Turner Syndrome Mosaicism after Diagnosis of Coeliac Disease-A High Index of Clinical Suspicion Required?

The association of coeliac disease (CD) in girls with Turner syndrome (TS) is well described. There is, however, a paucity of current research describing TS in patients with known CD. We report two cases of mosaic Turner syndrome diagnosed in girls with CD who failed to achieve expected catch-up growth despite strict adherence to a gluten-free diet (GFD) and the normalisation of TGA-IgA levels. We highlight the need to consider additional diagnoses in patients with CD and ongoing faltering growth. In such patients, referral to a paediatric endocrinologist and relevant investigations, including genetic investigations, should be considered if growth remains suboptimal after one year with a GFD. First-line investigations should include thyroid function, IGF-1, cortisol, gonadotrophins, oestrogen/testosterone, prolactin, karyotype and a bone age X-ray. Clinical suspicion in this situation is key, as an early diagnosis of TS will allow timely treatment with growth hormone, inform discussion around ovarian function and allow screening for important TS associations.

Cardiovascular risk factors in coeliac disease (ARCTIC): a protocol of multicentre series of studies

INTRODUCTION

There is only limited and controversial information available on the cardiovascular (CV) risk in coeliac disease (CD). In this study, we plan to investigate the body composition and CV risk-related metabolic parameters at the diagnosis of CD and on a gluten-free diet in a Hungarian cohort of patients with CD.

METHODS AND ANALYSIS

This study consists of two case-control studies and a prospective cohort study, involving newly diagnosed and treated patients with CD with age and sex-matched non-CD control subjects with an allocation ratio of 1:1. CD-related symptoms, quality of life, quality of the diet and CV risk will be assessed with questionnaires. Our primary outcomes are body composition parameters, which will be estimated with InBody 770 device. Secondary outcomes are CV-risk related metabolic parameters (eg, serum lipids, haemoglobin A1c, homeostatic model assessment index, liver enzymes, homocysteine, interleukin 6, galectin-3) and enteral hormones (leptin, ghrelin, adiponectin) measured from venous blood samples for all participants. Fatty liver disease will be assessed by transabdominal ultrasonography. In statistical analysis, descriptive and comparative statistics will be performed. With this study, we aim to draw attention to the often neglected metabolic and CV aspect of the management of CD. Findings may help to identify parameters to be optimised and reassessed during follow-up in patients with CD.

ETHICS AND DISSEMINATION

The study was approved by the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (27521-5/2022/EÜIG). Findings will be disseminated at research conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05530070.

Population-Based Screening for Coeliac Disease in Lithuanian Children from 2009 to 2014

Background and Objectives. Coeliac disease is an autoimmune disorder provoked by a dietary group of proteins called gluten in genetically predisposed individuals. Over the past several decades, the prevalence of coeliac disease has been steadily growing and it is now recognized to be occurring worldwide. The prevalence varies greatly between ethnic, racial groups and regionally. Such variability makes local epidemiological studies important for spreading awareness and setting a threshold for suspicion of coeliac disease. We explored the potential application of a quick point-of-care test for the purpose of detecting a presence of IgA class TG2 antibodies for coeliac disease and screening in a Lithuanian pediatric population. Previously, there were no data regarding coeliac disease prevalence in Lithuania. Materials and Methods. Overall, we included 1458 children 11-13 years of age from several Lithuanian schools selected randomly in this study. Utilizing one point-of-care test using a single blood sample taken from a fingertip, we identified the existence of IgA class TG2 antibodies. Only children whose parents gave consent were enrolled in the study. Those with positive IgA class TG2-ab were directed to a tertiary hospital for additional clinical assessment and confirmation of suspected coeliac disease. Results. A total of two (0.14%) of the 1458 enrolled children were detected with the presence of TG2 antibodies and the coeliac disease diagnosis was further confirmed with histological examination of duodenal biopsy samples. Additionally, we checked that patients had not previously reported any clinical symptoms and signs that could suggest coeliac disease or any other disease of the gastrointestinal tract. Conclusions. The detected prevalence of coeliac disease in the Lithuanian pediatric population is 1:729. The rapid finger prick test for the presence of IgA class TG2 antibodies is a reasonable and accurate method to screen for celiac disease in children.

Low Gluten Beers Contain Variable Gluten and Immunogenic Epitope Content

Gluten content labels inform food choice and people practicing a gluten-free diet rely upon them to avoid illness. The regulations differ between jurisdictions, especially concerning fermented foodstuffs such as beer. Gluten abundance is typically measured using ELISAs, which have come into question when testing fermented or hydrolysed foodstuffs such as beer. Mass spectrometry can be used to directly identify gluten peptides and reveal false negatives recorded by ELISA. In this survey of gluten in control and gluten-free beers, gluten protein fragments that contain known immunogenic epitopes were detected using liquid chromatography-mass spectrometry in multiple beers that claim to be gluten-free and have sufficiently low gluten content, as measured by ELISA, to qualify as being gluten-free in some jurisdictions. In fact, several purportedly gluten-free beers showed equivalent or higher hordein content than some of the untreated, control beers. The shortcomings of ELISAs for beer gluten testing are summarised, the mismatch between ELISA and mass spectrometry results are explored, and the suitability of existing regulations as they pertain to the gluten content in fermented foods in different jurisdictions are discussed.

Deep Vein Thrombosis Revealing A "Silent" Coeliac Disease

Introduction

We present a clinical case of a 45-year-old man with recurrent deep vein thrombosis (DVT) and multiple hospital admissions due to severe infectious conditions. A newfound hypoalbuminemia raised the suspicion of a protein-losing condition, with an upper endoscopy revealing lesions at the D2 level compatible with coeliac sprue and HLA typing positive for both DQ-2 and DQ-8.

Methods

A gluten free diet was started and apixaban was suspended.

Results

No new complications were reported.

Discussion

Multiple mechanisms are believed to be behind the association between DVT and coeliac disease. However, to this date, no consensus exists regarding the ideal duration of anticoagulation.

LEARNING POINTS

Coeliac disease should always be considered a systemic disease.Thromboembolism is a possible extraintestinal manifestation of coeliac disease.Coeliac disease should be considered as a possible cause of thromboembolism even in the absence of gastrointestinal symptoms, which it can precede by several years.

Update on the Pathogenesis of Enteropathy-Associated T-Cell Lymphoma

EATL is an aggressive T-cell non-Hodgkin lymphoma with poor prognosis and is largely localized to the small intestine. EATL is closely associated with coeliac disease (CD) and is seen mostly in patients originating from Northern Europe. Various factors are associated with an increased risk of developing EATL, such as viral infection, advanced age, being male, and the presence of the HLA-DQ2 haplotype. Clonal rearrangements in the TCR-β and γ genes have been reported in all EATL morphological variants with distinctive immunophenotypic characteristics. Although EATL can occur de novo, individuals with RCDII are at a higher risk of developing EATL. The cells of origin of EATL has been postulated to be normal small intestinal intraepithelial T-lymphocytes (IELs), and more recent evidence suggests a link between innate precursor IELs and EATL derived from refractory coeliac disease type II (RCDII). The immune microenvironment of mucosal cells within the small intestine enhances the process of neoplastic transformation of IELs into EATL. Cytokines such as IL-15 can activate and crucially deregulate the JAK-STAT signaling pathway by binding to receptors on the surface of IELs. Furthermore, mutations in the JAK/STAT pathway have been associated with RCDII-derived EATL.

A rare case of SCHMID metaphyseal chondrodysplasia associated with hypothyroidism,growth hormone deficiency and celiac disease: case report

SCHMID metaphyseal chondrodysplasia is a rare cause of short stature with a good prognosis regarding other types of chondrodysplasia in reason of the normal integrity of the growth plate.

CASE PRESENTATION

The authors present a rare case of 4-year-2-month-old boy referred to our Unit for harmonious short stature, he had a waddling gait, subtle micromelia, and hyperlordosis, no special facies.

CLINICAL DISCUSSION

The skeletal scan made the diagnosis of SCHMID metaphyseal chondrodysplasia. The first laboratory workup showed elevated thyroid stimulating hormone and anti-tissue transglutaminase immunoglobulin A. The duodenal biopsies confirmed the diagnosis of coeliac disease. Treatment of levothyroxine was initiated with a gluten-free diet .6 years later, his re-evaluation showed a low insulin-like growth factor 1 and low growth hormone peaks confirming the diagnosis of growth hormone deficiency, Growth hormone therapy was initiated with an adjusted dose of levothyroxine.

CONCLUSION

Other causes of short stature should not be missed when diagnosing chondrodysplasia, and further investigations should be carried out to detect other concomitant disorders since metaphyseal chondrodysplasia is a rare cause for short stature while hypothyroidism and coeliac disease are relatively common.

The Impact of Cellular Therapies on Gastrointestinal Diseases: Applications and Challenges

Gastrointestinal diseases are highly prevalent, and their burden significantly impacts the quality of life of affected individuals. Inflammatory and immune-mediated intestinal diseases usually have a chronic course without adequate therapeutic modalities. Although much has been reported to comprehend these diseases, many remain resistant and refractory to conventional treatment approaches. Therefore, recent approaches to cellular therapy using stem cells, like hematopoietic stem cells and mesenchymal stem cells, and other cellular immunosuppressive modalities, like T-regulatory cells, were introduced and investigated in treating gastrointestinal diseases. We aimed to conduct a literature review to discuss the applications and challenges of cellular therapeutics in gastrointestinal diseases. Evidence from published clinical trials supports the safety and efficacy of cellular treatment in different immune-mediated and inflammatory gastrointestinal diseases. They can offer a longer duration of remission, being able to adjust the dysregulated immune system. However, there are various challenges to be considered by future trials, including the limitations of current clinical trials, challenges in retrieval and application of these therapeutics, and their mutagenesis potential.

Diet quality, ultra-processed food consumption, and quality of life in a cross-sectional cohort of adults and teens with celiac disease

BACKGROUND

Coeliac disease (CeD), a common autoimmune condition, requires strict adherence to a gluten-free diet (GFD). Adherence to the GFD has been associated with quality of life (QOL). However, there may be other diet-related concerns, such as overall diet patterns, including diet quality or ultra-processed food (UPF) consumption, possibly associated with QOL among people with CeD following a GFD that have not been examined.

METHODS

Diet quality was determined based on 24-h diet recalls of a cross-sectional prospectively recruited sample of 80 participants (50 adults and 30 teens) with biopsy-confirmed CeD ('Study Sample') using the Healthy Eating Index and Alternate Mediterranean Diet score. The amount of UPF consumed was assessed using Nova, a food processing classification system. QOL was measured using Celiac Disease-Specific Quality of Life (CDQOL) and Celiac Disease Pediatric-Specific Quality of Life (CDPQOL). The Study Sample's diet patterns were compared with National Health and Nutrition Examination Survey (NHANES) groups (25 adults reporting prior CeD and GFD; 51 adults with new CeD and no GFD; 15,777 adults and 2296 teens without CeD). The relationship of the Study Sample's diet patterns with CDQOL/CDPQOL was assessed using analysis of covariance.

RESULTS

The Study Sample's diet patterns were suboptimal but generally favourable compared with all NHANES groups. Compared to Study Adults with the highest tertile of UPF, those with the lowest tertile had significantly higher CDQOL (mean: 67.6 vs. 78.3, p < 0.001). Compared to Study Teens with the lowest tertile of AMED, those with the highest tertile had significantly higher CDPQOL (mean: 67.0 vs. 79.9, p < 0.01).

CONCLUSIONS

Maintaining high diet quality and minimising UPF may be important for CeD-specific QOL among individuals with CeD maintaining a GFD.

Updated European guidelines for coeliac disease in children

In January 2020, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) updated its guidelines for the diagnosis of paediatric coeliac disease. The revised ESPGHAN guidelines offer a more streamlined approach to diagnostic pathways for the detection of this disease in children. This article provides an update for clinicians on how to diagnose and manage coeliac disease in children based on the revised guidelines and other available literature.

Effects of Lactiplantibacillus plantarum and Lacticaseibacillus paracasei supplementation on the faecal metabolome in children with coeliac disease autoimmunity: a randomised, double-blinded placebo-controlled clinical trial

Introduction

Coeliac disease is a lifelong immune-mediated enteropathy manifested as gluten intolerance in individuals carrying specific human leukocyte antigen (HLA) molecules. Other factors than genetics and gluten intake, however, may play a role in triggering the disease. The gut internal environment is thought to be one of these potential contributing factors, and it can be influenced throughout life.

Methods

We examine the impact of Lactiplantibacillus plantarum HEAL9 and Lacticaseibacillus paracasei 8700:2 supplementation on the faecal metabolome in genetically predisposed children having tissue transglutaminase autoantibodies, i.e., coeliac disease autoimmunity. Probiotic strains were selected based on their beneficial properties, including mucosal permeability and immune modulation effects. The intervention group (n = 40) and control group (n = 38) took the probiotics or placebo daily for 6 months in a double-blinded randomised trial. Faecal samples were collected at baseline and after 3 and 6 months and analysed using the 1H NMR for metabolome. The incorporation of 16S rRNA sequencing as a supportive dataset complemented the analysis of the metabolome data.

Results

During the 6 months of intervention, the stool concentrations of 4-hydroxyphenylacetate increased in the intervention group as compared to controls, whereas concentrations of threonine, valine, leucine, isoleucine, methionine, phenylalanine, aspartate, and fumarate decreased. Additionally, a noteworthy effect on the glycine, serine, and threonine metabolic pathway has been observed.

Conclusion

The findings suggest a modest yet significant impact of the probiotics on the faecal metabolome, primarily influencing proteolytic processes in the gut.

Clinical trial registration

ClinicalTrials.gov, NCT03176095.

Celiac Disease Masquerading as Extreme Thrombocytosis and Severe Anemia in a 52-Year-Old Female Patient: A Rare Case Presentation and Literature Review

Celiac disease (CD) is a chronic autoimmune disorder characterized by an immune-mediated response to gluten, resulting in small intestinal mucosal damage. While gastrointestinal (GI) symptoms are commonly associated with CD, atypical presentations can pose diagnostic challenges, particularly when hematological abnormalities are the primary manifestation. We report a case of a 52-year-old female patient who presented with paraesthesia, numbness in her hands and feet, marked thinness, extreme thrombocytosis, severe anemia, and mild electrolyte imbalance. Physical examination was unremarkable, except for the notable thinness. GI symptoms were absent, and there was no family history of gastroenterological diseases. Diagnostic evaluations, including serological tests and duodenal biopsy, confirmed the diagnosis of CD with grade 4 Marsh 3C classification. This case emphasizes the significance of considering CD as a potential cause for atypical hematological manifestations, such as extreme thrombocytosis secondary to severe anemia. Prompt recognition and appropriate management, including adherence to a gluten-free diet, can lead to symptom improvement and resolution of hematological abnormalities. It is crucial for healthcare professionals to recognize and be familiar with these atypical presentations to promote early diagnosis and enhance patient outcomes.

Skin gluten-related disorders: new and old cutaneous manifestations to be considered

The term gluten-related disorders (GRD) refer to a spectrum of different clinical manifestations triggered by the ingestion of gluten in genetically susceptible individuals, including coeliac disease (CD), wheat allergy and non-celiac gluten sensitivity (NCGS). GRD are characterized by a large variety of clinical presentations with both intestinal and extra-intestinal manifestations. The latter may affect almost every organ of the body, including the skin. Besides the well-known association between CD and dermatitis herpetiformis, considered as the cutaneous specific manifestation of CD, many other muco-cutaneous disorders have been associated to GRD. In this review, we analyzed the main features of dermatological diseases with a proven association with GRD and those that improve after a gluten-free diet, focusing on the newly described cutaneous manifestations associated with NCGS. Our main hypothesis is that a "cutaneous-gluten sensitivity," as specific cutaneous manifestation of NCGS, may exist and could represent a diagnostic marker of NCGS.

Helicobacter Pylori-Associated Gastritis in Middle Eastern Patients: A Case Series

Helicobacter pylori (H. pylori) infection is a common chronic infection responsible for upper gastrointestinal symptoms such as indigestion, belching, heartburn, and abdominal fullness along with nausea and vomiting. It is considered a transmissible infection, although the exact chain of transmission is not clear. H. pylori-associated infection is a major pathogenic factor for gastroduodenal ulcers and gastric carcinoma in most patients, which can be prevented with eradication therapy. Transmission of the bacterium occurs mainly between family members and during childhood. Others may remain asymptomatic or may present with atypical symptoms such as headache, fatigue/weakness, anxiety, and bloating. We present five interesting cases of H. pylori-positive patients who had variable presentations and were successfully treated with first-line therapy and salvage therapy.

Coeliac Disease: A Rare Cause of Myocardial Infarction With Non-Obstructive Coronary Arteries

Myocardial infarction with non-obstructive coronary arteries (MINOCA) poses a diagnostic dilemma. Identifying the underlying etiology is essential to ensuring appropriate management. Cardiac magnetic resonance (CMR) is a valuable tool that can aid clinicians for that purpose. Coeliac disease (CD) is characterized by hypercoagulability and a thrombotic state and represents an exceptional cause of MINOCA. We report the case of a 28-year-old woman who presented with chest pain. The diagnosis of non-ST-elevation MI was obtained based on ECG abnormalities and elevated troponin levels. Coronary angiography was normal. CMR showed late gadolinium enhancement in the lateral left ventricular wall, confirming the diagnosis of MINOCA. A duodenal biopsy allowed the diagnosis of CD. Anticoagulation and a gluten-free diet proved beneficial, with a good outcome after a five-year follow-up. This case highlights the essential role of CMR in MINOCA investigations and the importance of thorough etiological assessment in young patients with no cardiovascular risk factors.

Systematic Review and Dose-Response Meta-Analysis on the Relationship between Different Gluten Doses and Risk of Coeliac Disease Relapse

Gluten proteins are known as immunological triggers for inflammation resulting in mucosal lesions in patients with coeliac disease (CD). Adherence to a strict gluten-free diet (GFD) is currently known as the only effective treatment for CD. In this study, we performed a systematic review and dose-response meta-analysis on data from previous studies to investigate the association between different gluten doses administered and the risk of CD relapse. Electronic databases were systematically searched to retrieve studies that investigated the response of CD patients to different amounts of gluten intake and evaluated the clinical, serologic, and/or histologic evidence to recognize disease relapse. Study-specific relative risks (RRs) were combined using a random effects model. A total of 440 identified published papers were screened, of which 7 records were selected following full-text reviewing and eligibility assessment for dose-response meta-analysis. According to our analysis, the risk of CD relapse is estimated to be 0.2% (RR: 1.002; 95% CI: 1.001 to 1.004) following the consumption of 6 mg gluten/day, which was increased to 7% (RR: 1.07; 95% CI: 1.03 to 1.10), 50% (RR: 1.50; 95% CI: 1.23 to 1.82), 80% (RR: 1.80; 95% CI: 1.36 to 2.38), and 100% (RR: 2.00; 95% CI: 1.43 to 2.78) by the daily intake of 150, 881, 1276, and 1505 mg gluten, respectively. Although good adherence to a GFD can adequately control CD-related symptoms, disease relapse might happen even with a very low dose of gluten, and the duration of exposure to gluten is also an important matter. The current literature has substantial limitations, such as relying on the data from just a few countries that were different in terms of the amount of gluten administered, the duration of the challenge, etc. Therefore, more randomized clinical trials using a standardized gluten challenge protocol are needed to confirm the findings of the present study.

Clinical utility of urinary gluten immunogenic peptides in the follow-up of patients with coeliac disease

BACKGROUND

Gluten-free diet (GFD) is the only treatment for patients with coeliac disease (CD) and its compliance should be monitored to avoid cumulative damage.

AIMS

To analyse gluten exposures of coeliac patients on GFD for at least 24 months using different monitoring tools and its impact on duodenal histology at 12-month follow-up and evaluate the interval of determination of urinary gluten immunogenic peptides (u-GIP) for the monitoring of GFD adherence.

METHODS

Ninety-four patients with CD on a GFD for at least 24 months were prospectively included. Symptoms, serology, CDAT questionnaire, and u-GIP (three samples/visit) were analysed at inclusion, 3, 6, and 12 months. Duodenal biopsy was performed at inclusion and 12 months.

RESULTS

At inclusion, 25.8% presented duodenal mucosal damage; at 12 months, this percentage reduced by half. This histological improvement was indicated by a reduction in u-GIP but did not correlate with the remaining tools. The determination of u-GIP detected a higher number of transgressions than serology, regardless of histological evolution type. The presence of >4 u-GIP-positive samples out of 12 collected during 12 months predicted histological lesion with a specificity of 93%. Most patients (94%) with negative u-GIP in ≥2 follow-up visits showed the absence of histological lesions (p < 0.05).

CONCLUSION

This study suggests that the frequency of recurrent gluten exposures, according to serial determination of u-GIP, could be related to the persistence of villous atrophy and that a more regular follow-up every 6 months, instead of annually, provides more useful data about the adequate adherence to GFD and mucosal healing.

Coeliac Disease Case-Control Study: Has the Time Come to Explore beyond Patients at Risk?

The worldwide prevalence of asymptomatic coeliac disease (CD) is increasing, which is in part due to the routine screening of children with risk factors. Both symptomatic and asymptomatic patients with CD are at risk of long-term complications. The objective of this study was to compare the clinical characteristics of asymptomatic and symptomatic children at the time of CD diagnosis. A case-control study was conducted using data from a cohort of 4838 CD patients recruited from 73 centers across Spain between 2011 and 2017. A total of 468 asymptomatic patients (cases) were selected and matched by age and sex with 468 symptomatic patients (controls). Clinical data, including any reported symptoms, as well as serologic, genetic, and histopathologic data were collected. No significant differences were found between the two groups in most clinical variables, nor in the degree of intestinal lesion. However, the asymptomatic patients were taller (height z-score -0.12 (1.06) vs. -0.45 (1.19), p < 0.001) and were less likely to have anti transglutaminase IgA antibodies ≥ 10 times the upper normal limit (66.2% vs. 758.4%, p = 0.002). Among the 37.1% of asymptomatic patients who were not screened for CD due to the absence of risk factors, only 34% were truly asymptomatic, while the remaining 66% reported non-specific CD-related symptoms. Therefore, expanding CD screening to any child who undergoes a blood test could reduce the burden of care for some children, as many of those considered asymptomatic reported non-specific CD-related symptoms.

Regional Swedish study found that one in seven coeliac patients experienced loss of follow up during childhood

AIM

To examine the clinical follow up of paediatric coeliac disease and the rate of loss of follow up during childhood, for which data are scarce.

METHODS

In a cohort of coeliac children diagnosed in 2013-2018 in Gothenburg, Sweden, we retrospectively explored the follow-up practice of paediatric coeliac disease until June 2021. We used medical records from hospital-based paediatric gastroenterology and general paediatric outpatient clinics, laboratory records, and questionnaires. Loss of follow up was defined no coeliac disease-related follow up or tissue transglutaminase test over the past 2 years of study enrolment.

RESULTS

We included 162 children (58% girls) aged 7.8-18.2 years (average 12.7). Most participants (76%) were followed at general paediatric outpatient clinics rather than hospital-based clinics. After 2.3-8.8 (average 5.3) years since diagnosis, 23 patients (14%; 95% confidence interval, 9%-21%) had been lost to follow up. Patients with loss of follow up were more often boys (61% versus 39%, p = 0.08), with a somewhat longer average disease duration of 5.8 versus 5.2 years (p = 0.11). There were no between-group differences in socio-economic characteristics and patient-reported experience measures of coeliac disease care.

CONCLUSION

One in seven coeliac patients may experience loss of follow up during childhood.

Severity of coeliac disease and clinical management study when using a non-metabolised medication: a phase I pharmacokinetic study

OBJECTIVE

The non-metabolised antihistamine fexofenadine has oral absorption resulting from transporter activity. Uptake by enterocyte organic anion transporting polypeptides and efflux by an ATP-binding cassette transporter (P-glycoprotein) are primary determinants. Coeliac disease-mediated lesions to the small intestinal mucosa may alter oral absorption of the drug probe, fexofenadine.

DESIGN

A phase I, open-label, single-dose, pharmacokinetic study SETTING: London, Ontario, Canada PARTICIPANTS: Patients with coeliac disease (n=41) with positive serology and healthy individuals (n=48).

MAIN OUTCOME MEASURES

Patients with coeliac disease-duodenal histology and oral fexofenadine pharmacokinetics within a 3-week period. Healthy individuals-oral fexofenadine pharmacokinetics with water and grapefruit juice.

RESULTS

Patients with coeliac disease were stratified by disease severity: Group A (n=15, normal), B+C (n=14, intraepithelial lymphocytosis with/without mild villous blunting) and D (n=12, moderate to severe villous blunting). Patients with coeliac disease in groups A, B+C and D and healthy individuals receiving water had similar fexofenadine AUC0-8 (2038±304, 2259±367, 2128±410, 1954±138 ng.h/mL; p>0.05; mean±SEM) and Cmax (440±73, 513±96, 523±104, 453±32 ng/mL; p>0.05), respectively. These four groups all had higher fexofenadine AUC0-8 (1063±59; p<0.01) and Cmax (253±18; p<0.05) compared with those for healthy individuals receiving grapefruit juice. Coeliac groups had a positive linear trend between disease severity and fexofenadine Tmax (2.0±0.3, 2.7±0.4, 3.1±0.5 hours; p<0.05).

CONCLUSIONS

Coeliac disease severity based on duodenal histopathology did not affect oral fexofenadine bioavailability. Increased Tmax suggested absorption distal to the duodenum (jejunum + ileum), where histology seems more normal which may be the key determinant. Patients with coeliac disease may not require consideration for alternative clinical drug management for a number of non-metabolised and transport-mediated medications.

The Opinion of Polish Coeliac Patients on the Knowledge of Medical Professionals and Support Groups about Coeliac Disease-A Pilot Study

A high quality of knowledge and how it is communicated by healthcare professionals (HCPs) let the patient understand coeliac disease (CD) and result in better adherence to therapeutic recommendations. Therefore, the aim of the current study was to assess the opinion of Polish respondents with CD on the comprehension of CD among Polish HCPs. The analysis was based on 796 responses from patients (the members of the Polish Coeliac Society) with confirmed CD diagnosis (224; 28.1% children and 572; 71.9% adults). The most frequently consulted HCPs regarding CD symptoms in the analysed group were gastroenterologists, and various support groups and associations for CD patients. Furthermore, their comprehension of CD was rated best, as 89.3% (n = 552) of the patients who had contact with support groups and associations classified their knowledge on CD as good. More than a half of the respondents (n = 310, 56.6%) who had contact with general practitioners (GPs) due to their symptoms, rated the doctor's knowledge on CD as bad. Nurses' comprehension on CD was classified as bad by 45 (52.3%) respondents who had contact with a nurse. Out of 294 Polish patients with CD who had contact with a dietician, 247 (84.0%) assessed that the dietician communicated their knowledge on CD well. The respondents rated that GPs and nurses communicated their knowledge on CD in the worst manner (60.4% and 58.1%, respectively). Out of 796 respondents, 792 (99.5%) provided information about the number of appointments with GPs due to symptoms that occurred prior to CD diagnosis. The respondents had contact with GPs 13 863 times before obtaining a CD diagnosis due to their symptoms. After the establishment of a CD diagnosis, the number of appointments with GPs decreased to 3850, and the average number of appointments decreased from 17.8 to 5.1. The respondents assessed that the knowledge on CD of HCPs is not satisfactory. The work of support groups and associations on CD, who promote reliable CD diagnosis and treatment methods, should be promoted. The cooperation between various HCPs needs to be encouraged, which may lead to better compliance.

Serum Citrulline and Ornithine: Potential Markers of Coeliac Disease Activity

INTRODUCTION

To date, there is not generally accepted and universal indicator of activity, and functional integrity of the small intestine in patients with coeliac disease. The aim of our study was to investigate whether serum concentrations of the non-essential amino acids citrulline and ornithine might have this function.

METHODS

We examined serum citrulline and ornithine concentrations in a subgroup of patients with proven coeliac disease and healthy controls (blood donors).

RESULTS

A total of 94 patients with coeliac disease (29 men, mean age 53 ± 18 years; 65 women, mean age 44 ± 14 years) and 35 healthy controls (blood donors) in whom coeliac disease was serologically excluded (10 men, mean age 51 ± 14 years; 25 women, mean age 46 ± 12 years) were included in the study. Significantly lower concentrations of serum ornithine were found in patients with coeliac disease (mean 65 ± 3 μmol/L; median 63 μmol/L, IQR 34 μmol/L, p < 0.001). No statistically nor clinically significant differences were found in the citrulline concentrations between the study and control group.

CONCLUSIONS

Serum ornithine (but not citrulline) may be useful for assessing the functional status of the small intestine in uncomplicated coeliac disease. Further studies involving more detailed analysis of dietary and metabolic changes in patients will be needed to reach definitive conclusions.

Point-of-Care Screening for Coeliac Disease in Schoolchildren Reveals Higher Disease Prevalence in Croatia

Coeliac disease (CD) is an immune-mediated inflammatory disease triggered by dietary gluten and related proteins in genetically predisposed individuals. Point-of-care (POC) methods are non-invasive and easily performed tests, which could help to reduce the diagnostic delay of CD. The aim of our study was to determine the prevalence of CD using rapid POC test in first-grade schoolchildren in Zagreb, Croatia. A rapid qualitative immunoassay POC test designed for detection of immunoglobulin (Ig) A and IgG deamidated gliadin antibodies (DGP), as well as total IgA (to identify IgA deficient patients) in whole blood, was used to test healthy children on gluten containing diet. Out of 1404 tested children (51% female), 85 (6.05%) had a positive rapid POC test result and were referred to paediatric gastroenterologist. Finally, 7 children were diagnosed with CD (0.5%). There was no significant difference in children with CD and children with positive POC but negative serology in sex, BMI, or symptoms. However, children diagnosed with CD complained of abdominal pain significantly more often. The prevalence of CD in first-grade schoolchildren was 1:200 (0.5%), higher than in previous studies performed in Croatia. The results imply the possible benefit of IgA and IgG DGP-based POC tests in population screening.

The Mediterranean Diet in Paediatric Gastrointestinal Disorders

The Mediterranean diet is considered one of the healthiest dietary patterns worldwide, thanks to a combination of foods rich mainly in antioxidants and anti-inflammatory nutrients. Many studies have demonstrated a strong relationship between the Mediterranean diet and some chronic gastrointestinal diseases. The aim of this narrative review was to analyse the role of the Mediterranean diet in several gastrointestinal diseases, so as to give a useful overview on its effectiveness in the prevention and management of these disorders.

From Chilblains (Pernio) to Coeliac Disease-Should We Still Consider It Random?

Coeliac disease (CD) is a gluten-triggered, immune-mediated inflammatory disease occurring in genetically predisposed individuals, causing a variety of gastrointestinal and extraintestinal symptoms. The most common cutaneous association of CD is dermatitis herpetiformis, although recent reports have sought to link CD with other dermatological and autoimmune diseases. Chilblain, also called pernio, is usually a benign, superficial and localized inflammatory skin disorder that results from a maladaptive vascular response to non-freezing cold. We present a patient with pernio (chilblains) and newly diagnosed CD, with a significant intestinal lesion-total villous atrophy, as there are only two known cases of this feature associated with CD published in the literature. In the workup of chilblains (pernio) in children, an active case finding for coeliac disease should be conducted with coeliac-specific serology testing.