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Chandler K, Robins G. Determining whether coeliac disease case-finding in primary care is better than random testing: a retrospective study. BJGP Open 2019; 3:bjgpopen19X101648. [PMID: 31366679 DOI: 10.3399/bjgpopen19X101648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/05/2019] [Indexed: 11/24/2022] Open
Abstract
Background Over 75% of patients (approximately half a million) with coeliac disease in the UK have not been formally diagnosed. Aim To determine if case-finding of coeliac disease is better than random testing in primary care. Design & setting A pragmatic study looked at all referrals across a 12-month period (December 2013–November 2014) for coeliac serology testing and the indications for testing across 38 GP practices in a well-defined geographical area in North Yorkshire. There was further follow-up for an additional 12 months to determine conversion of positive serology to duodenal biopsy. Method All serology samples sent into York Hospital biochemistry department during the study period were analysed for the indication for testing. Positive results were cross-referenced for duodenal biopsies over the following 12 months on the York Hospital pathology database. Results Case-finding of coeliac patients in primary care is no better than random testing of the population. Only 71% of patients with positive serology went on to have a duodenal biopsy in the following 12 months. Conclusion More education of the population and of primary care physicians is needed around the indications for checking for coeliac disease. It may be that primary care is not the best place to case-find patients with coeliac disease.
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Cheminant M, Bruneau J, Malamut G, Sibon D, Guegan N, van Gils T, Cording S, Trinquand A, Verkarre V, Lhermitte L, Brousse N, Jannot AS, Khater S, Frenzel L, Delarue R, Suarez F, Marçais A, Mulder CJ, Macintyre E, Asnafi V, Pouyet L, Bonnafous C, Lhospice F, Molina TJ, Meresse B, Cellier C, Cerf-Bensussan N, Hermine O. NKp46 is a diagnostic biomarker and may be a therapeutic target in gastrointestinal T-cell lymphoproliferative diseases: a CELAC study. Gut 2019; 68:1396-1405. [PMID: 30448772 DOI: 10.1136/gutjnl-2018-317371] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/15/2018] [Accepted: 11/05/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Primary GI T-cell lymphoproliferative diseases (T-LPD) are heterogeneous entities, which raise difficult diagnosis and therapeutic challenges. We have recently provided evidences that lymphomas complicating coeliac disease (CD) arise from innate-like lymphocytes, which may carry NK receptors (NKRs). DESIGN NKRs expression was compared by flow cytometry in intraepithelial lymphocytes (IEL) from CD, type I or type II refractory CD (RCD). NKp46 was next assessed by immunohistochemistry in paraffin-embedded biopsies from 204 patients with CD, RCDI, RCDII or GI T-cell lymphomas and from a validation cohort of 61 patients. The cytotoxic properties of an anti-NKp46 monoclonal antibody conjugated to pyrrolobenzodiazepine (PBD) was tested ex vivo in human primary tumour cells isolated from fresh duodenal biopsies. RESULTS NKp46 (but not CD94, NKG2A, NKG2C, NKG2D) was significantly more expressed by malignant RCDII IEL than by normal IEL in CD and RCDI. In paraffin biopsies, detection of >25 NKp46+ IEL per 100 epithelial cells discriminated RCDII from CD and RCDI. NKp46 was also detected in enteropathy-associated T-cell lymphomas (EATL, 24/29) and in monomorphic epitheliotropic intestinal T-cell lymphomas (MEITL, 4/4) but not in indolent T-LPD (0/15). Treatment with anti-NKp46-PBD could efficiently and selectively kill human NKp46+ primary IEL ex vivo. CONCLUSION NKp46 is a novel biomarker useful for diagnosis and therapeutic stratification of GI T-LPD. Strong preclinical rationale identifies anti-NKp46-PBD as a promising therapy for RCDII, EATL and MEITL.
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Affiliation(s)
- Morgane Cheminant
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Julie Bruneau
- INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Pathology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - Georgia Malamut
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, HEGP Hospital, AP-HP, Paris, France.,INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - David Sibon
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Nicolas Guegan
- INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - Tom van Gils
- Department of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Sascha Cording
- INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - Amélie Trinquand
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Biological Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1151, Necker-Enfants Malades Institute, Paris, France
| | - Virginie Verkarre
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Pathology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - Ludovic Lhermitte
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Biological Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1151, Necker-Enfants Malades Institute, Paris, France
| | - Nicole Brousse
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Pathology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - Anne-Sophie Jannot
- Biomedical Informatics and Public Health Department, HEGP Hospital, AP-HP, Paris, France
| | - Sherine Khater
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, HEGP Hospital, AP-HP, Paris, France
| | - Laurent Frenzel
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Richard Delarue
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Felipe Suarez
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Ambroise Marçais
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Chris Jj Mulder
- Department of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Elizabeth Macintyre
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Biological Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1151, Necker-Enfants Malades Institute, Paris, France
| | - Vahid Asnafi
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Biological Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1151, Necker-Enfants Malades Institute, Paris, France
| | | | | | | | - Thierry Jo Molina
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Pathology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France
| | - Bertrand Meresse
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - Christophe Cellier
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Department of Gastroenterology, HEGP Hospital, AP-HP, Paris, France.,INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - Nadine Cerf-Bensussan
- Paris Descartes University-Sorbonne Paris Cité, Paris, France.,INSERM UMR1163, Laboratory of Intestinal Immunity, Imagine Institute, Paris, France
| | - Olivier Hermine
- Clinical Haematology, Necker-Enfants Malades University Hospital, AP-HP, Paris, France.,INSERM UMR1163 & CNRS URL 8254, Imagine Institute, Paris, France.,Paris Descartes University-Sorbonne Paris Cité, Paris, France
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Abstract
Over the last decades, there has been an impressive progress in our understanding of coeliac disease pathogenesis and it has become clear that the disorder is the final result of complex interactions of environmental, genetic, and immunological factors. Coeliac disease is now considered a prototype of T-cell-mediated disease characterized by loss of tolerance to dietary gluten and the targeted killing of enterocytes by T-cell receptor αβ intraepithelial lymphocytes. Accumulating evidence, however, indicates that the induction of a gluten-specific T helper-1 response must be preceded by the activation of the innate immune system. Mast cells are key players of the innate immune response and contribute to the pathogenesis of a multitude of diseases. Here, we review the results of studies aimed at investigating the role of mast cells in the pathogenesis of coeliac disease, showing that these cells increase in number during the progression of the disease and contribute to define a pro-inflammatory microenvironment.
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Abstract
Wheat gluten has an immense impact on human nutrition as it largely determines the processing properties of wheat flour, and in particular the ability to make leavened breads, other baked products, pasta and noodles. However, there has been increasing interest in wheat gluten over the past two decades because of its well-established role in triggering coeliac disease, and its perceived role in other adverse reactions to wheat. The literature on wheat gluten is vast and extends back over two centuries, with most studies focusing on the structures of gluten proteins and their role in determining the functional properties of wheat flour and dough. This article provides a concise account of wheat gluten, focusing on properties, and features which are relevant to its role in triggering coeliac disease and, to a lesser extent, other gluten-related disorders. It includes descriptions of the biological role of the gluten proteins, the structures and relationships of gluten protein families, and the presence of related types of protein which may also contribute to functional properties and impacts on health. It therefore provides an understanding of the gluten protein system at the level required by those focusing on its impact on human health.
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Affiliation(s)
- Peter Shewry
- Rothamsted Research, Harpenden, Hertfordshire, United Kingdom
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205
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Snir O, Kanduri C, Lundin KEA, Sandve GK, Sollid LM. Transcriptional profiling of human intestinal plasma cells reveals effector functions beyond antibody production. United European Gastroenterol J 2019; 7:1399-1407. [PMID: 31839965 DOI: 10.1177/2050640619862461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 06/05/2019] [Indexed: 01/22/2023] Open
Abstract
Background Plasma cells (PCs) are terminally differentiated B-lymphocytes producing antibodies. In coeliac disease (CeD) there is increased density of PCs in the small-intestinal lesion. Many of these PCs produce disease-specific autoantibodies targeting transglutaminase 2 (TG2). Objective The plasmacytosis of CeD motivated us to study the transcriptional programme of PCs from coeliac gut lesions. Methods RNA-seq was performed on the PCs of CeD patients and disease controls, being specific or non-specific for TG2. Results Being antibody-producing cells, 67% of the PCs' transcript was aligned to immunoglobulin genes. Strikingly, genes encoding ligands and receptors of chemokines and cytokines were abundant. Higher transcript levels of genes associated with cell activation and immune responses were observed in PCs of CeD patients compared to controls. TG2-specific compared to non-TG2 specific PCs expressed increased levels of CXCR3, CXCL10 and interleukin-15; factors that have been implicated in the pathogenesis of CeD yet with production attributed to other cells than PCs. The presence of transcripts of HLA class II and T-cell co-stimulatory molecules suggests that PCs may serve as antigen-presenting cells for CD4 + helper T cells. Conclusions Our findings shed new light on the biology of intestinal PCs, implicating functions that go beyond the production of immunoglobulins.
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Affiliation(s)
- Omri Snir
- Department of Immunology, University of Oslo and Oslo University Hospital-Rikshospitalet, Oslo, Norway.,KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
| | - Chakravarthi Kanduri
- KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway.,Department of Informatics, University of Oslo, Oslo, Norway
| | - Knut E A Lundin
- KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Geir Kjetil Sandve
- KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway.,Department of Informatics, University of Oslo, Oslo, Norway
| | - Ludvig M Sollid
- Department of Immunology, University of Oslo and Oslo University Hospital-Rikshospitalet, Oslo, Norway.,KG Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
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206
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Hanci O, Jeanes YM. Are gluten-free food staples accessible to all patients with coeliac disease? Frontline Gastroenterol 2019; 10:222-228. [PMID: 31281622 PMCID: PMC6583765 DOI: 10.1136/flgastro-2018-101088] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/14/2018] [Accepted: 09/23/2018] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Within England the removal of prescribed gluten-free (GF) foods from many Clinical Commissioning Groups has resulted in a greater reliance on commercially available GF food by adults and children with coeliac disease (CD). High cost and limited availability of GF foods are associated with poorer dietary adherence in people with CD. AIM To assess if the rise in popularity of GF diets globally has improved the cost or availability of cereal-based GF foods over the past 6 years. DESIGN Observational study where data were collected on cereal-based GF foods from 50 stores and 10 internet retailers. The number of GF foods within each food category and the cost per 100 g of GF and gluten-containing (GC) foods were compared by store type. RESULTS GF food availability has increased in premium stores and online. The majority (82%) of GF food categories were significantly more expensive online compared with regular supermarkets. On average, GF breads were 400% more expensive compared with GC breads (p<0.001); no narrowing in cost difference over time observed. Convenience stores did not stock any GF bread nor GF pasta and only one of the budget supermarkets stocked them, similar to data reported 6 years ago. CONCLUSIONS GF food availability has increased, predominately in premium markets. The GF food desert within convenience and budget stores will continue to disproportionately impact poor socioeconomic cohorts, the elderly and physically disabled. A lack of accessibility to GF foods impacts GF dietary adherence, increasing related comorbidities and healthcare costs.
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Affiliation(s)
- Ozan Hanci
- Department of Paediatrics, Royal Surrey County Hospital, Guildford, UK
| | - Yvonne M Jeanes
- Department of Life Sciences, Health Sciences Research Centre, University of Roehampton, London, UK
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207
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Pasternack C, Koskinen I, Hervonen K, Kaukinen K, Järvelin J, Reunala T, Collin P, Huhtala H, Mattila VM, Salmi T. Risk of fractures in dermatitis herpetiformis and coeliac disease: a register-based study. Scand J Gastroenterol 2019; 54:843-848. [PMID: 31280614 DOI: 10.1080/00365521.2019.1636132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Dermatitis herpetiformis (DH) is a cutaneous manifestation of coeliac disease. Bone fracture risk is increased in coeliac disease, but little knowledge exists about bone complications in DH. This study aimed to evaluate the risk of hip and other hospital-treated fractures in DH and coeliac disease in a high prevalence area with good adherence to a gluten-free diet. Materials and methods: Hip, proximal humerus, wrist and ankle fractures in 368 treated DH and 1076 coeliac disease patients between 1970 and 2015 were reviewed from the National Hospital Discharge Register. Hip fracture incidence rates for DH and coeliac disease patients were compared to those for the general population. The overall fracture risk for DH was compared to coeliac disease. Results: The hip fracture incidence rates for DH and coeliac disease patients did not differ from the general population. In females aged 80-89, the hip fracture incidence was higher in DH than in coeliac disease, but the risk for any hospital-treated fracture was lower in DH compared to coeliac disease (adjusted HR 0.620, 95% CI 0.429-0.949). The DH and coeliac disease patients with hospital-treated fractures were diagnosed at an older age, but the degree of small bowel mucosal damage did not significantly differ between patients with and without fractures. Conclusion: The incidence of hip fracture is not increased in treated DH or coeliac disease in an area with high awareness and dietary compliance rates. However, patients with DH seem to have a lower risk for fractures overall compared to coeliac disease.
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Affiliation(s)
- Camilla Pasternack
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University , Tampere , Finland
| | - Inka Koskinen
- Department of Internal Medicine, Central Finland Central Hospital , Jyväskylä , Finland
| | - Kaisa Hervonen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University , Tampere , Finland.,Department of Dermatology, Tampere University Hospital , Tampere , Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University , Tampere , Finland.,Department of Internal Medicine, Tampere University Hospital , Tampere , Finland
| | - Jutta Järvelin
- National Institute for Health and Welfare , Helsinki , Finland
| | - Timo Reunala
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University , Tampere , Finland.,Department of Dermatology, Tampere University Hospital , Tampere , Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital , Tampere , Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University , Tampere , Finland
| | - Ville M Mattila
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital , Tampere , Finland
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Health Technology, Tampere University , Tampere , Finland.,Department of Dermatology, Tampere University Hospital , Tampere , Finland
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208
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Antiga E, Maglie R, Quintarelli L, Verdelli A, Bonciani D, Bonciolini V, Caproni M. Dermatitis Herpetiformis: Novel Perspectives. Front Immunol 2019; 10:1290. [PMID: 31244841 PMCID: PMC6579917 DOI: 10.3389/fimmu.2019.01290] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023] Open
Abstract
Dermatitis herpetiformis (DH) is an inflammatory disease of the skin, considered the specific cutaneous manifestation of celiac disease (CD). Both DH and CD occur in gluten-sensitive individuals, share the same Human Leukocyte Antigen (HLA) haplotypes (DQ2 and DQ8), and improve following the administration of a gluten-free diet. Moreover, almost all DH patients show typical CD alterations at the small bowel biopsy, ranging from villous atrophy to augmented presence of intraepithelial lymphocytes, as well as the generation of circulating autoantibodies against tissue transglutaminase (tTG). Clinically, DH presents with polymorphic lesions, including papules, vesicles, and small blisters, symmetrically distributed in typical anatomical sites including the extensor aspects of the limbs, the elbows, the sacral regions, and the buttocks. Intense pruritus is almost the rule. However, many atypical presentations of DH have also been reported. Moreover, recent evidence suggested that DH is changing. Firstly, some studies reported a reduced incidence of DH, probably due to early recognition of CD, so that there is not enough time for DH to develop. Moreover, data from Japanese literature highlighted the absence of intestinal involvement as well as of the typical serological markers of CD (i.e., anti-tTG antibodies) in Japanese patients with DH. Similar cases may also occur in Caucasian patients, complicating DH diagnosis. The latter relies on the combination of clinical, histopathologic, and immunopathologic findings. Detecting granular IgA deposits at the dermal-epidermal junction by direct immunofluorescence (DIF) from perilesional skin represents the most specific diagnostic tool. Further, assessing serum titers of autoantibodies against epidermal transglutaminase (eTG), the supposed autoantigen of DH, may also serve as a clue for the diagnosis. However, a study from our group has recently demonstrated that granular IgA deposits may also occur in celiac patients with non-DH inflammatory skin diseases, raising questions about the effective role of eTG IgA autoantibodies in DH and suggesting the need of revising diagnostic criteria, conceivably emphasizing clinical aspects of the disease along with DIF. DH usually responds to the gluten-free diet. Topical clobetasol ointment or dapsone may be also applied to favor rapid disease control. Our review will focus on novel pathogenic insights, controversies, and management aspects of DH.
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Affiliation(s)
- Emiliano Antiga
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Roberto Maglie
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Lavinia Quintarelli
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Alice Verdelli
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Diletta Bonciani
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Veronica Bonciolini
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Marzia Caproni
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
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209
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Croall ID, Trott N, Rej A, Aziz I, O'Brien DJ, George HA, Hossain MY, Marks LJS, Richardson JI, Rigby R, Hadjivassiliou M, Hoggard N, Sanders DS. A Population Survey of Dietary Attitudes towards Gluten. Nutrients 2019; 11:E1276. [PMID: 31195638 DOI: 10.3390/nu11061276] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023] Open
Abstract
It is unclear how the prevalence of people who believe the gluten-free diet (GFD) to be generally healthy (“Lifestylers”) is impacting the overall rates of self-reported gluten sensitivity (GS). We repeated a population survey from 2012 in order to examine how attitudes towards GS have changed over time. Our survey (N = 1004) was administered in Sheffield (UK) in 2015, replicating the 2012 experiment. The questionnaire included a food frequency survey and assessed self-reported GS as well as associated variables (prevalence, current diet, pre-existing conditions, etc.). The overall rates of key variables and chi-squared analysis in comparison to the previous survey were as follows: self-reported GS was 32.8% (previously 12.9%, p < 0.001), pre-existing coeliac disease (CD) was 1.2% (previously 0.8%, p = 0.370), following a GFD was 3.7% (previously 3.7%, p = 0.997). Self-reported GS was positively associated with some pre-existing conditions, including anxiety, depression, chronic fatigue, headaches, and other food allergies/intolerances (including irritable bowel syndrome (IBS); chi-squared analyses, all p < 0.001). Over a 3-year period, the fraction of people who self-reported GS increased by over 250%. Despite this, arguably more meaningful indications of underlying physiological GS remained comparable. This research suggests that the public perception of gluten is causing a marked increase in the number of people who erroneously believe they are sensitive to it.
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210
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Stroud C, Almilaji O, Nicholas D, Kirkham S, Surgenor SL, Williams I, Snook J. Evolving patterns in the presentation of coeliac disease over the last 25 years. Frontline Gastroenterol 2019; 11:98-103. [PMID: 32134410 PMCID: PMC7043089 DOI: 10.1136/flgastro-2018-101170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/11/2019] [Accepted: 05/18/2019] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To document changes in the clinical features of coeliac disease (CD) at presentation over the last 25 years. DESIGN Observational study. PATIENTS 802 subjects diagnosed between 1993 and 2017 at a single general hospital. OUTCOME MEASURES Date of diagnosis, age, sex, postcode, symptoms, haematinic deficiency, smoking status, serology, family history and autoimmune phenomena. RESULTS The incidence of diagnosed CD rose threefold during the course of the study, with a rising prevalence of positive coeliac serology and positive family history of CD, and a falling prevalence of symptoms and haematinic deficiencies. There was little change in the female predominance, age at diagnosis or high prevalence of other autoimmune conditions over the 25 years, and a paucity throughout of cigarette smokers, particularly heavy smokers. A cohort of patients with seronegative CD was identified who shared many of the characteristics of seropositive CD, but with a significantly older age at diagnosis and a higher prevalence of cigarette smokers. CONCLUSION There have been major changes in the epidemiology of CD over the last 25 years, of relevance to both our understanding of the aetiopathogenesis of CD and the requirement for service provision. The implications are discussed.
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211
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Fernández-Bañares F, Carrasco A, Rosinach M, Arau B, García-Puig R, González C, Tristán E, Zabana Y, Esteve M. A Scoring System for Identifying Patients Likely to Be Diagnosed with Low-Grade Coeliac Enteropathy. Nutrients 2019; 11:E1050. [PMID: 31083384 DOI: 10.3390/nu11051050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND & AIMS Determining whether patients with lymphocytic enteritis (LE) have coeliac disease is a challenge. We analysed the variables associated with a low-grade coeliac enteropathy diagnosis in patients with suspected coeliac disease but without villous atrophy, and developed a scoring system to identify them. METHODS We collected data from 2010 through to 2016 on patients with lymphocytic enteritis and persistent symptoms compatible with the clinical spectrum of coeliac disease. One hundred and four patients starting on a gluten-free diet (GFD) were included. Duodenal biopsies were collected before the GFD and analysed for numbers of CD3+ T-cell receptor gamma delta+ (TCRγδ+), and CD3- intraepithelial lymphocytes. We performed a logistic regression analysis to identify factors associated with a low-grade coeliac enteropathy diagnosis. RESULTS Sixty-two patients achieved clinical remission after the GFD. Fifty of these 62 patients were diagnosed with low-grade coeliac enteropathy. Multivariate analysis identified the presence of >25% intraepithelial lymphocytosis, HLA-DQ2.5, positive serology, and increased numbers of TCRγδ+ cells with a low-grade coeliac enteropathy diagnosis. We developed a scoring system that identified patients with an area under the ROC curve (AUC) of 0.91. Scores of >10 had 86% sensitivity and 85% specificity. CONCLUSION We developed a scoring system that identifies patients likely to be diagnosed with low-grade coeliac enteropathy with an AUC value of 0.91.
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Pritchard L, Waters C, Murray IA, Bebb J, Lewis S. Comparing alternative follow-up strategies for patients with stable coeliac disease. Frontline Gastroenterol 2019; 11:93-97. [PMID: 32134411 PMCID: PMC7043074 DOI: 10.1136/flgastro-2018-101156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/19/2019] [Accepted: 04/07/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Once clinically stable, patients with coeliac disease should have annual follow-up. Lack of capacity in gastroenterology outpatient clinics mean alternatives are required. OBJECTIVES We studied the effectiveness of follow-up deferred to general practitioners (GP-FU) and compared this with a neighbouring Trust where follow-up was through a dedicated nurse-led telephone clinic (T-FU). DESIGN All patients with coeliac disease were posted a questionnaire examining patient satisfaction, adherence with gluten-free diet and calcium intake. RESULTS 517 of 825 patients (62.7%) completed a postal questionnaire (median age 61, 72% female). 28% of GP-FU and 84% of T-FU patients received an annual review. Of those seen, 33% (GP-FU) and 53% (T-FU) were weighed (χ2 65.8, p<0.001), 44% and 63% had symptom review (χ2 81.1, p<0.001) and 33% and 51% had dietary adherence checked (χ2 60.6, p<0.001). Almost all patients considered their adherence with gluten-free diet (GFD) good or excellent, although the majority of patients failed to achieve the recommended daily intake of calcium. GP-FU patients were more likely to receive calcium±vitamin D supplements (77% vs 42%, χ2 88.2, p<0.001) and they were also more likely to receive appropriate vaccinations (67% vs 38%, χ2 17.6, p<0.001). CONCLUSIONS Discharge of patients with coeliac disease to primary-care in many cases results in their complete loss to follow-up. When patients were reviewed, either by GP-FU and T-FU, many aspects of their care are not addressed. Whether this will result in late complications remains to be seen.
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Affiliation(s)
| | - Carolyn Waters
- Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - James Bebb
- Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
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213
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Gazi MA, Das S, Mahfuz M, Hasan MM, Hossain MS, Fahim SM, Alam MA, Noor Z, Gilchrist CA, Petri WA, Rahman MM, Mazumder RN, Haque R, Sarker SA, Ahmed T. Screening for coeliac disease in children and adults living in a slum of Dhaka, Bangladesh. BMJ Open Gastroenterol 2019; 6:e000294. [PMID: 31139429 PMCID: PMC6506126 DOI: 10.1136/bmjgast-2019-000294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/28/2019] [Accepted: 04/03/2019] [Indexed: 11/22/2022] Open
Abstract
Background and objective Serological screening with a confirmation through biopsy has improved the understanding of coeliac disease (CD) epidemiology worldwide. Prevalence of CD in Bangladesh is not yet explored and therefore, we aimed to assess the seroprevalence of CD in slum-dwelling malnourished children and adults in Dhaka. Methods Serum samples were collected from three different cohorts: stunted (length-for-age Z-scores (LAZ) <−2) and at risk of stunting children (LAZ <−1 to −2) and malnourished adults (body mass index <18.5 kg/m2). Samples from all the participants were assessed for anti-tissue transglutaminase antibody (tTG-IgA) and total serum IgA by ELISA. Positive tTG-IgA and randomly selected low IgA values were reconfirmed using anti-tTG-IgG and gliadin IgG ELISA. CD was diagnosed when second screening tests were found positive and the participants were further investigated by small bowel biopsy. Results A total of 818 participants (240 stunted, 272 at risk of stunting children and 306 malnourished adults) were enrolled in the study. Overall, anti-tTG-IgA was positive in 5/818 (0.6%; 95% CI 0.25% to 1.46%). Of the five positive cases, anti-tTG-IgG and gliadin IgG were found positive in only one participant. Duodenal biopsy of positive participant revealed characteristic lesions of CD. Randomly selected low IgA values were found negative in tTG-IgG and gliadin IgG for all the participants. No participant was found total IgA deficient. Conclusion The incidence of coeliac autoimmunity is low in malnourished slum dwellers regardless of age in Bangladesh. It is important to investigate the nationwide prevalence to reveal the definite picture.
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Affiliation(s)
- Md Amran Gazi
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Subhasish Das
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Mehedi Hasan
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Shabab Hossain
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Md Ashraful Alam
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Zannatun Noor
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Carol A Gilchrist
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, Virginia, USA
| | - William A Petri
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, Virginia, USA
| | - M Masudur Rahman
- Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh
| | | | - Rashidul Haque
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
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Habura I, Fiedorowicz K, Woźniak A, Idasiak-Piechocka I, Kosikowski P, Oko A. IgA nephropathy associated with coeliac disease. Cent Eur J Immunol 2019; 44:106-8. [PMID: 31114445 DOI: 10.5114/ceji.2019.84021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/08/2018] [Indexed: 11/23/2022] Open
Abstract
Coeliac disease (CD) is an autoimmune disorder of the small intestine triggered by ingested gluten from barley, rye and wheat. It can be associated with other autoimmune conditions, such as type 1 diabetes, autoimmune thyroiditis and hepatitis, Sjögren’s syndrome and IgA nephropathy (IgAN). We describe here a case of a 24-year-old man with the above-mentioned atypical form of coeliac disease for whom the diagnosis started with renal disorder. The diagnosis of nephrotic syndrome was established and the coexistence with CD was also suspected. In fact, immunoglobulin (Ig) A and IgG antibodies against endomysium and against gliadin were detected in serum of the patient and the endoscopic biopsy of the duodenum revealed stage 3B CD. Percutaneous kidney biopsy was also performed. Class I IgAN was diagnosed. Gluten-free diet, ACE inhibitor and oral iron were introduced to the patient. The improvement of clinical and laboratory disorders of CD as well as gradual remission of the nephrotic syndrome were observed. In conclusion, there may be a small group of patients with IgAN coexisting with CD in whom a gluten-free diet seems to be the treatment of choice for the resolution of kidney disease.
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215
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Gallo M, Nigro F, Passannanti F, Nanayakkara M, Lania G, Parisi F, Salameh D, Budelli A, Barone MV, Nigro R. Effect of pH control during rice fermentation in preventing a gliadin P31-43 entrance in epithelial cells. Int J Food Sci Nutr 2019; 70:950-958. [PMID: 30969137 DOI: 10.1080/09637486.2019.1599827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Coeliac disease is an increasingly recognised pathology, induced by the ingestion of gluten in genetically predisposed patients. Undigested gliadin peptide can induce adaptive and innate immune response that unleash the typical intestinal mucosal alterations. A growing attention is paid to alternative therapeutic approaches to the gluten-free diet: one of these approaches is the use of probiotics and/or postbiotics. We performed lactic fermentation of rice flour with and without pH control, using Lactobacillus paracasei CBA L74 as fermenting strain. We evaluated bacterial growth, lactic acid production during fermentation and gliadin peptide P31-43 entrance in CaCo-2 cells with and without pH control. When pH control was applied no differences were observed in terms of bacterial growth; on the contrary, lactic acid production was greater, as expected. Both samples could inhibit the P31-43 entrance in CaCo-2 cells but the effect was significantly greater for samples obtained when the pH control was applied.
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Affiliation(s)
- Marianna Gallo
- DICMAPI, University of Naples Federico II , Naples , Italy.,Engineering Department, University of Rome Niccolò Cusano , Rome , Italy
| | - Federica Nigro
- Engineering Department, University of Rome Niccolò Cusano , Rome , Italy
| | | | - Merlin Nanayakkara
- Department of Translational Medical Science, DISMET, University of Naples Federico II , Naples , Italy.,European Laboratory for the Investigation of Food Induced Disease (ELFID) , Naples , Italy
| | - Giuliana Lania
- Department of Translational Medical Science, DISMET, University of Naples Federico II , Naples , Italy.,European Laboratory for the Investigation of Food Induced Disease (ELFID) , Naples , Italy
| | | | - Dana Salameh
- DICMAPI, University of Naples Federico II , Naples , Italy
| | | | - Maria Vittoria Barone
- Department of Translational Medical Science, DISMET, University of Naples Federico II , Naples , Italy.,European Laboratory for the Investigation of Food Induced Disease (ELFID) , Naples , Italy
| | - Roberto Nigro
- DICMAPI, University of Naples Federico II , Naples , Italy
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216
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Jesús S, Latorre A, Vinuela A, Fahn S, Bhatia KP, Balint B. Stimulus Sensitive Foot Myoclonus: A Clue to Coeliac Disease. Mov Disord Clin Pract 2019; 6:320-323. [PMID: 31061841 DOI: 10.1002/mdc3.12753] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 02/06/2023] Open
Abstract
Background Coeliac disease (CD) is an autoimmune enteropathy that may feature extraintestinal manifestations including cerebellar ataxia and myoclonus. Methods and Results A descriptive series of five patients with CD who presented with prominent stimulus-sensitive foot myoclonus. Conclusions Stimulus-sensitive foot myoclonus is a distinct clinical sign and may be a useful clue to the diagnosis of CD.
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Affiliation(s)
- Silvia Jesús
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences London United Kingdom.,Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla Seville Spain.,Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED) Spain
| | - Anna Latorre
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences London United Kingdom.,Department of Human Neurosciences Sapienza University of Rome Italy
| | - Angel Vinuela
- Division of Movement Disorders, Department of Neurology Columbia University Medical Center New York NY USA
| | - Stanley Fahn
- Division of Movement Disorders, Department of Neurology Columbia University Medical Center New York NY USA
| | - Kailash P Bhatia
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences London United Kingdom
| | - Bettina Balint
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences London United Kingdom.,Department of Neurology University Hospital Heidelberg Heidelberg Germany
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217
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Bar Yehuda S, Axlerod R, Toker O, Zigman N, Goren I, Mourad V, Lederman N, Cohen N, Matz E, Dushnitzky D, Gavish M, Borovsky N, Schwarts D, Dotan I, Turner D. The Association of Inflammatory Bowel Diseases with Autoimmune Disorders: A Report from the epi-IIRN. J Crohns Colitis 2019; 13:324-329. [PMID: 30304371 DOI: 10.1093/ecco-jcc/jjy166] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There are conflicting data on the association between inflammatory bowel diseases [IBD] and autoimmunity disorders. The aim of this study was to explore this association including the effect of medications. METHODS We utilized health administrative data collected by three of the four health maintenance organizations [HMOs] in Israel, covering 52% of the country's population. We explored the prevalence of the following autoimmune disorders: insulin-dependent diabetes mellitus [IDDM], psoriasis, Sjögren syndrome, coeliac disease, systemic lupus erythematosus [SLE], primary sclerosis cholangitis [PSC] and autoimmune thyroiditis, among all IBD patients vs non-IBD controls. Case ascertainment was determined according to validated computerized algorithms. RESULTS In total, 12625 IBD patients were compared to 12625 controls. A total of 1395 [11.1%] IBD patients had at least one autoimmune disease compared with 740 [5.9%] of non-IBD controls (odds ratio [OR] = 1.99 [95% confidence interval 1.81-2.19]; p < 0.05); all autoimmune diseases, except for thyroiditis, were more prevalent among IBD patients. Adjusted for confounding variables, anti-tumour necrosis factor [anti-TNF] medications were associated with a higher prevalence of psoriasis (54 [5.7%] in IBD vs 177 [4.1%] in controls; OR = 1.50 [1.07-2.08]; p < 0.05) but lower prevalence of Sjögren (1 [0.1%] vs 39 [0.9%]; OR [95% CI] = 0.13 [0.02-0.94]; p < 0.05) and coeliac disease (11 [1.2%] vs 68 [1.6%]; OR [95% CI] = 0.51 [0.27-0.99]; p < 0.05). Thiopurines and 5-aminosalicylates were not associated with any autoimmune disorder. CONCLUSION IBD is associated with all autoimmune diseases explored here except for thyroiditis. Anti-TNF users have a higher prevalence of psoriasis, and lower prevalence of Sjögren and coeliac disease.
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Affiliation(s)
- Shahar Bar Yehuda
- The Juliet Keidan Institute of Paediatric Gastroenterology, Hepatology and Nutrition, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Rachel Axlerod
- The Juliet Keidan Institute of Paediatric Gastroenterology, Hepatology and Nutrition, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Ori Toker
- Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nir Zigman
- Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Iris Goren
- Maccabi Healthcare Services, Tel-Aviv, Israel
| | | | | | | | - Eran Matz
- Leumit Health Services, Tel-Aviv, Israel
| | | | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | | | | | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, and the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Paediatric Gastroenterology, Hepatology and Nutrition, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
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218
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Szakács Z, Csiszár B, Kenyeres P, Sarlós P, Erőss B, Hussain A, Nagy Á, Kőszegi B, Veczák I, Farkas N, Bódis E, Márta K, Szentesi A, Tőkés-Füzesi M, Berki T, Vincze Á, Tóth K, Hegyi P, Bajor J. Haemorheological and haemostatic alterations in coeliac disease and inflammatory bowel disease in comparison with non-coeliac, non-IBD subjects (HERMES): a case-control study protocol. BMJ Open 2019; 9:e026315. [PMID: 30904871 PMCID: PMC6475350 DOI: 10.1136/bmjopen-2018-026315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Haemorheological and haemostatic changes predispose to the development of arterial and venous thrombotic events; however, limited information is available on the status of these changes in coeliac disease (CeD) and inflammatory bowel disease (IBD). In this study, we aim to describe the haemorheological and haemostatic profiles of CeD and IBD patients in a Hungarian cohort of patients to investigate whether any alterations contribute to elevated thrombotic risk. METHODS AND ANALYSIS This is a case-control study involving newly diagnosed and followed CeD and IBD patients with age-matched and sex-matched non-CeD, non-IBD subjects with an allocation ratio of 1:1:1.After informed consent is obtained, a detailed medical history will be collected, including venous and arterial thrombotic risk factors and medications. Symptoms in CeD patients will be assessed with the Gastrointestinal Symptoms Rating Scale, and disease activity in IBD patients will be determined by disease-specific scores. Dietary adherence will be assessed among CeD patients with a thorough interview together with a measurement of self-reported adherence, dietary knowledge and urine analysis (detection of gluten immunogenic peptides). In addition to routine laboratory parameters, haemorheological (ie, erythrocyte deformability and aggregation, viscosity of whole blood and plasma) and haemostatic parameters (eg, protein C, protein S and antithrombin) with immunological indicators (ie, coeliac-specific serology and antiphospholipid antibodies) will be measured from venous blood for every participant.Primary and secondary outcomes will be haemorheological and haemostatic parameters, respectively. Univariate and multivariate statistics will be used to compare CeD and IBD patients to control subjects. Subgroup analysis will be performed by disease type in IBD, (Crohn's disease and ulcerose colitis), dietary adherence in CeD, and disease activity in IBD and CeD. ETHICS AND DISSEMINATION The study was approved by the Regional and Local Research Ethics Committee, University of Pécs (Ref. No. 6917). Findings will be disseminated at research conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN49677481.
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Affiliation(s)
- Zsolt Szakács
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Beáta Csiszár
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Cardiology and Angiology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Péter Kenyeres
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Cardiology and Angiology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Alizadeh Hussain
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Hematology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ágnes Nagy
- Division of Hematology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Balázs Kőszegi
- Department of Biochemistry and Medical Chemistry, Medical School, University of Pécs, Pécs, Hungary
| | - Ibolya Veczák
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Emőke Bódis
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Tőkés-Füzesi
- Department of Laboratory Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tímea Berki
- Department of Immunology and Biotechnology, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Kálmán Tóth
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Cardiology and Angiology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Clinical Medicine Doctoral School, University of Szeged, Szeged, Hungary
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
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219
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Adam UU, Melgies M, Kadir S, Henriksen L, Lynch D. Coeliac disease in Caucasian and South Asian patients in the North West of England. J Hum Nutr Diet 2019; 32:525-530. [PMID: 30891843 DOI: 10.1111/jhn.12622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Coeliac disease is an autoimmune enteropathy characterised by mucosal inflammation subsequent to gluten exposure, leading to malabsorption. Treatment is strict dietary control, relying on the patient's ability to maintain lifestyle modifications. The present study aimed to compare clinical presentation and adherence to a gluten-free diet between South Asian and Caucasian patients with coeliac disease in East Lancashire METHODS: In total, 33 South Asian and 113 Caucasian adult patients diagnosed with coeliac disease under the care of the Dietetics Department at East Lancashire Hospitals NHS Trust were selected using a convenience sampling method and then allocated to the South Asian or Caucasian group. A subjective assessment of dietetic notes from follow-up visits within 1 year of the first appointment was undertaken by two investigators who subsequently allocated the patients to one of the three categories: (i) fully-adherent; (ii) partly-adherent; and (iii) non-adherent. Presenting complaint, vitamin D, vitamin B12 , folate and ferritin levels were also compared. RESULTS There was a significant difference in adherence to gluten-free diet between the groups, with a larger proportion of Caucasian patients being fully adherent to gluten-free diet compared to South Asian patients (64.6% versus 12.1%, P < 0.001). In addition, a significantly higher proportion of South Asian patients were vitamin D deficient compared with Caucasian patients (70.8% versus 32.8%, P = 0.002). CONCLUSIONS The rates of strict adherence to gluten-free diet and vitamin D levels were significantly lower in South Asian patients with coeliac disease compared to the Caucasian coeliac population. Further studies are required to investigate the causes and improve adherence in the South Asian population.
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Affiliation(s)
- U U Adam
- Gastroenterology Department, Royal Blackburn Hospital, Blackburn, UK
| | - M Melgies
- Gastroenterology Department, Royal Blackburn Hospital, Blackburn, UK
| | - S Kadir
- Gastroenterology Department, Royal Blackburn Hospital, Blackburn, UK
| | - L Henriksen
- Dietetics Department, Royal Blackburn Hospital, Blackburn, UK
| | - D Lynch
- Gastroenterology Department, Royal Blackburn Hospital, Blackburn, UK
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220
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Zingone F, Iovino P, Bucci C, Ciacci C. Coeliac disease: no difference in milk and dairy products consumption in comparison with controls. BMJ Nutr Prev Health 2019. [PMID: 33235956 DOI: 10.1136/bmjnph-2018-000022.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Nutritional deficiencies are common in patients with coeliac disease and they can cause osteopenia among other associated diseases. Reduced consumption of milk and dairy products may play a major role in determining low bone mass in patients with coeliac disease. Aim We aimed to investigate milk and dairy products consumption in patients with coeliac disease compared with the general population. Methods We examined the average consumption of milk and dairy products and the reasons for not consuming them. An online survey was sent by email to patients with coeliac disease on a gluten-free diet and aged 18-75. Matched controls were selected among volunteers who responded to the survey posted on the public access sites. Differences in frequencies and means between the two groups were calculated using the χ2 test and t-test, respectively. All tests were two-tailed with a significance level set at p<0.05. Results 176 patients with coeliac disease and 528 controls participated in the study. We found that 22.2% of the patients with coeliac disease and 19.9% of controls did not drink fluid milk on a regular basis; lactose-free milk was preferred by 20.4% of the patients with coeliac disease and by 19% of controls (p=0.69). Only a minority of patients with coeliac disease contacted a doctor before having lactose-free milk, despite this being led by the presence of gastrointestinal symptoms. More patients with coeliac disease than the general population reported a breath test before avoiding milk and dairy products. Conclusions There is no significant difference between patients with coeliac disease and controls in regular milk consumption. Follow-up visits for patients with coeliac disease could avoid unnecessary dietary restrictions.
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Affiliation(s)
- Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Paola Iovino
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
| | - Cristina Bucci
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
| | - Carolina Ciacci
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
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221
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Affiliation(s)
- Luca Elli
- Center for the Prevention and Diagnosis of Coeliac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy.
| | - Beatrice Marinoni
- Center for the Prevention and Diagnosis of Coeliac Disease, Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy.
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Cadenhead JW, Wolf RL, Lebwohl B, Lee AR, Zybert P, Reilly NR, Schebendach J, Satherley R, Green PHR. Diminished quality of life among adolescents with coeliac disease using maladaptive eating behaviours to manage a gluten-free diet: a cross-sectional, mixed-methods study. J Hum Nutr Diet 2019; 32:311-320. [PMID: 30834587 DOI: 10.1111/jhn.12638] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Certain approaches to managing a strict gluten-free diet (GFD) for coeliac disease (CD) may lead to impaired psychosocial well-being, a diminished quality of life (QOL) and disordered eating. The present study aimed to understand adolescents' approaches to managing a GFD and the association with QOL. METHODS Thirty adolescents with CD (13-17 years old) following the GFD for at least 1 year completed the Celiac Dietary Adherence Test (CDAT) and QOL survey. Their approaches to GFD management were explored using a semi-structured interview, where key themes were developed using an iterative process, and further analysed using a psychosocial rubric to classify management strategies and QOL. CDAT ratings were compared across groups. RESULTS Gluten-free diet management strategies were classified on a four-point scale. Adaptive eating behaviours were characterised by greater flexibility (versus rigidity), trust (versus avoidance), confidence (versus controlling behaviour) and awareness (versus preoccupation) with respect to maintaining a GFD. Approximately half the sample (53.3%) expressed more maladaptive approaches to maintaining a GFD and those who did so were older with lower CD-Specific Pediatric Quality of Life (CDPQOL) scores, mean subscale differences ranging from 15.0 points for Isolation (t = 2.4, P = 0.03, d.f. = 28) to 23.4 points for Limitations (t = 3.0, P = 0.01, d.f. = 28). CONCLUSIONS Adolescents with CD who manage a GFD with maladaptive eating behaviours similar to known risk factors for feeding and eating disorders experience diminished QOL. In accordance with CD management recommendations, we recommend ongoing follow-up with gastroenterologists and dietitians and psychosocial support referrals, as needed.
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Affiliation(s)
- J W Cadenhead
- Department of Health and Behavior Studies, Program in Nutrition, Teachers College, Columbia University, New York, NY, USA
| | - R L Wolf
- Department of Health and Behavior Studies, Program in Nutrition, Teachers College, Columbia University, New York, NY, USA
| | - B Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Harkness Pavilion, New York, NY, USA
| | - A R Lee
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Harkness Pavilion, New York, NY, USA
| | - P Zybert
- Department of Health and Behavior Studies, Program in Nutrition, Teachers College, Columbia University, New York, NY, USA
| | - N R Reilly
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Harkness Pavilion, New York, NY, USA
| | - J Schebendach
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - R Satherley
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, King's College London, London, UK
| | - P H R Green
- Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Harkness Pavilion, New York, NY, USA
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223
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Real Delor RE, Aldama Negrete G, Benítez Duarte P. [Tetany as a form of presentation of adult celiac disease.]. ACTA ACUST UNITED AC 2019; 76:56-8. [PMID: 30882343 DOI: 10.31053/1853.0605.v76.n1.20212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/16/2018] [Accepted: 10/21/2018] [Indexed: 11/21/2022]
Abstract
Introduction celiac disease is an autoimmune disease with symptoms involving multiple organs. The forms of presentation vary considerably, which makes it difficult to diagnose. The objective is to present an atypical case of celiac disease. Methodology descriptive, retrospective, cross-sectional study of a case of an adult woman who presented with tetany Results investigating the case, the diagnosis of tetany was reached secondary to an intestinal malabsorption Conclusion celiac disease can occur atypically as a tetany
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224
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Abstract
Gluten proteins, major determinants of the bread-making quality of wheat, are related to several digestive disorders. Advances in plant genetic breeding have allowed the production of wheat lines with very low gliadin content through the use of RNAi and gene editing technologies. In this review, we carried out a comprehensive study of the application of these cutting-edge technologies towards the development of wheat lines devoid of immunogenic gluten, and their genetic, nutritional and clinical characterization. One line, named E82, showed outstanding nutritional properties, with very low immunogenic gluten and a low stimulation capacity of T-cells from celiac patients. Moreover, a clinical trial with non-celiac wheat sensitivity (NCWS) patients showed that the consumption of bread made with this E82 low gliadin line induced positive changes in the gut microbiota composition.
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Affiliation(s)
- María Dolores García-Molina
- Department of Plant Breeding, Institute for Sustainable Agriculture (IAS-CSIC), 14004 Córdoba, Spain.
- DAFNE Department, University of Tuscia, 01100 Viterbo, Italy.
| | - María José Giménez
- Department of Plant Breeding, Institute for Sustainable Agriculture (IAS-CSIC), 14004 Córdoba, Spain.
| | - Susana Sánchez-León
- Department of Plant Breeding, Institute for Sustainable Agriculture (IAS-CSIC), 14004 Córdoba, Spain.
| | - Francisco Barro
- Department of Plant Breeding, Institute for Sustainable Agriculture (IAS-CSIC), 14004 Córdoba, Spain.
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225
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Bajor J, Szakács Z, Juhász M, Papp M, Kocsis D, Szegedi É, Földi I, Farkas N, Hegyi P, Vincze Á. HLA-DQ2 homozygosis increases tTGA levels at diagnosis but does not influence the clinical phenotype of coeliac disease: A multicentre study. Int J Immunogenet 2019; 46:74-81. [PMID: 30779476 DOI: 10.1111/iji.12415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 01/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Magnitude of gluten-specific T-cell responses in coeliac disease (CD) might be dependent on HLA-DQ2 gene dose. We aimed to investigate the effects of HLA-DQB1*02 allele dose on clinical outcomes. METHODS We reviewed the charts of all coeliac patients attending to three Hungarian university clinics after 1997 and included those patients, who (a) were diagnosed with CD, (b) underwent high-resolution HLA typing and (c) were ≥18 years at the time of data collection. HLA typing was performed to determine DQB1*02 allele dose. Patients were divided into risk groups by DQB1*02 allele dose, as follows: high-, intermediate- and low-risk groups corresponded to a double, single and zero doses, respectively. We used ANOVA and Pearson's chi-squared test to explore association between HLA risk and clinical variables. RESULTS A total of 727 coeliac patients attended the clinics but only 105 (14.4%) patients were eligible for inclusion. High, intermediate and low HLA risk patients comprised 35.3%, 52.3% and 12.3% of the study population, respectively. Double dose of HLA-DQB1*02 was more frequent in patient with high tTGA level (>10 times the upper limit of normal; p = 0.045). Gene dose was not associated with younger age at diagnosis (p = 0.549), gender (p = 0.739), more severe diagnostic histology (p = 0.318), more frequent classical presentation (p = 0.846), anaemia (p = 0.611), metabolic bone disease (p = 0.374), dermatitis herpetiformis (p = 0.381) and autoimmune diseases (p = 0.837). CONCLUSIONS Our study shows a significant gene dose effect in terms of tTGA level at diagnosis, but no significant association between HLA-DQB1*02 allele dose and the clinical outcomes in CD.
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Affiliation(s)
- Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Márk Juhász
- Department of Internal Medicine, St. Margit Hospital, Budapest, Hungary
| | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dorottya Kocsis
- Second Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Éva Szegedi
- Department of Interventional Gastroenterology, National Institute of Oncology, Budapest, Hungary
| | - Ildikó Földi
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nelli Farkas
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.,Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Hungarian Academy of Sciences, Momentum Gastroenterology Multidisciplinary Research Group, University of Szeged, Szeged, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
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226
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Siriwardhane T, Krishna K, Devarajan K, Ranganathan V, Jayaraman V, Wang T, Bei K, Rajasekaran JJ, Krishnamurthy H. Insights into cardiovascular risk and nutritional status in subjects with wheat-related disorders. Biomarkers 2019; 24:303-307. [PMID: 30734586 DOI: 10.1080/1354750x.2019.1578829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective: Wheat-related disorders are a spectrum of disorders associated with different autoimmune and non-autoimmune diseases. However, it is unclear whether these wheat-related disorders lead to adverse health effects such as cardiovascular risk, nutritional deficiencies etc. The objective of the study was to explore the lipid profiles and the nutritional status of subjects with wheat-related disorders to understand the potential threat of wheat on cardiovascular risk and nutritional deficiency. Method: A total of 1041 subjects who showed wheat-related symptoms were initially tested for the wheat protein antibody panel (Wheat Zoomer (WZ) panel and Coeliac Disease (CD) panel), then for cardiovascular panel and the micronutrient panel at Vibrant America Clinical Laboratory. Results: Subjects with both Wheat Zoomer positivity (WZ+) and Coeliac Disease positivity (CD+) had significantly low levels of high-density lipoproteins (HDL) (279/483(57.8%) and 29/47(61.7%) respectively), but only subjects with WZ + had low levels of Apo A1 (44/424(9.5%)), and high levels of Omega 6 fatty acids (53/334(15.9%)). None of the micronutrients tested showed a significant imbalance in WZ + subjects. Conclusion: Subjects with positive serology for WZ have deranged blood lipid profiles but did not show any significant micronutrient deficiency. Hence, our results showcase a significant association of wheat-related disorders to cardiovascular risk.
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Affiliation(s)
| | | | | | | | | | | | - Kang Bei
- b Vibrant Sciences LLC , San Carlos , CA , USA
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227
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Abstract
The prevalence of food allergy and food intolerance is increasing and it is an important public health problem affecting children. Food allergy results from an immunological reaction to certain food(s) and affects numerous organs in the body. Food intolerances are non-immunological reactions including metabolic, toxic, pharmacological and undefined mechanisms. Cow milk is the most common cause of food allergy and food intolerance, especially in young children. Food intolerance can present with similar symptoms to those of food allergy. Health-care personnel, patients and their caregivers often confuse food intolerance with food allergy. This review focuses on the clinical manifestations, diagnostic evaluation, treatment and prevention of food allergy and food intolerance.
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Affiliation(s)
- Wiparat Manuyakorn
- a Department of Pediatrics, Faculty of Medicine , Mahidol University , Bangkok , Thailand
| | - Pornthep Tanpowpong
- a Department of Pediatrics, Faculty of Medicine , Mahidol University , Bangkok , Thailand
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228
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Affiliation(s)
- Mohamed Alsaffar
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland
| | - Joanne Balfe
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - Fiona McGrane
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - Montasser Nadeem
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - Shoana Quinn
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Tallaght Hospital, Dublin, Ireland
| | - Eleanor Molloy
- Discipline of Paediatrics and Child Health, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Tallaght Hospital, Dublin, Ireland
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229
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Pensieri MV, Pulvirenti F, Schiepatti A, Maimaris S, Lattanzio S, Quinti I, Klersy C, Corazza GR, Biagi F. The high mortality of patients with common variable immunodeficiency and small bowel villous atrophy. Scand J Gastroenterol 2019; 54:164-168. [PMID: 31006294 DOI: 10.1080/00365521.2019.1568543] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Common variable immunodeficiency (CVID) is a primary humoral immunodeficiency characterised by reduced serum levels of immunoglobulins, recurrent infections, autoimmune phenomena and lymphoproliferative disorders. Gastrointestinal symptoms are very common in these patients and a coeliac-like villous atrophy was described in some of them. Since mortality in CVID is much higher than in the general population, our aim was to evaluate mortality rates and clinical predictors of survival in patients with both CVID and duodenal villous atrophy. PATIENTS AND METHODS Sex, date of diagnosis of villous atrophy, HLA genomic typing, date of death/last follow-up, type of complication were retrospectively collected from medical files. Univariate analysis for each predictor was conducted and Kaplan-Meier curves were generated to evaluate survival. RESULTS Twenty-three patients were enrolled (9 females, mean age at diagnosis of villous atrophy 38 ± 13 years) and 8 of them died after a median time of 96 months (25th-75th 60-120 months) corresponding to a mortality rate of 3.9 per 100 person-years (95% CI 1.9-7.7). Mortality was higher in men compared to women (60 vs. 11/1000 person-years), although not statistically significant. Causes of death included onco-haematological disorders and infections. CONCLUSIONS Although based on a small cohort, our results confirm that patients with CVID and villous atrophy are burdened by a very high mortality mainly due to onco-immunological disorders and infections. Strict follow-up is required in these patients.
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Affiliation(s)
- Maria Vittoria Pensieri
- a Coeliac Centre/First Department of Internal Medicine , Fondazione IRCCS Policlinico San Matteo University of Pavia , Pavia , Italy
| | - Federica Pulvirenti
- b Department of Molecular Medicine , University of Rome Sapienza , Rome , Italy
| | - Annalisa Schiepatti
- a Coeliac Centre/First Department of Internal Medicine , Fondazione IRCCS Policlinico San Matteo University of Pavia , Pavia , Italy
| | - Stiliano Maimaris
- a Coeliac Centre/First Department of Internal Medicine , Fondazione IRCCS Policlinico San Matteo University of Pavia , Pavia , Italy
| | | | - Isabella Quinti
- b Department of Molecular Medicine , University of Rome Sapienza , Rome , Italy
| | - Catherine Klersy
- d Biometry and Clinical Epidemiology , Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Gino Roberto Corazza
- a Coeliac Centre/First Department of Internal Medicine , Fondazione IRCCS Policlinico San Matteo University of Pavia , Pavia , Italy
| | - Federico Biagi
- a Coeliac Centre/First Department of Internal Medicine , Fondazione IRCCS Policlinico San Matteo University of Pavia , Pavia , Italy
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230
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Abstract
The gluten-free diet (GFD) is currently the only effective treatment in remitting the symptoms of coeliac disease (CD), a chronic systemic autoimmune disorder caused by a permanent intolerance to gluten proteins in genetically susceptible individuals. The diet entails the substitution of gluten-containing products with gluten-free-rendered products. However, over recent decades the nutritional profile of gluten-free (GF) food products has been increasingly questioned within the scientific community. The aim of this paper is to review the nutritional profile of gluten-free-rendered products currently available on the market, and discuss the possible relationship thereof with the nutritional status of coeliac patients on a GFD. Key inadequacies of currently available GF products are low protein content and a high fat and salt content. More adequate levels of dietary fiber and sugar than in the past have been reported. Population studies confirmed the above mentioned inadequacies. Further efforts are required to conceive adoptable interventions for product development and reformulation in order to achieve compliance with nutritional recommendations.
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Affiliation(s)
- Valentina Melini
- CREA Research Centre for Food and Nutrition; Via Ardeatina 546, I-00178 Rome, Italy.
| | - Francesca Melini
- CREA Research Centre for Food and Nutrition; Via Ardeatina 546, I-00178 Rome, Italy.
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231
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Paramanandam V, Hadjivassiliou M, Olszewska DA, Munteanu T, Williams L, Magennis B, Fearon C, O'Connell M, Sarrigiannis P, Lynch T. Reversible Corticobasal Syndrome due to Coeliac Disease. Mov Disord Clin Pract 2019; 5:551-554. [PMID: 30637273 DOI: 10.1002/mdc3.12659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 05/18/2018] [Accepted: 06/08/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences Royal Hallamshire Hospital Sheffield South Yorkshire S1 3JD United Kingdom
| | | | - Tudor Munteanu
- Dublin Neurological Institute at the Mater Misericordiae University Hospital Ireland
| | - Laura Williams
- Dublin Neurological Institute at the Mater Misericordiae University Hospital Ireland
| | - Brian Magennis
- Dublin Neurological Institute at the Mater Misericordiae University Hospital Ireland
| | - Conor Fearon
- Dublin Neurological Institute at the Mater Misericordiae University Hospital Ireland
| | - Martin O'Connell
- Department of Radiology Mater Misericordiae University Hospital Ireland
| | - Ptolemaios Sarrigiannis
- Academic Department of Neurosciences Royal Hallamshire Hospital Sheffield South Yorkshire S1 3JD United Kingdom
| | - Tim Lynch
- Dublin Neurological Institute at the Mater Misericordiae University Hospital Ireland
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232
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Vitaglione P, Zingone F, Virgilio N, Ciacci C. Appetite and Gastrointestinal Hormone Response to a Gluten-Free Meal in Patients with Coeliac Disease. Nutrients 2019; 11:nu11010082. [PMID: 30609862 PMCID: PMC6356816 DOI: 10.3390/nu11010082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 12/20/2022] Open
Abstract
Coeliac disease (CeD) is an immune-mediated inflammatory enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Gastrointestinal (GI) hormone response related to appetite and glucose metabolism is still under-investigated in patients with CeD. This study aimed at shedding light on the appetite sensations, glycaemia and hormone response induced by a complex meal in patients with coeliac disease. Twenty-two women with CeD, nine at the diagnosis (CeDD) and thirteen under a gluten-free diet (CeDGF), and ten healthy subjects (HS) were enrolled in a single day intervention study. All subjects consumed a test meal, recorded their appetite sensations, and blood was collected over three hours after meal consumption. The study found a lower decrease in hunger in CeDD compared to CeDGF and HS after meal intake. Data showed no difference of fullness and satiety between the groups. CeDD had lower insulin and glucose-dependent insulinotropic polypeptide (GIP) than CeDGF and HS. Both CeDD and CeDGF experienced a lower post-prandial response of glucose than HS. Data suggested that patients with CeD have an impaired glucose absorption after more than 12 months of gluten-free diet. Postprandial GIP may play a significant role in appetite cues and insulin response to a complex meal.
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Affiliation(s)
- Paola Vitaglione
- Department of Agricultural Sciences, University of Naples "Federico II", 80055 Portici, Italy.
| | - Fabiana Zingone
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, 35100 Padua, Italy.
| | - Nicolina Virgilio
- Department of Agricultural Sciences, University of Naples "Federico II", 80055 Portici, Italy.
| | - Carolina Ciacci
- Department of Medicine, Surgery, and Dentistry, "Scuola Medica Salernitana" University of Salerno, 84084 Fisciano, Italy.
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233
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Zingone F, Iovino P, Bucci C, Ciacci C. Coeliac disease: no difference in milk and dairy products consumption in comparison with controls. BMJ Nutr Prev Health 2019; 2:39-42. [PMID: 33235956 PMCID: PMC7678477 DOI: 10.1136/bmjnph-2018-000022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/22/2019] [Accepted: 01/26/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Nutritional deficiencies are common in patients with coeliac disease and they can cause osteopenia among other associated diseases. Reduced consumption of milk and dairy products may play a major role in determining low bone mass in patients with coeliac disease. AIM We aimed to investigate milk and dairy products consumption in patients with coeliac disease compared with the general population. METHODS We examined the average consumption of milk and dairy products and the reasons for not consuming them. An online survey was sent by email to patients with coeliac disease on a gluten-free diet and aged 18-75. Matched controls were selected among volunteers who responded to the survey posted on the public access sites. Differences in frequencies and means between the two groups were calculated using the χ2 test and t-test, respectively. All tests were two-tailed with a significance level set at p<0.05. RESULTS 176 patients with coeliac disease and 528 controls participated in the study. We found that 22.2% of the patients with coeliac disease and 19.9% of controls did not drink fluid milk on a regular basis; lactose-free milk was preferred by 20.4% of the patients with coeliac disease and by 19% of controls (p=0.69). Only a minority of patients with coeliac disease contacted a doctor before having lactose-free milk, despite this being led by the presence of gastrointestinal symptoms. More patients with coeliac disease than the general population reported a breath test before avoiding milk and dairy products. CONCLUSIONS There is no significant difference between patients with coeliac disease and controls in regular milk consumption. Follow-up visits for patients with coeliac disease could avoid unnecessary dietary restrictions.
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Affiliation(s)
- Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Paola Iovino
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
| | - Cristina Bucci
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
| | - Carolina Ciacci
- Celiac Center, AOU San Giovanni di Dio e Ruggi diAragona, University of Salerno, Department of Medicine, Surgery, and Dentistry Scuola Medica Salernitana, Salerno, Italy
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234
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Wegiel M, Antosz A, Gieburowska J, Szeliga K, Hankus M, Grzybowska-Chlebowczyk U, Wiecek S, Malecka-Tendera E, Gawlik A. Autoimmunity Predisposition in Girls With Turner Syndrome. Front Endocrinol (Lausanne) 2019; 10:511. [PMID: 31417494 PMCID: PMC6682631 DOI: 10.3389/fendo.2019.00511] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Turner Syndrome is associated with an increased risk of autoimmune diseases, such as autoimmune thyroiditis, coeliac disease, type 1 diabetes mellitus, inflammatory bowel disease, alopecia areata, or vitiligo. The presence of isochromosome iXq and exposure to estradiol may contribute to the development of the autoimmune process. The aim of this study was to determine the prevalence of autoimmune diseases in a group of TS patients and to assess the impact of karyotype and puberty on the development of autoimmune diseases. Patients and Methods: The analysis encompassed clinical and biochemical data of 134 patients treated between 2001 and 2018. All the patients were examined for autoimmune disease symptoms and tested for the presence of antithyroperoxidase (anti-TPO) and antithyreoglobulin (anti-TG) antibodies. In 73 of the patients, anti-transglutaminase (anti-tTG) antibodies were measured. Thyroid function was assessed by measuring TSH and fT4 levels. Results: The mean follow-up was 5.7 ± 3 years. An autoimmune disease was diagnosed in 46 (34.3%) patients: 39 (29.1%) had only one disorder, whilst 7 (5.2%) presented two disorders. The most common disorder, observed in 40 (29.9%) patients, was thyroid autoimmunity. Hashimoto disease was diagnosed in 20 (14.9%) patients. Of the 73 patients tested for coeliac disease, 4 (5.5%) had anti-tTG and 2 (2.7%) presented overt coeliac disease. Vitiligo was diagnosed in 3 (2.2%) patients, type 1 diabetes mellitus or psoriasis were diagnosed in 2 (1.5%) patients, whilst alopecia areata or lichen sclerosus were diagnosed in 1 (0.7%) patient. The impact of karyotype or estradiol exposure on developing autoimmune diseases were not statistically significant. Conclusions: Our study showed a higher incidence of autoimmune diseases in TS, which is in line with the literature; however, the impact of iXq, or spontaneous/inducted puberty was not confirmed.
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Affiliation(s)
- Malgorzata Wegiel
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aleksandra Antosz
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Joanna Gieburowska
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Kamila Szeliga
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Magdalena Hankus
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Sabina Wiecek
- Department of Pediatrics, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Ewa Malecka-Tendera
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
- *Correspondence: Aneta Gawlik
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235
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Giuffrida P, Vanoli A, Arpa G, Bonometti A, Luinetti O, Solcia E, Corazza GR, Paulli M, Di Sabatino A. Small Bowel Carcinomas Associated with Immune-Mediated Intestinal Disorders: The Current Knowledge. Cancers (Basel) 2018; 11:E31. [PMID: 30597986 DOI: 10.3390/cancers11010031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/10/2018] [Accepted: 12/24/2018] [Indexed: 12/14/2022] Open
Abstract
Small bowel carcinomas (SBC) are uncommon neoplasms, whose predisposing conditions include hereditary syndromes and immune-mediated intestinal disorders including coeliac disease (CD) and Crohn's disease (CrD). Although both CD-associated SBC (CD-SBC) and CrD-associated SBC (CrD-SBC) arise from an inflammatory background, they differ substantially in tumour cell phenotype, frequency of microsatellite instability and nuclear β-catenin expression, as well as in prognosis. For these patients, high tumour-infiltrating lymphocyte density and glandular/medullary histotype represent independent positive prognostic factors. Dysplasia adjacent to SBC is rare and characterized by intestinal phenotype and nuclear β-catenin in CD, while it is frequent and typified by gastro-pancreatobiliary marker expression and preserved membranous β-catenin in CrD. Recent evidence suggests that Epstein-Barr virus-positive dysplasia and SBC, albeit exceptional, do exist and are associated with CrD. In this review, we summarize the novel pathological and molecular insights of clinical and therapeutic interest to guide the care of CD-SBC and CrD-SBC.
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Abstract
The world-wide incidence of many immune-mediated and metabolic diseases, including those of the intestines and liver, is steadily increasing. Gut microbiota plays a central role in the pathogenesis of these diseases as it mediates environmental changes to the intestinal immune system. Various environmental factors including diet, food additives and medication also trigger the compositional and functional alterations of microbiota, that is, dysbiosis, and this dysbiosis is closely associated with many chronic inflammatory diseases. However, the causal relationship remains unclear for the majority of these diseases. In this review, we discuss essential epidemiological data, known pathogenetic factors including those of genetic and environmental nature, while mainly focusing on the role of gut microbiota in the development of selected intestinal and liver diseases. Using specific examples, we also briefly describe some of the most widely-used animal models including gnotobiotic models and their contribution to the research of pathogenetic mechanisms of the host-microbiota relationship.
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Affiliation(s)
- Tomas Hrncir
- 1 Institute of Microbiology, The Czech Academy of Sciences, Czech Republic
| | - Lucia Hrncirova
- 1 Institute of Microbiology, The Czech Academy of Sciences, Czech Republic.,2 Faculty of Medicine, Charles University, Czech Republic
| | - Miloslav Kverka
- 1 Institute of Microbiology, The Czech Academy of Sciences, Czech Republic
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237
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Ghaith J, Raslan IA, Szilagyi A, Alameldin M. Case of olmesartan-associated enteropathy and transient positive antitissue transglutaminase serology. BMJ Case Rep 2018; 11:11/1/e225518. [PMID: 30567230 PMCID: PMC6301511 DOI: 10.1136/bcr-2018-225518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Olmesartan-associated enteropathy (OAE) is increasingly being recognised as a major differential diagnosis in patients with villous atrophy and negative coeliac disease (CD) serology. OAE and positive coeliac markers have rarely been reported. We report a case of diarrhoea and small bowel villous blunting associated with a transient elevation of antitissue transglutaminase antibody (ATTG). On discontinuation of olmesartan, symptoms improved, repeat biopsies were normal and levels of ATTG also returned normal. We discuss a possible explanation for the transient elevation in ATTG and the significance of considering OAE/CD overlap.
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Affiliation(s)
- Jenan Ghaith
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Ismail A Raslan
- Internal Medicine Residency Program, University of McGill, Montreal, Quebec, Canada
| | - Andrew Szilagyi
- Medicine Division of Gastroenterology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Mona Alameldin
- Department of Pathology, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec, Canada
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238
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van Gils T, Senler TG, van der Horst HE, Mulder CJ, Bouma G, de Vries H. The daily practice of (suspected) coeliac disease management by general practitioners: A qualitative approach. Eur J Gen Pract 2018; 24:236-242. [PMID: 30277085 PMCID: PMC6171459 DOI: 10.1080/13814788.2018.1516203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 07/25/2018] [Accepted: 08/15/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND General practitioners (GPs) play a crucial role in diagnosing coeliac disease (CD). However, data on GP management of (suspected) CD patients is sparse. OBJECTIVES To provide insights into the daily practice of diagnosis, treatment, and follow-up of CD by GPs. METHODS A qualitative study using topic list-based semi-structured in-depth interviews with Dutch GPs with more than five years' experience carried out between January and March 2017. GPs were purposively sampled. The number of GPs interviewed depended on when data saturation was reached. We applied content analysis to the semi-structured interviews. RESULTS Seven GPs were interviewed, five of whom were female. Analysis of the interviews resulted in three main themes: 'awareness,' 'diagnostics' and 'management.' Vague gastrointestinal symptoms and diarrhoea were often mentioned as a possible presentation of CD. Antibodies were used in CD diagnosis, although some GPs would start a gluten-free diet as a first diagnostic tool. Some GPs diagnosed CD only based on positive antibodies without referring to secondary care or duodenal biopsy analysis. GPs mentioned no role for primary care physicians in the follow-up of CD and noted the important role of dieticians in CD management. CONCLUSION The different views of GPs on how to diagnose and monitor CD could be a basis for further research to improve CD detection rate and CD care.
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Affiliation(s)
- Tom van Gils
- Coeliac Centre Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Talha G. Senler
- Coeliac Centre Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Chris J.J. Mulder
- Coeliac Centre Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Gerd Bouma
- Coeliac Centre Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
| | - Henk de Vries
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, Amsterdam UMC, location VU University Medical Centre, Amsterdam, The Netherlands
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239
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Pastorelli L, Scaldaferri F. Editorial: Intestinal Inflammation. Front Med (Lausanne) 2018; 5:318. [PMID: 30483509 PMCID: PMC6243125 DOI: 10.3389/fmed.2018.00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/25/2018] [Indexed: 11/21/2022] Open
Affiliation(s)
- Luca Pastorelli
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Franco Scaldaferri
- Internal Medicine, Gastroenterology and Hepatic Diseases Unit, Gastroenterological Area, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
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240
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Yavan MA, Isman E, Kocahan S. Evaluation of condylar structures on panoramic radiographs in adolescent patients with coeliac disease. Folia Morphol (Warsz) 2018; 78:191-194. [PMID: 30402878 DOI: 10.5603/fm.a2018.0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coeliac disease (CD) is a common disorder that usually originates from calcium malabsorption. Thus, it is accepted that patients with CD have lo- wer bone mineral density than that of healthy individuals. The aim of this study was to assess condylar height, width, area, and perimeter on digital panoramic radiographs in patients with CD. MATERIALS AND METHODS Panoramic radiographs obtained from 44 patients with CD were age- and sex-matched with 44 Class 1 (ANB: 2 ± 2°) patients, and out- comes were analysed. Radiographs were digitised using Image J software, and condylar height, width, area, and perimeter were compared. RESULTS Condylar area (3.66 ± 1.02 cm2), perimeter (9.29 ± 1.38 cm), and height (2.69 ± 0.46 cm) values were significantly higher (p < 0.05) in the control group than those in the patient group (area: 2.52 ± 0.63 cm2, perimeter: 8.47 ± 1.42 cm, height: 2.51 ± 0.37 cm), whereas width (coeliac: 2.83 ± 0.63 cm, control: 3.00 ± 0.59 cm) did not differ between the groups (p > 0.05). CONCLUSIONS These outcomes may be due to the low bone density of patients with CD. A controlled trial conducted using a larger sample is needed to support and extend these data.
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Affiliation(s)
- M A Yavan
- Department of Orthodontics, Faculty of Dentistry, University of Adiyaman, Turkey
| | - E Isman
- Private Orthodontist, Gaziantep, Turkey
| | - S Kocahan
- Department of Physiology, Faculty of Medicine, University of Adiyaman, Turkey. .,International Scientific Centre, Baku State University, Baku, Azerbaijan.
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241
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Busby E, Bold J, Fellows L, Rostami K. Mood Disorders and Gluten: It's Not All in Your Mind! A Systematic Review with Meta-Analysis. Nutrients 2018; 10:E1708. [PMID: 30413036 PMCID: PMC6266949 DOI: 10.3390/nu10111708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
Gluten elimination may represent an effective treatment strategy for mood disorders in individuals with gluten-related disorders. However, the directionality of the relationship remains unclear. We performed a systematic review of prospective studies for effects of gluten on mood symptoms in patients with or without gluten-related disorders. Six electronic databases (CINAHL, PsycINFO, Medline, Web of Science, Scopus and Cochrane Library) were searched, from inception to 8 August 2018, for prospective studies published in English. Meta-analyses with random-effects were performed. Three randomised-controlled trials and 10 longitudinal studies comprising 1139 participants fit the inclusion criteria. A gluten-free diet (GFD) significantly improved pooled depressive symptom scores in GFD-treated patients (Standardised Mean Difference (SMD) -0.37, 95% confidence interval (CI) -0.55 to -0.20; p < 0.0001), with no difference in mean scores between patients and healthy controls after one year (SMD 0.01, 95% CI -0.18 to 0.20, p = 0.94). There was a tendency towards worsening symptoms for non-coeliac gluten sensitive patients during a blinded gluten challenge vs. placebo (SMD 0.21, 95% CI -0.58 to 0.15; p = 0.25). Our review supports the association between mood disorders and gluten intake in susceptible individuals. The effects of a GFD on mood in subjects without gluten-related disorders should be considered in future research.
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Affiliation(s)
- Eleanor Busby
- The School of Allied Health and Community, University of Worcester, Worcester WR2 6AJ, UK.
| | - Justine Bold
- The School of Allied Health and Community, University of Worcester, Worcester WR2 6AJ, UK.
| | - Lindsey Fellows
- The School of Allied Health and Community, University of Worcester, Worcester WR2 6AJ, UK.
| | - Kamran Rostami
- Department of Gastroenterology, Mid-Central District Health Board, Palmerston North Hospital, Palmerston North 4442, New Zealand.
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242
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Rostami K, Ensari A, Ciacci C, Srivastava A, Volta U, Villanacci V, Marsh MN. Coeliac biopsies: numbers are valid, alphabets not. Gut 2018; 67:2069-2070. [PMID: 29158235 DOI: 10.1136/gutjnl-2017-315517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Kamran Rostami
- Department of Gastroenterology, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Carolina Ciacci
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Villanacci
- Department of Pathology, Institute of Pathology Spedali Civili, Brescia, Italy
| | - Michael N Marsh
- Department of Gastroenterology, Luton and Dunstable University Hospital, Luton, UK.,Wolfson College, University of Oxford, Oxford, United Kingdom
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243
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Zis P, Julian T, Hadjivassiliou M. Headache Associated with Coeliac Disease: A Systematic Review and Meta-Analysis. Nutrients 2018; 10:E1445. [PMID: 30301194 DOI: 10.3390/nu10101445] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 09/25/2018] [Accepted: 09/29/2018] [Indexed: 01/09/2023] Open
Abstract
Objective: The aim of this systematic review was to explore the relationship between coeliac disease (CD) and headache. The objectives were to establish the prevalence of each entity amongst the other, to explore the role of gluten free diet (GFD), and to describe the imaging findings in those affected by headaches associated with CD. Methodology: A systematic computer-based literature search was conducted on the PubMed database. Information regarding study type, population size, the age group included, prevalence of CD amongst those with headache and vice versa, imaging results, the nature of headache, and response to GFD. Results: In total, 40 articles published between 1987 and 2017 qualified for inclusion in this review. The mean pooled prevalence of headache amongst those with CD was 26% (95% CI 19.5–33.9%) in adult populations and 18.3% (95% CI 10.4–30.2%) in paediatric populations. The headaches are most often migraine-like. In children with idiopathic headache, the prevalence of CD is 2.4% (95% CI 1.5–3.7%), whereas data for adult populations is presently unavailable. Brain imaging can be normal, although, cerebral calcifications on CT, white matter abnormalities on MRI and deranged regional cerebral blood flow on SPECT can be present. GFD appears to be an effective management for headache in the context of CD, leading to total resolution of headaches in up to 75% of patients. Conclusions: There is an increased prevalence of CD amongst idiopathic headache and vice versa. Therefore, patients with headache of unknown origin should be screened for CD, as such patients may symptomatically benefit from a GFD.
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244
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Hadjivassiliou M, Grünewald RA, Sanders DS, Zis P, Croal I, Shanmugarajah PD, Sarrigiannis PG, Trott N, Wild G, Hoggard N. The Significance of Low Titre Antigliadin Antibodies in the Diagnosis of Gluten Ataxia. Nutrients 2018; 10:nu10101444. [PMID: 30301184 PMCID: PMC6213789 DOI: 10.3390/nu10101444] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 11/25/2022] Open
Abstract
Background: Patients with gluten ataxia (GA) without enteropathy have lower levels of antigliadin antibodies (AGA) compared to patients with coeliac disease (CD). Magnetic Resonance Spectroscopy (NAA/Cr area ratio) of the cerebellum improves in patients with GA following a strict gluten-free diet (GFD). This is associated with clinical improvement. We present our experience of the effect of a GFD in patients with ataxia and low levels of AGA antibodies measured by a commercial assay. Methods: Consecutive patients with ataxia and serum AGA levels below the positive cut-off for CD but above a re-defined cut-off in the context of GA underwent MR spectroscopy at baseline and after a GFD. Results: Twenty-one consecutive patients with GA were included. Ten were on a strict GFD with elimination of AGA, 5 were on a GFD but continued to have AGA, and 6 patients did not go on a GFD. The NAA/Cr area ratio from the cerebellar vermis increased in all patients on a strict GFD, increased in only 1 out of 5 (20%) patients on a GFD with persisting circulating AGA, and decreased in all patients not on a GFD. Conclusion: Patients with ataxia and low titres of AGA benefit from a strict GFD. The results suggest an urgent need to redefine the serological cut-off for circulating AGA in diagnosing GA.
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Affiliation(s)
- Marios Hadjivassiliou
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Richard A Grünewald
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - David S Sanders
- Departments of Gastroenterology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Panagiotis Zis
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Iain Croal
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Priya D Shanmugarajah
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Ptolemaios G Sarrigiannis
- Academic Departments of Neurosciences and Neuroradiology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Nick Trott
- Departments of Dietetics, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Graeme Wild
- Departments of Immunology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
| | - Nigel Hoggard
- Departments of Gastroenterology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK.
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245
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Abstract
Olmesartan-induced enteropathy (OIE) typically presents with a constellation of signs and symptoms including chronic diarrhoea, weight loss and villous atrophy on biopsy. We describe a 68-year-old Caucasian woman with a history of hypothyroidism and hypertension who presented to our hospital with recurrent episodes of acute intermittent diarrhoea, nausea, vomiting, renal failure and 15 lbs weight loss. After an extensive workup, she was diagnosed with possible OIE. Cessation of the offending drug resulted in improvement of clinical symptoms and also hospital admissions for severe diarrhoea reinforcing the diagnosis of OIE. Among the adverse effects of drug therapy, diarrhoea is a relatively frequent adverse event accounting for about 7%. This report serves as an addition to existing literature and to increase the awareness of olmesartan-induced sprue-like enteropathy among the primary care physicians and gastroenterologists.
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Affiliation(s)
- Nirmal K Onteddu
- Internal Medicine, Texas Tech University Health Sciences Center at Permian Basin, Odessa, Texas, USA
| | | | - Mihira Ginnavaram
- Internal Medicine, Bhaskar Medical College, Ranga Reddy, Telangana, India
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246
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Allen B, Orfila C. The Availability and Nutritional Adequacy of Gluten-Free Bread and Pasta. Nutrients 2018; 10:nu10101370. [PMID: 30257431 PMCID: PMC6213709 DOI: 10.3390/nu10101370] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/14/2018] [Accepted: 09/21/2018] [Indexed: 12/16/2022] Open
Abstract
Management of coeliac disease (CD) requires the removal of gluten from the diet. Evidence of the availability, cost, and nutritional adequacy of gluten-free (GF) bread and pasta products is limited. GF flours are exempt from UK legislation that requires micronutrient fortification of white wheat flour. This study surveyed the number and cost of bread and pasta products available and evaluated the back-of-pack nutritional information, the ingredient content, and the presence of fortification nutrients of GF bread and pasta, compared to standard gluten-containing equivalent products. Product information was collected from four supermarket websites. Standard products were significantly cheaper, with more products available than GF (p < 0.05). GF bread products were significantly higher in fat and fiber (p < 0.05). All GF products were lower in protein than standard products (p < 0.01). Only 5% of GF breads were fortified with all four mandatory fortification nutrients (calcium, iron, nicotinic acid or nicotamide and thiamin), 28% of GF breads were fortified with calcium and iron only. This lack of fortification may increase the risk of micronutrient deficiency in coeliac sufferers. It is recommended that fortification legislation is extended to include all GF products, in addition to increased regulation of the nutritional content of GF foods.
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Affiliation(s)
- Beatrice Allen
- School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK.
| | - Caroline Orfila
- School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK.
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247
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Bıçak DA, Urgancı N, Akyüz S, Usta M, Kızılkan NU, Alev B, Yarat A. Clinical evaluation of dental enamel defects and oral findings in coeliac children. Eur Oral Res 2018; 52:150-156. [PMID: 30775719 DOI: 10.26650/eor.2018.525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/22/2017] [Accepted: 01/11/2018] [Indexed: 12/18/2022] Open
Abstract
Purpose To examine dental hard and soft tissue changes of coeliac children in order to increase the awareness of the pediatric dentists in prediagnosis of especially undiagnosed coeliac disease. Materials and methods Sixty children, 28 (46.7%) boys and 32 (53.3%) girls whose ages were between 6 to 16 years were included in the present study. Thirty children who had undergone endoscopy and diagnosed with the coeliac disease in the Şişli Hamidiye Etfal Hospital, İstanbul, Turkey, formed the study group. Also, thirty children clinically suspected of having the coeliac disease with the same gastrointestinal complaints had undergone endoscopy and proven not coeliac were chosen as the control group. Oral examination involved assessment of dentition and specific and unspecific dental enamel defects. Also, soft tissue lesions, clinical delay of the dental eruption, salivary flow rate, pH, and buffering capacity were examined. Results Twenty coeliac patients had enamel defects, however none in the control subjects. In the coeliac group, all enamel defects were diagnosed in permanent teeth and as specific in all children. Grade I dental enamel defects found mainly in the incisors. The clinical delayed eruption was observed in 10 (33.3%) of 30 coeliac children and none of the children in the control group. While the level of DMFT/S numbers and stimulated salivary flow rate were found significantly lower in the coeliac group, pH was found significantly higher. Conclusion Oral cavity may be involved in coeliac disease and pediatric dentists can play an important role in the early diagnosis of the coeliac disease.
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Affiliation(s)
- Damla Akşit Bıçak
- Department of Pediatric Dentistry, Near East University, Faculty of Dentistry, KKTC
| | - Nafiye Urgancı
- Clinic of Pediatric Gastroenterology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Serap Akyüz
- Department of Pediatric Dentistry, Marmara University, Faculty of Dentistry, İstanbul, Turkey
| | - Merve Usta
- Clinic of Pediatric Gastroenterology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Nuray Uslu Kızılkan
- Clinic of Pediatric Gastroenterology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey.,Clinic of Pediatric Gastroenterology, Koç University Hospital, İstanbul, Turkey
| | - Burçin Alev
- Department of Basic Medical Sciences, Division of Biochemistry, Marmara University, Faculty of Dentistry, İstanbul, Turkey
| | - Ayşen Yarat
- Department of Basic Medical Sciences, Division of Biochemistry, Marmara University, Faculty of Dentistry, İstanbul, Turkey
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248
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De Marchi G, Zanoni G, Conti Bellocchi MC, Betti E, Brentegani M, Capelli P, Zuliani V, Frulloni L, Klersy C, Ciccocioppo R. There Is No Association between Coeliac Disease and Autoimmune Pancreatitis. Nutrients 2018; 10:nu10091157. [PMID: 30149525 PMCID: PMC6163375 DOI: 10.3390/nu10091157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 02/07/2023] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare disorder whose association with coeliac disease (CD) has never been investigated, although CD patients display a high prevalence of both endocrine and exocrine pancreatic affections. Therefore, we sought to evaluate the frequency of CD in patients with AIP and in further medical pancreatic disorders. The screening for CD was carried out through the detection of tissue transglutaminase (tTG) autoantibodies in sera of patients retrospectively enrolled and divided in four groups: AIP, chronic pancreatitis, chronic asymptomatic pancreatic hyperenzymemia (CAPH), and control subjects with functional dyspepsia. The search for anti-endomysium autoantibodies was performed in those cases with borderline or positive anti-tTG values. Duodenal biopsy was offered to all cases showing positive results. One patient out of 72 (1.4%) with AIP had already been diagnosed with CD and was following a gluten-free diet, while one case out of 71 (1.4%) with chronic pancreatitis and one out of 92 (1.1%) control subjects were diagnosed with de novo CD. No cases of CD were detected in the CAPH group. By contrast, a high prevalence of cases with ulcerative colitis was found in the AIP group (13.8%). Despite a mutual association between CD and several autoimmune disorders, our data do not support the serologic screening for CD in AIP. Further studies will clarify the usefulness of CD serologic screening in other pancreatic disorders.
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Affiliation(s)
- Giulia De Marchi
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona; Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Giovanna Zanoni
- Immunology Unit, Department of Pathology and Diagnostics, AOUI Policlinico G.B. Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Maria Cristina Conti Bellocchi
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona; Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Elena Betti
- Clinica Medica I, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, Piazzale Golgi, 19, 27100 Pavia, Italy.
| | - Monica Brentegani
- Immunology Unit, Department of Pathology and Diagnostics, AOUI Policlinico G.B. Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Paola Capelli
- Pathology Unit, Department of Pathology and Diagnostics, AOUI Policlinico G.B. Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Valeria Zuliani
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona; Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Luca Frulloni
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona; Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Catherine Klersy
- Clinical Epidemiology & Biometry Unit, IRCCS Fondazione Policlinico San Matteo; Viale Golgi 19, 27100 Pavia, Italy.
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona; Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
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Vinagre-Aragón A, Zis P, Grunewald RA, Hadjivassiliou M. Movement Disorders Related to Gluten Sensitivity: A Systematic Review. Nutrients 2018; 10:E1034. [PMID: 30096784 PMCID: PMC6115931 DOI: 10.3390/nu10081034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/05/2018] [Accepted: 08/06/2018] [Indexed: 12/25/2022] Open
Abstract
Gluten related disorders (GRD) represent a wide spectrum of clinical manifestations that are triggered by the ingestion of gluten. Coeliac disease (CD) or gluten sensitive enteropathy is the most widely recognised, but extra-intestinal manifestations have also been increasingly identified and reported. Such manifestations may exist in the absence of enteropathy. Gluten sensitivity (GS) is another term that has been used to include all GRD, including those where there is serological positivity for GS related antibodies in the absence of an enteropathy. Gluten ataxia (GA) is the commonest extraintestinal neurological manifestation and it has been the subject of many publications. Other movement disorders (MDs) have also been reported in the context of GS. The aim of this review was to assess the current available medical literature concerning MDs and GS with and without enteropathy. A systematic search was performed while using PubMed database. A total of 48 articles met the inclusion criteria and were included in the present review. This review highlights that the phenomenology of gluten related MDs is broader than GA and demonstrates that gluten-free diet (GFD) is beneficial in a great percentage of such cases.
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Affiliation(s)
- Ana Vinagre-Aragón
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Panagiotis Zis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Richard Adam Grunewald
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, South Yorkshire, UK.
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Abstract
Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.
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Affiliation(s)
| | - David S Sanders
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
| | - Reena Sidhu
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
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