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Elwenspoek MM, Thom H, Sheppard AL, Keeney E, O'Donnell R, Jackson J, Roadevin C, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Jones HE, Mallett S, Whiting PF. Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling. Health Technol Assess 2022; 26:1-310. [PMID: 36321689 PMCID: PMC9638887 DOI: 10.3310/zuce8371] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. OBJECTIVES The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. DESIGN (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. DATA SOURCES For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. REVIEW METHODS For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. RESULTS People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. LIMITATIONS The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. CONCLUSIONS Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). FUTURE WORK Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42019115506 and CRD42020170766. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martha Mc Elwenspoek
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athena L Sheppard
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel O'Donnell
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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2
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Iron Deficiency in Celiac Disease: Prevalence, Health Impact, and Clinical Management. Nutrients 2021; 13:nu13103437. [PMID: 34684433 PMCID: PMC8537360 DOI: 10.3390/nu13103437] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
Iron is an essential nutrient to life and is required for erythropoiesis, oxidative, metabolism, and enzymatic activities. It is a cofactor for mitochondrial respiratory chain enzymes, the citric acid cycle, and DNA synthesis, and it promotes the growth of immune system cells. Thus, iron deficiency (ID) leads to deleterious effects on the overall health of individuals, causing significant morbidity. Iron deficiency anemia (IDA) is the most recognized type of anemia in patients with celiac disease (CD) and may be present in over half of patients at the time of diagnosis. Folate and vitamin B12 malabsorption, nutritional deficiencies, inflammation, blood loss, development of refractory CD, and concomitant Heliobacter pylori infection are other causes of anemia in such patients. The decision to replenish iron stores and the route of administration (oral or intravenous) are controversial due, in part, to questions surrounding the optimal formulation and route of administration. This paper provides an algorithm based on the severity of symptoms; its impact on the health-related quality of life (HRQL); the tolerance and efficiency of oral iron; and other factors that predict a poor response to oral iron, such as the severity of histological damage, poor adherence to GFD, and blood loss due to mucosal lesions.
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Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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4
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Remes-Troche JM, Uscanga-Domínguez LF, Aceves-Tavares RG, Calderón de la Barca AM, Carmona-Sánchez RI, Cerda-Contreras E, Coss-Adame E, Icaza-Chávez ME, Lopéz-Colombo A, Milke-García MP, Morales-Arámbula M, Peláez-Luna M, Ramos Martínez P, Sánchez-Sosa S, Treviño-Mejía MC, Vázquez-Frías R, Worona-Dibner LB, Zamora-Nava LE, Rubio-Tapia A. Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2018; 83:434-450. [PMID: 30197183 DOI: 10.1016/j.rgmx.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/12/2018] [Accepted: 05/24/2018] [Indexed: 12/17/2022]
Abstract
Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México.
| | - L F Uscanga-Domínguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R G Aceves-Tavares
- Servicio de Gastroenterología, Hospital General del Estado Dr. Ernesto Ramos, Bours, Hermosillo, Sonora, México
| | | | | | - E Cerda-Contreras
- ITESM. Medicina Interna y Gastroenterología Fundación Clínica Médica Sur, Ciudad de México, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Gastroenterología de la UNIMAYAB, , Mérida, Yucatán, México
| | - A Lopéz-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, México
| | - M P Milke-García
- Dirección de Nutrición, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M Morales-Arámbula
- Servicio de Gastroenterología y Endoscopía Gastrointestinal, Hospital Country 2000, Guadalajara, Jalisco, México
| | - M Peláez-Luna
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - S Sánchez-Sosa
- Jefe de Patología, Hospital Ángeles de Puebla, Universidad de Las Américas Puebla (UDLAP), Puebla, México
| | - M C Treviño-Mejía
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - R Vázquez-Frías
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - L B Worona-Dibner
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - L E Zamora-Nava
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - A Rubio-Tapia
- División de Gastroenterología y Hepatología, Mayo Clinic, Rochester, Minnesota, Estados Unidos de América
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Mahadev S, Laszkowska M, Sundström J, Björkholm M, Lebwohl B, Green PHR, Ludvigsson JF. Prevalence of Celiac Disease in Patients With Iron Deficiency Anemia-A Systematic Review With Meta-analysis. Gastroenterology 2018; 155:374-382.e1. [PMID: 29689265 PMCID: PMC7057414 DOI: 10.1053/j.gastro.2018.04.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/10/2018] [Accepted: 04/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Anemia is common in patients with celiac disease (CD) and a frequent mode of presentation. Guidelines recommend screening patients with iron-deficiency anemia (IDA) for CD. However, the reported prevalence of CD in patients with IDA varies. We performed a systematic review to determine the prevalence of biopsy-verified CD in patients with IDA. METHODS We performed a systematic review of articles published in PubMed Medline or EMBASE through July 2017 for the term "celiac disease" combined with "anemia" or "iron deficiency." We used fixed-effects inverse variance-weighted models to measure the pooled prevalence of CD. Meta-regression was used to assess subgroup heterogeneity. RESULTS We identified 18 studies composed of 2998 patients with IDA for inclusion in our analysis. Studies originated from the United Kingdom, United States, Italy, Turkey, Iran, and Israel. The crude unweighted prevalence of CD was 4.8% (n = 143). Using a weighted pooled analysis, we found a prevalence of biopsy-confirmed CD of 3.2% (95% confidence interval = 2.6-3.9) in patients with IDA. However, heterogeneity was high (I2 = 67.7%). The prevalence of CD was not significantly higher in studies with a mean participant age older or younger than 18 years or in studies with a mixed-sex vs female-predominant (≥60%) population. On meta-regression, year of publication, female proportion, age at CD testing, and prevalence in the general population were not associated with the prevalence of CD in patients with IDA. In the 8 studies fulfilling all our quality criteria, the pooled prevalence of CD was 5.5% (95% confidence interval = 4.1-6.9). CONCLUSIONS In a systematic review and meta-analysis, we found that approximately 1 in 31 patients with IDA have histologic evidence of CD. This prevalence value justifies the practice of testing patients with IDA for CD.
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Affiliation(s)
- Srihari Mahadev
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, and Uppsala Clinical Research Center, SE-751 85 Uppsala, Sweden
| | - Magnus Björkholm
- Department of Medicine, Division of Hematology, Karolinska University Hospital and Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Peter HR Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jonas F Ludvigsson
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
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6
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Abdalla A, Saifullah SM, Osman M, Baniya R, Sidahmed S, LaChance J, Bachuwa G. Prevalence of occult celiac disease in females with iron deficiency in the United States: an NHANES analysis. J Community Hosp Intern Med Perspect 2017; 7:347-350. [PMID: 29296246 PMCID: PMC5738635 DOI: 10.1080/20009666.2017.1396169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/17/2017] [Indexed: 01/16/2023] Open
Abstract
Aim: The prevalence of celiac disease (CD) in patients with iron deficiency (ID) is estimated at 0–6% in European countries. The prevalence of celiac disease in patients with iron deficiency in the USA is unknown. Given the treatable nature of gluten hypersensitivity, estimating the prevalence of CD in patients with ID can help to determine the need to screen these patients for occult CD. Methods: Data were obtained from the NHANES database, a nationally representative health survey conducted from 2009 to 2010. We included 2,105 females aged 6 years or older. Iron deficiency was defined as serum ferritin level <20 ng/ml and considered positive for celiac disease when subjects were tested positive for both immunoglobulin A (IgA) tissue transglutaminase antibody and IgA endomysial antibody. Subjects were divided between two groups (ID and non-ID). The association of CD and ID, which was the primary outcome, was obtained after adjusting for other covariates using logistic regression. Results: Among the sample of 2,105 subjects, 569 had ID and 1536 did not have ID. Five people were identified as having CD among the ID group, as were two people in the non-ID group. After adjusting for selected covariates, the prevalence of CD was higher in female subjects with ID with OR of 12.5 (95% CI 1.74–90). Conclusions: The overall prevalence of celiac disease in the USA’ female population is low, however, the prevalence is higher in subjects with iron deficiency. Further prospective studies are needed to validate our findings.
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Affiliation(s)
- Ahmed Abdalla
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, College of Human Medicine, Flint, MI, USA
| | - Shaik Mohamed Saifullah
- Hematology/oncology attending, Hurley Medical Center, Michigan State University, College of Human Medicine, Flint, MI, USA
| | - Mohamed Osman
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, College of Human Medicine, Flint, MI, USA
| | - Ramkaji Baniya
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, College of Human Medicine, Flint, MI, USA
| | - Shima Sidahmed
- School of Medicine, University of Khartoum, Khartoum, Sudan
| | - Jenny LaChance
- Department of Research, Hurley Medical Center, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, College of Human Medicine, Flint, MI, USA
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Kondala R, Singh Puri A, Banka AK, Sachdeva S, Sakhuja P. Potential celiac disease in Indian patients: Response. United European Gastroenterol J 2017; 5:140-141. [PMID: 28405334 PMCID: PMC5384562 DOI: 10.1177/2050640616659999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Raghuram Kondala
- Department of Gastroenterology, GB Pant Hospital, JL Nehru Marg, New Delhi, India
| | - Amarender Singh Puri
- Department of Gastroenterology, GB Pant Hospital, JL Nehru Marg, New Delhi, India
| | - Ameet Kumar Banka
- Department of Gastroenterology, GB Pant Hospital, JL Nehru Marg, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, GB Pant Hospital, JL Nehru Marg, New Delhi, India
| | - Puja Sakhuja
- Department of Pathology, GB Pant Hospital, JL Nehru Marg, New Delhi, India
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