4.7% [95% CI 3.4–5.9%, N = 1,089], P = 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, P < 0.0001). Fifty-one participants were randomized to a GFD (N = 27) or GCD (N = 24). No HbA1c differences were seen between the groups (+0.14%, 1.5 mmol/mol; 95% CI −0.79 to 1.08; P = 0.76), although greater postprandial glucose increases (4-h +1.5 mmol/L; 95% CI 0.4–2.7; P = 0.014) emerged with a GFD. CONCLUSIONS CD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.

Background: Significant variability is reported as to the presence and quality of gastrointestinal (GI) symptoms in patients with type 1 diabetes (T1D). Objective: To assess reported GI symptoms and associated comorbidities in adults and children with T1D. Methods: The Gastrointestinal Symptom Scale (GISS) and a Visual Analog Scale (VAS) were used to assess GI symptom type and severity in 2,370 patients with T1D aged 8-45 years as part the screening phase of the Celiac Disease and Diabetes Dietary Intervention and Evaluation Trial (CD-DIET). Co-morbidities, including diabetes-related complications, were extracted from clinical records. The presence and severity of GI symptoms and relationships with demographic, clinical and other diabetes-related factors were evaluated. Results: Overall, 1368 adults (57.7%) aged 19-45 years and 1002 (42.3%) pediatric patients aged 8-18 years were studied. At least one GI symptom was reported in 34.1% of adults as compared with 21.7% of children (p Conclusions: In this large screening study in a contemporary T1D cohort, significant differences were found between age groups with more frequent GI symptoms in adults. Significant associations were observed between GI symptoms and diabetes complications along with diabetes duration. Disclosure F.H. Mahmud: None. E. Nunes de Melo: None. A.B. Clarke: None. E. Assor: None. A. Parikh: None. A. Advani: Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH. Other Relationship; Self; Boehringer Ingelheim GmbH. B.A. Perkins: Advisory Panel; Self; Boehringer Ingelheim GmbH. Research Support; Self; Boehringer Ingelheim GmbH, Novo Nordisk Inc.. Advisory Panel; Self; Novo Nordisk Inc., Abbott. Speaker's Bureau; Self; Abbott, Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Insulet Corporation. Speaker's Bureau; Self; Insulet Corporation, Dexcom, Inc.. B.R. Shah: None. C.S. Zuijdwijk: None. C. McDonald: None. D. Mack: None. D. Koltin: None. E. Hsieh: None. E.M. Szentgyorgyi: None. F. Saibil: None. G. Mukerji: None. H.A. Lochnan: Research Support; Self; Amylin Pharmaceuticals, Boston Therapeutics, Inc., Sanofi. J. Gilbert: Other Relationship; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi. K. Bax: None. M.L. Lawson: None. M.D. Beaton: Advisory Panel; Self; Takeda Canada Inc., Janssen Pharmaceuticals, Inc., AbbVie Inc.. N.A. Saloojee: None. O. Lou: None. P.H. Gallego: None. R.L. Houlden: Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., AstraZeneca, Eli Lilly and Company. R. Aronson: Other Relationship; Self; Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi, AstraZeneca. Research Support; Self; Eli Lilly and Company, Becton, Dickinson and Company, Merck & Co., Inc., Senseonics, Boehringer Ingelheim Pharmaceuticals, Inc.. S.E. Kirsch: None. W.G. Paterson: None. Z. Punthakee: Research Support; Self; Amgen, Astra Zeneca/Bristol Myers Squibb, Lexicon, Merck, NovoNordisk, Sanofi. Speaker's Bureau; Self; Abbott, Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Janssen, Merck, NovoNordisk, Pfizer, Sanofi. Advisory Panel; Self; Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Dexcom, Janssen, Medtronic, NovoNordisk, Pfizer, Sanofi. M.A. Marcon: None.

Background: Celiac Disease (CD) is more common in individuals with type 1 diabetes (T1D) and is frequently asymptomatic. Despite this association, evidence as to the impact and diagnostic accuracy of CD screening is limited in asymptomatic patients with T1D. Objective: To describe CD serology and biopsy positivity rates in T1D patients screened as part of the Celiac Disease and Diabetes Dietary Intervention and Evaluation Trial (CD-DIET). Methods: Prospective data from patients, aged 8-45 years, with T1D screened at 22 sites across Ontario, Canada as part of CD-DIET were analyzed with respect to demographics, clinical symptoms and CD status. Serological and biopsy-confirmed rates of CD were evaluated. Results: Overall, 2585 patients were approached and 2386 patients completed serological testing using tissue transglutaminase antibodies. The sample included 1298 (54.4%) adults, aged 19-45 years, and 1088 (45.6%) pediatric subjects, aged 8-18 years. Mean age was 23.1 ± 10.3 years, 49.2% female, with mean duration of diabetes 12.2 ± 9.0 years. A small number of screened patients (N=45) were symptomatic for CD as per study criteria with clinical GI symptoms (n=39), osteoporosis (n=2), apthous ulcers (n=1), weight loss (n=1), and/or anemia (n=2). Overall, 140 asymptomatic patients were serologically positive for CD. A positive CD serology rate of 7.2% (94/1298) was seen in adults as compared to 4.2% (46/1088) in pediatric subjects (p=0.0064). Endoscopy was completed in 104 patients and CD was subsequently confirmed using duodenal biopsy in 54/71 adults (76.1%) and 28/33 pediatric patients (84.8%), with overall biopsy positivity rates of 4.2% and 2.6% respectively (p=0.034). Conclusions: Significant differences were observed in CD serology and biopsy positivity, with higher rates seen in adults as compared with children with T1D, which may be due to increasing risk of autoimmune co-morbidities with age as well as many adults being naïve to celiac disease screening. Disclosure F.H. Mahmud: None. A.B. Clarke: None. K.C. Joachim: None. E. Assor: None. A. Parikh: None. A. Advani: Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH. Other Relationship; Self; Boehringer Ingelheim GmbH. B.A. Perkins: Advisory Panel; Self; Boehringer Ingelheim GmbH. Research Support; Self; Boehringer Ingelheim GmbH, Novo Nordisk Inc.. Advisory Panel; Self; Novo Nordisk Inc., Abbott. Speaker's Bureau; Self; Abbott, Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Insulet Corporation. Speaker's Bureau; Self; Insulet Corporation, Dexcom, Inc.. B.R. Shah: None. C.S. Zuijdwijk: None. C. McDonald: None. D. Mack: None. D. Koltin: None. E. Hsieh: None. E.M. Szentgyorgyi: None. F. Saibil: None. G. Mukerji: None. H.A. Lochnan: Research Support; Self; Amylin Pharmaceuticals, Boston Therapeutics, Inc., Sanofi. J. Gilbert: Other Relationship; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi. K. Bax: None. M.L. Lawson: None. M.D. Beaton: Advisory Panel; Self; Takeda Canada Inc., Janssen Pharmaceuticals, Inc., AbbVie Inc.. N.A. Saloojee: None. O. Lou: None. P.H. Gallego: None. R.L. Houlden: Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., AstraZeneca, Eli Lilly and Company. R. Aronson: Other Relationship; Self; Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi, AstraZeneca. Research Support; Self; Eli Lilly and Company, Becton, Dickinson and Company, Merck & Co., Inc., Senseonics, Boehringer Ingelheim Pharmaceuticals, Inc.. S.E. Kirsch: None. W.G. Paterson: None. Z. Punthakee: Research Support; Self; Amgen, Astra Zeneca/Bristol Myers Squibb, Lexicon, Merck, NovoNordisk, Sanofi. Speaker's Bureau; Self; Abbott, Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Janssen, Merck, NovoNordisk, Pfizer, Sanofi. Advisory Panel; Self; Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Dexcom, Janssen, Medtronic, NovoNordisk, Pfizer, Sanofi. M.A. Marcon: None.

Background: As related autoimmune conditions, celiac disease (CD) is more common in individuals with type 1 diabetes (T1D) and is frequently asymptomatic. Despite this association, evidence as to the diagnostic accuracy of screening as well as the potential benefits or harms of screening for CD is limited in asymptomatic patients with T1D. Methods: T1D patients, aged 8-45 years, were serologically screened for CD at multiple centers across Ontario, Canada as part of the Celiac Disease and Diabetes Dietary Intervention and Evaluation Trial (CD-DIET). Patients were deemed asymptomatic on the basis of the absence of GI symptoms, weight changes, anemia and other CD-related clinical features. Screening was conducted in 2,386 patients using chemiluminescent (CL, BioFlash™) and/or ELISA (Celikey™) tissue transglutaminase (TTG) IgA assays, yielding 140 positives. Of these, 104 patients had a duodenal biopsy with CD confirmation (Marsh ≥2). Receiver operating characteristic (ROC) curve analysis was conducted and positive predictive values (PPV) of available screening tests for CD were evaluated. Results: CL and ELISA data were available for 100/104 and 36/104 patients, respectively. The area under the curve of the ROC for CL TTG was 0.918, while the PPV using the manufacturer referenced upper limit (RUL) of 30 CU was 85.9% (95% CI: 82.3-90.8%). According to our data, an optimal cut-off of 156.5 CU, or 5.2 times the RUL, showed an improved PPV of 95.8% (95% CI: 92.4-100.0%). With respect to ELISA TTG, the PPV was 94.4% at the RUL of 8 U/ml and reached to 100% at the optimal cut-off determined by our analysis of 58.7 U/ml, which translates to 7.3 times the RUL. Conclusion: Results from serologic CL and ELISA TTG assays that were greater than 5 times the reported upper limit showed a high PPV for biopsy-confirmed CD in asymptomatic adult and pediatric T1D patients, which may help guide diagnostic evaluation in this population. Disclosure M. Gould: None. F.H. Mahmud: None. A.B. Clarke: None. E. Assor: None. A. Parikh: None. A. Advani: Research Support; Self; AstraZeneca, Boehringer Ingelheim GmbH. Other Relationship; Self; Boehringer Ingelheim GmbH. B.A. Perkins: Advisory Panel; Self; Boehringer Ingelheim GmbH. Research Support; Self; Boehringer Ingelheim GmbH, Novo Nordisk Inc.. Advisory Panel; Self; Novo Nordisk Inc., Abbott. Speaker's Bureau; Self; Abbott, Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Insulet Corporation. Speaker's Bureau; Self; Insulet Corporation, Dexcom, Inc.. B.R. Shah: None. C.S. Zuijdwijk: None. C. McDonald: None. D. Mack: None. D. Koltin: None. E. Hsieh: None. E.M. Szentgyorgyi: None. F. Saibil: None. G. Mukerji: None. H.A. Lochnan: Research Support; Self; Amylin Pharmaceuticals, Boston Therapeutics, Inc., Sanofi. J. Gilbert: Other Relationship; Self; AstraZeneca, Boehringer Ingelheim GmbH, Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi. K. Bax: None. M.L. Lawson: None. M.D. Beaton: Advisory Panel; Self; Takeda Canada Inc., Janssen Pharmaceuticals, Inc., AbbVie Inc.. N.A. Saloojee: None. O. Lou: None. P.H. Gallego: None. R.L. Houlden: Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., AstraZeneca, Eli Lilly and Company. R. Aronson: Other Relationship; Self; Novo Nordisk Inc., Janssen Pharmaceuticals, Inc., Sanofi, AstraZeneca. Research Support; Self; Eli Lilly and Company, Becton, Dickinson and Company, Merck & Co., Inc., Senseonics, Boehringer Ingelheim Pharmaceuticals, Inc.. S.E. Kirsch: None. W.G. Paterson: None. Z. Punthakee: Research Support; Self; Amgen, Astra Zeneca/Bristol Myers Squibb, Lexicon, Merck, NovoNordisk, Sanofi. Speaker's Bureau; Self; Abbott, Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Janssen, Merck, NovoNordisk, Pfizer, Sanofi. Advisory Panel; Self; Astra Zeneca/Bristol Myers Squibb, Boehringer Ingelheim/Eli Lilly, Dexcom, Janssen, Medtronic, NovoNordisk, Pfizer, Sanofi. M.A. Marcon: None.

To present a case of presumed autoimmune hypophysitis that occurred concurrently with severe postpartum cardiomyopathy and pneumonitis.We describe the clinical, laboratory, and imaging findings in a young postpartum woman who presented with decompensated heart failure.Two weeks after childbirth, a 37-year-old previously healthy woman required urgent pericardiocentesis and inotropic support because of new-onset left ventricular systolic dysfunction, pericardial effusions, and hypotension. Analysis of pericardial fluid was negative for malignant cells and culture, and no cardiac tamponade or thrombus was evident. Results of a rheumatologic serology survey were negative, as was an assessment for antithyroid antibodies. Chest radiography revealed bilateral pleural effusions. Magnetic resonance imaging of the pituitary showed a homogeneously enlarged gland, consistent with the postpartum state, but no discrete pituitary lesions. Laboratory results included low levels of thyrotropin, free triiodothyronine, free thyroxine, and cortisol and a high erythrocyte sedimentation rate. The patient's symptoms responded to prednisone therapy (60 mg/day) as well as an angiotensin-converting enzyme inhibitor and a b -adrenergic blocking agent. Follow-up magnetic resonance images showed an atrophic pituitary with an empty sella turcica.To our knowledge, this is the first reported case of concomitant presumed autoimmune hypophysitis, complete anterior pituitary failure, postpartum cardiomyopathy, and pneumonitis.

The objective was to prospectively define cardiac and vascular function in adolescents and young adults with type 1 diabetes over a 3-year period. Thirty-three subjects with type 1 diabetes were studied in 1998, and 28 returned for follow-up in 2001. There were 28 controls without diabetes. All subjects underwent ultrasonography of the carotid artery to determine distensibility, compliance, and intimal-medial thickness, as well as echocardiographic studies, lipid profile, and measurement of hemoglobin A1c (HbA1c) levels and urinary albumin excretion rate. The diabetes group showed no significant change over the 3-year follow-up in lipid profile, HbA1c level, or albumin excretion rate, but a significant increase in body mass index. The diabetes and control groups were similar in age, lipid profile, and albumin excretion rate. Carotid artery distensibility and compliance in the diabetes group increased significantly from baseline to follow-up but did not differ significantly from controls. The intimal-medial thickness of the diabetes group remained unchanged over time but tended to be higher than controls. Echocardiographic studies showed no difference between the diabetes and control groups, but there was a small change in left ventricular posterior diastolic wall diameter in the subjects with diabetes over the 3-year period. There was an overall improvement in carotid function and no change in cardiac measures in subjects with diabetes over the 3 years, such that cardiac and vascular function were similar to those of controls. The reason for the improvement is uncertain, but may relate to the improvement of insulin sensitivity at the end of the pubertal growth period, rather than to changes in metabolic control or lipid profiles.

Coronary heart disease is a major cause of morbidity and mortality in North America. Its prevention is therefore an important clinical goal. Individuals with both Type 1 and Type 2 diabetes mellitus are at increased risk of developing heart disease as compared with those without diabetes. Carotid ultrasound is now a well-validated tool to study the presence and progression of cardiovascular disease. Using ultrasound one can determine elastic properties of the vessel wall (distensibility and compliance) as well as intima-media thickness (IMT). Several large studies have shown that IMT is a useful predictor of future cardiovascular events such as myocardial infarction and stroke, and is well correlated with other traditional risk factors such as blood pressure, lipids, level of glycemic control, and smoking. For this reason, carotid ultrasound may add valuable clinical information above and beyond that provided by traditional risk factors. The use of carotid ultrasound in the pediatric and adolescent population is increasing, and one study has shown decreased distensibility in adolescents with Type 1 diabetes mellitus versus controls. However, IMT measurements in the children and teens with Type 1 diabetes have yielded conflicting results, and larger, longitudinal studies are needed in this area.

Objective: To determine the presence and correlates of early heart and blood vessel dysfunction in adolescents with type 1 diabetes mellitus (DM) of relatively short duration. Study design: A total of 33 patients with DM (20 male, mean age 15.8 ± 1.3 years, mean DM duration 9.3 ± 3.9 years) and 16 healthy subjects in a nondiabetic control group (7 male, mean age 17.4 ± 1.7 years) underwent (1) ultrasonography of the right carotid artery to assess distensibility, compliance, and intimal-medial thickness (IMT), (2) echocardiographic assessment of systolic and diastolic ventricular function, (3) lipid profile and hemoglobin A1c, and (4) overnight timed urine collections for albumin excretion rate. Results: Ultrasonography showed significantly lower carotid artery distensibility in the DM group (38.5 ± 8.2 × 10-3 vs 46.5 ± 11.7 × 10-3/kPa, P =.01) but no difference in compliance (14.0 ± 3.4 × 10-7 vs 15.8 ± 2.9 × 10-7m2/kPa, P =.08) or IMT (0.061 ± 0.013 vs 0.060 ± 0.014 cm, P =.77). Left ventricular (LV) end-diastolic diameter, LV posterior wall thickness, end-systolic wall stress, shortening fraction, ejection fraction, LV mass, and diastolic function were similar in both groups. Total cholesterol, low density lipoprotein, high density lipoprotein, triglycerides, and blood pressure were also similar. The median albumin excretion rate was 4.8 μg/min in the DM group (range 1.1 to 19.2) and 3.0 μg/min in the control group (range 1.4 to 5.8) (P =.03). Hemoglobin A1c correlated inversely with both distensibility (r = –.43, P =.02) and compliance (r = –.39, P =.032). Conclusions: This study indicates that early changes in macrovascular function, namely lower carotid artery distensibility, may precede abnormalities in cardiac function or in arterial IMT in adolescents with short duration type 1 DM. It also supports a relationship between hyperglycemia and carotid artery dysfunction. (J Pediatr 2000;137:465-9)

Introduction: Coeliac disease (CD) is an autoimmune condition characterised by gluten-induced intestinal inflammation, and observed at a 5-10 fold greater prevalence in type 1 diabetes. While universal screening for CD in patients with diabetes is frequently advocated, objective data is limited as to benefits on diabetes control, bone health or quality of life related to the adoption of a gluten-free diet (GFD) in the large proportion of patients with diabetes with asymptomatic CD. The Celiac Disease and Diabetes-Dietary Intervention and Evaluation Trial (CD-DIET) study is a multicenter, randomised controlled trial to evaluate the efficacy and safety of a GFD in patients with type 1 diabetes with asymptomatic CD. Methods and analysis: Children and adults (8-45 years) with type 1 diabetes will be screened for asymptomatic CD. Eligible patients with biopsy-proven CD will be randomly assigned in a 1:1 ratio to treatment with a GFD for 1 year, or continue with a gluten-containing diet. The primary outcome will evaluate the impact of the GFD on change in glycated haemoglobin. Secondary outcomes will evaluate changes in bone mineral density, blood glucose variability and health-related quality of life between GFD-treated and the regular diet group over a 1-year period. The study was initiated in 2012 and has subsequently expanded to multiple paediatric and adult centres in Ontario, Canada. Ethics and dissemination: The findings from this study will provide high-quality evidence as to the impact of GFD treatment on glycaemic control and complications in asymptomatic children and adults with CD and type 1 diabetes. Trial registration number: NCT01566110.

Context Problem based learning (PBL) has become an integral component of medical curricula around the world. In Ontario, Canada, PBL has been implemented in all five Ontario medical schools for several years. Although proper and timely feedback is an essential component of medical education, the types of feedback that students receive in PBL have not been systematically investigated. Objectives In the first multischool study of PBL in Canada, we sought to determine the types of feedback (grades, written comments, group feedback from tutor, individual feedback from tutor, peer feedback, self-assessment, no feedback) that students receive as well as their satisfaction with these different feedback modalities. Subjects and methods We surveyed a sample of 103 final year medical students at the five Ontario schools (University of Toronto, McMaster University, Queens University, University of Ottawa and University of Western Ontario). Subjects were recruited via E-mail and were asked to fill out a questionnaire. Results Many students felt that the most helpful type of feedback in PBL was individual feedback from the tutor, and indeed, individual feedback was one of the more common types of feedback provided. However, although students also indicated a strong preference for peer and group feedback, these forms of feedback were not widely reported. There were significant differences between schools in the use of grades, written comments, self-assessment and peer feedback, as well as the immediacy of the feedback given. Conclusions Across Ontario, students do receive frequent feedback in PBL. However, significant differences exist in the types of feedback students receive, as well as the timing. Although rated highly by students at all schools, the use of peer feedback and self-assessment is limited at most, but not all, medical schools.