Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis

Effect of low birth weight and preterm delivery on the development of childhood celiac disease: a systematic review and meta-analysis on observational studies

PURPOSE OF REVIEW

Whether low birth weight (LBW) and preterm delivery (PD) are associated with the risk of developing celiac disease (CD) in children remains unclear. This systematic review and meta-analysis aimed to evaluate the association between LBW and PD with CD development in children.

RECENT FINDINGS

We searched PubMed, Embase, Scopus, Web of Science, and Google Scholar databases based on the Mesh terms to find observational studies that investigated the association of LBW and PD with CD development in children up to July 18, 2024. This systematic review was based on the PRISMA 2020 checklist. Heterogeneity between studies was assessed with Cochran's Q and I2 tests. Meta-regression was used to control heterogeneity. Publication bias was evaluated using Egger's test. Finally, ten studies involving 3 434 290 participants were included. Based on 10 studies, the pooled prevalence of LBW was 6.4 per 1000 children with CD. A pooled estimate of ten studies did not show a significant relationship between LBW and the risk of developing CD in children [odds ratio (OR): 0.96, 95% confidence interval (CI): 0.76, 1.16, I 2 : 67.9%, P : 0.001). Also, the pooled estimate of six studies did not show a significant relationship between PD and the risk of developing CD in children (OR: 0.98, 95% CI: 0.81, 1.16, I2 : 67.5%, P : 0.001).

SUMMARY

We found no evidence of an association between LBW and PD with the risk of developing CD in children.

Investigating intestinal epithelium metabolic dysfunction in celiac disease using personalized genome-scale models

BACKGROUND

Celiac disease (CeD) is an autoimmune condition characterized by an aberrant immune response triggered by the ingestion of gluten, which damages epithelial cells lining the small intestine. Small intestinal epithelial cells (sIECs) play key roles in the enzymatic digestion and absorption of nutrients, maintaining gut barrier integrity, and regulating immune response. Chronic inflammation and tissue damage associated with CeD disrupt the intricate network of metabolic processes in sIECs that support these functions, impairing their ability to perform their essential roles. However, the specific disrupted metabolic processes underlying sIECs dysfunction in CeD remain largely undefined.

METHODS

To address this knowledge gap, personalized, sex-specific genome-scale models of sIECs metabolism were constructed using transcriptional data from intestinal biopsies of 42 subjects with active CeD, CeD in remission (on a gluten-free diet), and non-CeD controls. These models were computationally simulated under relevant dietary conditions for each group of subjects to assess the activity of several metabolic tasks essential for sIECs function and to profile metabolite secretion into the bloodstream and intestinal lumen.

RESULTS

Significant alterations in the activity of 28 essential metabolic tasks were observed in active CeD and remission CeD, impacting critical processes integral to sIECs function such as oxidative stress regulation, nucleotide synthesis and DNA repair, energy production, and polyamine and amino acid metabolism. Additionally, altered secretion profiles of several metabolites, encompassing amino acids, vitamins, polyamines, lipids, and fatty acids, into the bloodstream were detected in active CeD and remission CeD patients. These findings were partially supported by comparisons with independent external datasets and further corroborated through extensive review of existing literature. Furthermore, a drug target analysis was performed, identifying 22 FDA-approved drugs that target genes encoding impaired sIECs metabolic functions in CeD, potentially helping to restore their normal activity.

CONCLUSIONS

This study unveils new insights into the metabolic reprogramming of sIECs in CeD, highlighting specific dysregulated metabolic processes that compromise cellular functions essential for gut health. These findings offer a foundation for developing therapeutic interventions targeting impaired metabolic processes in CeD.

Epidemiology of Celiac Disease in Cantabria, Spain

Background/Objectives: Celiac disease is an enteropathy caused by a systemic autoimmune process of genetic predisposition to the ingestion of gluten. It is a public health problem worldwide because there are often long delays between the onset of symptoms and diagnosis. Our main objective is to describe the prevalence of celiac disease in our community, Cantabria, located in northern Spain. We start with an analytical database, with data collected from 2007 to 2016. We describe the possible differences in terms of age, sex, and geographic areas; family aggregation; and disease-associated comorbidities. Methods: The data for this research were obtained from a database from the Immunology Laboratory at the Marqués de Valdecilla University Hospital (HUMV), a reference laboratory for the entire Autonomous Community of Cantabria, located in northern Spain. The data were obtained from the analytical results collected from this database from January 2007 to January 2016, within this Community of 566,898 inhabitants in 2016. The data collected in this database consist of immunological tests, HLA-DQ2 or HLA-DQ8 antigenic patterns, focused on diagnosing celiac disease in the community of Cantabria, which have been positive during this period of time. Results: The prevalence of celiac disease in Cantabria is 0.14%. The mean age of diagnosis was 17.92 years. A higher percentage has been observed in the female sex and in children. Conclusions: The present study shows that celiac disease in the community of Cantabria is underdiagnosed. It is an important fact to consider when evaluating patients with symptoms that could be related to this disease to avoid increased use of medical consultations until a diagnosis is reached, in addition to avoiding long-term complications with this disease.

Evidence-based dietary recommendations for patients with psoriasis: A systematic review

Psoriasis is a chronic recurrent inflammatory skin disease mediated by immune, genetic, and environmental factors. Numerous studies have demonstrated that the excessive consumption of certain pro-inflammatory foods, including alcohol, dairy products, high-sugar foods, and gluten, can exacerbate psoriasis. Thus, modifying one's dietary habits can alleviate psoriasis symptoms. However, high-quality evidence regarding the relationship between diet and psoriasis is currently lacking. This review provides insight into the dietary management of psoriasis by reviewing previous dietary therapies. An extensive search of the PubMed, Embase, and Cochrane databases for clinical studies of psoriasis and diet revealed that diets meeting Mediterranean, gluten-free, or calorie-restricted principles, dietary fiber, probiotic, prebiotic, and n-3 fatty acid contents may be associated with improved psoriasis outcomes. Additionally, patients with psoriasis should avoid consuming alcohol and high amounts of salt. Overall, based on findings from the current literature, this review aimed to guide dietary treatment options for patients with psoriasis.

Long-term laboratory follow-up is essential in pediatric patients with celiac

OBJECTIVES

Celiac disease (CeD) requires long-term follow. The role of laboratory testing other than celiac serology during follow up is unclear. We aimed to determine which laboratory tests are required during follow up based on the prevalence of abnormal tests and timing of abnormalities appearance.

METHODS

Retrospective chart-review of children diagnosed with CeD between 1999 and 2018 was conducted. Demographic, clinical and laboratory data were recorded from diagnosis and during follow-up.

RESULTS

The cohort included 500 children with CeD [59.8% females, median(IQR) age at diagnosis 5.7(3.7-8.9) years]. Mean follow-up time was 5.5 years (range 1.5-16.2). The most frequently abnormal laboratory tests at time of diagnosis were low ferritin (64.3%), vitamin D (33.6%), zinc (29.9%), hemoglobin (29.2%), and folate (14.7%). In 74 (14.8%) patients, anemia developed only during follow up, while in another 46 patients, anemia resolved after diagnosis and reappeared later (after a mean ± SD 2.8 ± 2.1 years from CeD diagnosis, for the entire group). Abnormal values that developed during follow up were low folate in 40 patients (3.9 ± 2.6 years), and abnormal liver enzymes in 18 patients (3.1 ± 2.7 years). Elevated TSH during follow-up was observed in 14/280 (5%) patients, after a mean ± SD of 2.2 ± 1.6 years from diagnosis. Patients diagnosed as teenagers (12-18 years) had shorter intervals to reappearance of anemia and folate deficiency.

CONCLUSIONS

Multiple laboratory abnormalities may occur in pediatric patients with CeD, both at diagnosis and during long-term follow-up. We suggest continued monitoring of hemoglobin, ferritin, folate, liver, and thyroid function in addition to celiac serology during follow-up of CeD.

Interplay of n-3 Polyunsaturated Fatty Acids, Intestinal Inflammation, and Gut Microbiota in Celiac Disease Pathogenesis

Celiac disease (CD) is a chronic autoimmune disorder driven by both genetic and environmental factors, with the HLA DQ2/DQ8 genotypes playing a central role in its development. Despite the genetic predisposition, only a small percentage of individuals carrying these genotypes develop the disease. Gluten, a protein found in wheat, rye, and barley, is the primary environmental trigger, but other factors, such as the intestinal microbiota, may also contribute to disease progression. While the gluten-free diet (GFD) remains the cornerstone of treatment, many CD patients experience persistent inflammation and gut dysbiosis, leading to ongoing symptoms and complications. This chronic inflammation, which impairs nutrient absorption, increases the risk of malnutrition, anemia, and other autoimmune disorders. Recent studies have identified an altered gut microbiota in CD patients, both on and off the GFD, highlighting the potential role of the microbiota in disease pathogenesis. An emerging area of interest is the supplementation of n-3 polyunsaturated fatty acids (PUFAs), known for their anti-inflammatory properties, as a potential therapeutic strategy. n-3 PUFAs, found in fish oil and certain plant oils, modulate the immune cell function and cytokine production, making them a promising intervention for controlling chronic inflammation in CD. This review explores the current understanding of n-3 PUFAs' effects on the gut microbiota's composition and inflammation in CD, with the goal of identifying new avenues for complementary treatments to improve disease management.

Assessment of Reliability and Validity of Celiac Disease-Related YouTube Videos: Content Analysis

BACKGROUND

YouTube is an increasingly used platform for medical information. However, the reliability and validity of health-related information on celiac disease (CD) on YouTube have not been determined.

OBJECTIVE

This study aimed to analyze the reliability and validity of CD-related YouTube videos.

METHODS

On November 15, 2023, a search was performed on YouTube using the keyword "celiac disease." This search resulted in a selection of videos, which were then reviewed by 2 separate evaluators for content, origin, and specific features. The evaluators assessed the reliability and quality of these videos using a modified DISCERN (mDISCERN) score, the Journal of the American Medical Association (JAMA) benchmark criteria score, the usefulness score, video power index (VPI), and the Global Quality Scale (GQS) score.

RESULTS

In the analysis of 120 initially screened CD videos, 85 met the criteria for inclusion in the study after certain videos were excluded based on predefined criteria. While the duration of the videos uploaded by health care professionals was significantly longer than the other group (P=.009), it was concluded that the median scores for mDISCERN (4, IQR 4-5 vs 2, IQR 2-3; P<.001), GQS (4, IQR 4-5 vs 3, IQR 2-3; P<.001), JAMA (4, IQR 3-4 vs 2, IQR 2-3; P<.001), and usefulness (8, IQR 7-9 vs 6, IQR 3-6; P<.001) of the videos from this group were significantly higher than those from non-health care professionals. Video interaction parameters, including the median number of views, views per day, likes, dislikes, comments, and VPI, demonstrated no significant difference between the 2 groups.

CONCLUSIONS

This study showed that YouTube videos about CD vary significantly in reliability and quality depending on their source. Increasing the production of reliable videos by health care professionals may help to improve patient education and make YouTube a more reliable resource.

Burden of coeliac disease in Germany: real-world insights from a large retrospective health insurance claims database analysis

Background

Coeliac disease (CeD) is a chronic immune-mediated disease triggered by exposure to dietary gluten in genetically predisposed individuals. The burden of CeD on patients and the healthcare system remains poorly evaluated in Germany.

Objectives

To assess the healthcare resource utilisation (HCRU) and costs of diagnosed CeD patients in a German claims database.

Design

A retrospective CeD case-control study was conducted using German claims data between 2017 and 2021.

Methods

CeD diagnosis was defined by at least one inpatient or two outpatient diagnostic codes (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification (ICD-10-GM) K90.0) within four quarters (irrespective of calendar year) for CeD during the study period. Controls (non-CeD patients) were matched in a ratio of 5:1 by age, Charlson Comorbidity Index, sex and region. HCRU (hospitalisations, outpatient visits, medication use, sick leaves) and healthcare costs (outpatient services, inpatient services, outpatient pharmaceuticals, sick leaves and aids and remedies) were compared between CeD patients and controls.

Results

From the 3,352,188 patients with continuous enrolment during the study period (2017-2021), 8258 (0.25%) patients were identified as having a CeD diagnosis. The mean number of hospitalisations and outpatient visits within 5 years was 1.8- and 1.5-fold higher among matched CeD patients (n = 8243) compared to their controls (n = 41,215), resulting in an excess healthcare cost of €5251. Inpatient expenses were the main cost driver and accounted for 31.5% of total incremental costs.

Conclusion

The current study showed that CeD patients have considerably higher HCRU and related costs compared to matched controls. Our findings suggest the need for improved treatment options for CeD patients in addition to a gluten-free diet.

Human organoids and organ-on-chips in coeliac disease research

Coeliac disease (CeD) is an immune-mediated disorder characterised by gluten-triggered inflammation and damage in the small intestine, with lifelong gluten-free diet (GFD) as the only treatment. It is a multifactorial disease, involving genetic and environmental susceptibility factors, and its complexity and lack of comprehensive human model systems have hindered understanding of its pathogenesis and development of new treatments. Therefore, it is crucial to establish systems that recapitulate patient genetic background and the interactions between the small intestinal epithelial barrier, immune cells, and environment that contribute to CeD. In this review, we discuss disease complexity, recent advances in stem cell biology, organoids, tissue co-cultures, and organ-on-chip (OoC) systems that facilitate the development of comprehensive human model systems, and model applications in preclinical studies of potential treatments.

Living with Pediatric Coeliac Disease: Lessons for Health Service Delivery

BACKGROUND

Coeliac Disease (CD) affects up to 1.4% of children worldwide, with a rising global incidence. A less typical clinical presentation and the need for a life-long gluten exclusion diet raise challenges for diagnosis, management, and healthcare delivery with considerable impacts for CD patients and families as well as clinical services.

AIMS

To explore the lived experiences of caregivers of children with CD to identify barriers and enablers to diagnosis, referral, and treatment to inform a more streamlined service delivery model.

METHODS

Semi-structured interviews with caregivers of children with CD diagnosed for at least one month with no significant co-morbidities. Interviews were thematically analyzed.

RESULTS

Sixteen participants representing 12 family units were interviewed. Children with CD ranged in age from 3 to 18 years. Time from symptom onset to diagnosis varied from one month to > 10 years and symptoms were mainly atypical and non-specific. Six key themes were identified: the iterative diagnosis journey, restricted choices, child responsibility and autonomy, mental load (encompassing foodwork, emotional rollercoaster, and lack of trust), Google™ reigns for information, and where to from here?

CONCLUSION

There is a need to decentralize CD diagnosis and management to meet the increasing demand created by rising incidence. Participants highlighted the need for a more streamlined diagnosis pathway, increased training of health professionals, and access to age-appropriate resources. Efforts need to be made to advocate for increased community awareness. These insights will be used to reimagine and co-design a decentralized model of care for pediatric CD diagnosis and management in Queensland, Australia.

Utilizing both IgA tissue transglutaminase and IgG-deamidated gliadin peptide antibodies offers accurate celiac disease diagnosis without duodenal biopsy

BACKGROUND

Gastroenterologists still raise concerns about adopting a non-biopsy strategy for diagnosing celiac disease (CeD) in adults.

AIM

To assess the performance of the concurrent detection of two autoantibodies targeting two independent antigens, tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP).

METHODS

This prospective, multicenter, binational study collected consecutive patients with a high pre-test probability for CeD. Between 2018 and 2020, adults were enrolled at four Italian and one Argentinian center. Serology was also blindly analyzed by a central laboratory (Werfen, San Diego, USA) for tTG IgA and DGP IgG by Aptiva Particle-based multi-analyte technology (PMAT) assays. CeD diagnosis required histological confirmation of Marsh 3 damage.

RESULTS

181 adult patients with suspected CeD were enrolled (134 with histological diagnosis of CeD and 47 not histologically confirmed as CeD). Patients positive for both tTG IgA and DGP IgG (double positive) were predictive of CeD in 92.5 % of patients at >1x upper limit of normal (ULN). Double positivity for tTG IgA and DGP IgG, both at >10x ULN, had a 100 % positive predictive value for the presence of Marsh 3 histology.

CONCLUSIONS

Incorporating DGP IgG alongside tTG IgA in a single-step approach can be considered a valid confirmatory strategy for definitive non-biopsy diagnosis of CeD.

Life Challenges and Quality of Life of People Living With Coeliac Disease: Time of Diagnosis Matters

BACKGROUND

Previous studies have examined the quality of life of patients with coeliac disease. There is a lack of understanding about potential changes in emotional responses and life challenges after diagnosis. This exploratory study aimed to evaluate the emotional impact, life challenges and quality of life in people living with coeliac disease in Germany.

METHODS

An online survey was conducted among patients with coeliac disease to assess difficulties in implementing a gluten-free diet in daily life activities, including food shopping and preparation, and eating away from home, as well as additional costs of time and money. Furthermore, the questionnaire assessed the time of diagnosis, emotions felt after diagnosis and today, compliance regarding the gluten-free diet and sociodemographic data. Participants were recruited in 2022 via social media, newsletters and websites. Out of 1286 participants who had taken part in the survey, 766 met the inclusion criteria and were included in the data analysis.

RESULTS

The majority of the respondents (aged 18-83 years) were female (93%) and almost 50% were diagnosed more than 5 years ago. Negative emotion ratings related to the disease were associated with age at the time of diagnosis and years passed since diagnosis. While compliance was high with 89% of respondents strictly adhering to the gluten-free diet, patients with coeliac disease reported mainly life challenges in social situations involving food such as out-of-home consumption in restaurants, at work and while travelling. These challenges appear to persist over time.

CONCLUSIONS

Negative emotions and difficulties in implementing a gluten-free diet are negatively impacting individuals with coeliac disease, particularly in the first months after diagnosis. Particularly adolescents and young adults appear to be negatively impacted. The study emphasises the need to improve the quality of life in all impacted areas through better guidance and improved training of health professionals as well as food providers outside of home and through psychological counselling in the first year of diagnosis to better help individuals improve their quality of life.

Telemedicine in Coeliac Disease: In-Person Appointments Are Favoured by Patients With a Lower Education Attainment and Lower Household Income

INTRODUCTION

A gluten-free (GF) diet, the only treatment for people living with coeliac disease (CD), is challenging, and international guidelines highlight the valuable role of healthcare professionals in enabling self-management. The study aimed to explore the acceptability of telephone and online video consultations for adults with CD.

METHODS

A cross-sectional study consisting of an online and paper survey was promoted to adults with CD.

RESULTS

Data from 496 adults with CD (87% female, 96% White) are presented, and 44% were adhering to the GF diet. Over half (58%) were very confident in understanding food labels from supermarkets, whereas only 38% were very confident when shopping online. The largest proportion of patients preferred in-person healthcare appointments for CD (44%), with 20% reporting no preference and 21% preferring telephone appointments. Only 15% preferred online video consultations; of these, 97% were confident with online technology. A higher proportion of patients from a lower household income requested 'in-person' appointments compared with those with a higher income (65% vs. 45% (p < 0.01)). Likewise, 58% of patients without a degree qualification requested 'in-person' appointments compared with 45% of degree-educated patients (p = 0.027).

CONCLUSIONS

We highlight a significant proportion of adults with CD prefer an in-person appointment. The paper survey enabled the views of a broader range of digitally confident patients to contribute to the study. With a global shift towards telemedicine and online resources, access and digital literacy is an important consideration for equitable healthcare to optimize patient self-management of the GF diet.

What is new in the management of coeliac disease?

Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.

FOXP3 expression in duodenal mucosa: Unique role in pathogenesis and differential diagnosis of celiac disease

Forkhead box protein P3 (FOXP3) positive regulatory T lymphocytes are indispensable in the inflammatory homeostasis of the gastrointestinal tract and represent a significant subset of regulatory cells in inflammatory, autoimmune, and neoplastic conditions. This study aimed to elucidate the potential of FOXP3 expression in diagnosing and pathogenesis of celiac disease (CD) by comparing duodenal biopsies of CD cases with non-CD ones, some of which had increased intraepithelial lymphocytes (IELs). Two hundred sixty-one duodenal tissues of patients who applied to adult gastroenterology were reevaluated for immunohistochemical analysis. After excluding patients on a gluten-free diet (n = 44), the CD (n = 97) and non-CD (n = 120) groups were divided based on clinical complaints that could be associated with CD (intestinal or extraintestinal), serologic and histologic findings. The specific threshold was determined by receiver operating characteristic (ROC) analysis, and its relationship with CD diagnosis and clinicopathological data was evaluated. ROC analysis offered a ">14" cut-off value for diagnosing CD, for which AUC (Area Under The Curve): 0.968, p < 0.0001, sensitivity: 92.8, specificity: 91.7, positive and negative predictive values were 90 % and 94 %, respectively. High FOXP3 expression was associated with higher IEL, diagnosis of CD, more severe histologic (higher Marsh score) and endoscopic (scalloping) findings, and higher anti-tissue transglutaminase and anti-endomysium IgA titers (p < 0.001). It also correlates with IEL in CD patients and is unaffected by the increase in IEL and the presence of gastric Helicobacter Pylori in the non-CD group. FOXP3 is a sensitive and specific marker for diagnosing CD despite inflammatory conditions resulting from non-CD causes.

Gluten-free and conventional breads and pastas sold in Southern Brazil: a comparative study on cost, nutritional composition and ingredients

A gluten-free diet is the only treatment for patients with coeliac disease, who report dissatisfaction with the availability and variety of products, especially bread and pasta. The aim was to compare availability, cost, nutritional composition and ingredients of gluten-free and conventional bread and pasta products. Census of breads and pastas available in online commerce belonging to the third largest supermarket chain in southern Brazil. Information was collected at supermarket's and brand's websites. One hundred and fourteen products were analysed (n = 37 breads and n = 77 pastas): 32.4% (n = 12) gluten-free breads and 18.2% (n = 14) gluten-free pastas. Both gluten-free breads and pastas were significantly more expensive when compared to gluten-containing breads and pastas. Gluten-free breads have higher fat content, gluten-free pastas have higher content of sodium and ingredients. Gluten-free breads and pastas are less available, more expensive and have lower nutritional value compared to conventional versions.

Short- and Long-Term Nutritional Status in Children and Adolescents with Celiac Disease Following a Gluten-Free Diet: A Systematic Review

BACKGROUND/OBJECTIVES

Numerous studies have highlighted the nutritional imbalances that are commonly observed in children and adolescents diagnosed with celiac disease (CD) who follow a gluten-free diet (GFD). However, the development and timeline of these nutritional deficiencies remain unclear. The aim of the present study is to investigate the short-term (≥6 months to <12 months) and long-term (≥12 months) association between adherence to a GFD and nutrient intake as well as micronutrient blood status in children and adolescents aged from 0 to 18 years with CD.

METHODS

A systematic review was conducted in PubMed and Scopus for observational studies published up to June 2024.

RESULTS

A total of 15 studies (case-control, cross-sectional, and prospective studies) with 2004 children and adolescents were included. Their quality was assessed using the ROBINS-E tool. Despite the lack of high-quality data and the heterogeneity of the methods used in the included studies, the results of the cross-sectional/case-control studies show that, in the short term, children and adolescents with CD consumed excessive amounts of protein and carbohydrates compared to controls. After long-term adherence to a GFD, significant changes in the diets of children and adolescents with CD persisted. Fat intake was higher, while protein intake remained excessive compared to controls. Based on prospective studies, vitamin C and iodine intake improved both in the short and long term after adherence to a GFD. However, most other nutrients either remain inadequate or continue to decline, indicating that it is difficult to meet nutrient requirements despite dietary adjustments.

CONCLUSIONS

Gaps in adherence to dietary recommendations appear to be widespread in children and adolescents with CD, emphasizing the need for improved diet quality and regular monitoring.

Oxidative Stability of Novel Peptides (Linusorbs) in Flaxseed Meal-Fortified Gluten-Free Bread

Flaxseed meal, rich in water-soluble gums, improves the texture of gluten-free (GF) products. Bioactive antioxidant peptides from flaxseed, known as linusorbs (LOs) or cyclolinopeptides, may provide health benefits. However, the stability of flaxseed-derived LOs during dough preparation, baking, and storage remains unclear. To investigate this, GF bread dough and bread were prepared with flaxseed meal, and the LO content was determined in the flaxseed meal, the bread flour with the flaxseed meal, the dough, and the bread. The LO levels were also monitored during storage at various temperatures (-18 °C, 4 °C, and 22-23 °C) for 0, 1, 2, and 4 weeks using high-performance liquid chromatography-diode array detection (HPLC-DAD). The levels of oxidized LOs, such as [1-9-NαC],[1-(Rs,Ss)-MetO]-linusorb B2 (LO14), remained relatively stable in the flaxseed meal and the flour derived from it across under all conditions for up to 4 weeks. Due to microbial contamination, the dough could not be stored at either 4 or 21 °C, and the bread could only be stored at 21 °C for one week. However, the bread and dough could be stored for up to 4 weeks at -18 °C, and the bread at 4 °C, without a significant loss of LOs. The main changes in LOs occurred during processing rather than storage. Reduced LOs were found in higher concentrations in the flour and meal compared to the dough and bread, without a corresponding increase in oxidized LOs. The flaxseed meal-fortified bread maintained oxidative stability when stored at low temperatures. This is the first study to investigate the effect of baking conditions on LO content and antioxidant properties.

Coeliac disease: complications and comorbidities

Coeliac disease is an autoimmune disease characterized by small intestinal villus atrophy and inflammation upon exposure to gluten. It has a global prevalence of approximately 1%. Although the gluten-free diet can be an effective treatment, this diet is burdensome with practical difficulties and frequent inadvertent gluten exposure. Moreover, there are a variety of potential complications and comorbidities of coeliac disease that might be related to malabsorption and/or chronic immune activation. Overall, individuals with coeliac disease have increased mortality compared with the general population, underscoring the severity of this common disease. Comorbidities and complications that have been associated with coeliac disease include poor growth, reproductive complications, kidney and liver diseases, respiratory disease (such as pneumonia) and infections (including sepsis). Furthermore, coeliac disease has been linked to other autoimmune disease and psychiatric disease, as well as certain cancers. Data suggest that mucosal healing on a gluten-free diet might protect against some, but not all, of these complications. In this Review, we present absolute and relative risks of coeliac-associated disorders. We discuss underlying mechanisms, the role of the gluten-free diet and mucosal healing, as well as implications for follow-up and non-dietary treatment of coeliac disease.

Gastroenteropancreatic Neuroendocrine Neoplasms and Celiac Disease: Rare or Neglected Association?

Background: Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare tumors originating from neuroendocrine cells in the gastroenteropancreatic system. They are increasingly recognized as being potentially associated with chronic intestinal inflammatory conditions, namely Crohn's disease and ulcerative colitis. Celiac disease (CD) is an immune-mediated chronic gastrointestinal inflammation triggered by gluten in genetically predisposed individuals. This study aimed to explore the relationship between GEP-NENs and CD, providing a detailed review of the existing literature and addressing the (possible) gaps in current knowledge. Methods: We conducted an extensive search of international databases using relevant keywords, with the last update on 1 November 2024. A total of 19 studies, published between 1983 and 2024, were included: two prospective studies, five retrospective studies, and 12 case reports. Results: Overall, we included 107 GEP-NENs in our analysis. Among the 94 GEP-NENs identified in prospective and retrospective studies, the small intestine was the most common site (88.3%). The small intestine was also the most frequently reported site in the case report series (46.2%), accounting for 13 GEP-NENs in 12 patients with CD. Conclusions: Although most studies on the association between CD and GEP-NENs are heterogeneous, and while some lack crucial data, emerging evidence suggests that screening GEP-NEN patients for CD could offer valuable insights. Testing for the presence of CD might reveal whether the observed association is more than coincidental and possibly pave the way for exploring and understanding the role of chronic inflammation in the tumorigenesis of GEP-NENs in CD.

Celiac Disease: Beyond Diet and Food Awareness

Celiac disease is attributable to a combination of genetic predisposition and exposure to dietary gluten, with immune system involvement. The incidence is increasing globally, and the societal economic burden of celiac disease stretches beyond the cost of gluten-free food. This enteropathy that affects the small intestine has been related to different disorders and comorbidities. Thus, the implications of suffering from this disease are multidimensional and need further consideration. Celiac disease is a serious condition that remains under-recognized, resulting in an increased need for programs for better management. This review aims to summarize the current evidence regarding celiac diseases, with special emphasis on clinical implications, diagnosis, dietary management, socioeconomical aspects, and future perspectives.

Prevalence and incidence of celiac disease in patients with rheumatoid arthritis: a case-control study based on the RECORD cohort

Background

The reported prevalence of coeliac disease (CD) in rheumatoid arthritis (RA) is variable.

Objective

To evaluate the prevalence and incidence of CD in RA and controls.

Design

Case-control study on administrative data.

Methods

The RECord linkage On Rheumatic Disease database (administrative data, 2004-2013) was used to retrieve patients with RA and age and sex-matched controls. Prevalence and incidence of CD were calculated and stratified according to age, gender, and calendar year.

Results

The cohort included 346,956 subjects (mean age 59.9 (14.5), 70.7% females), of which 70,061 RA and 276,895 controls. Median follow-up was 9 years (IQR 9-9). The prevalence of CD was higher in RA (171/70,061 = 0.24% (0.2-0.3%) vs 398/276895 = 0.14% (0.1-0.2%), p < 0.001). The prevalence of CD among females with RA was increased compared to controls (0.3% vs 0.08%, p < 0.001), but was not increased in males with RA. The incidence was higher in RA and remained stable throughout the observation period.

Conclusion

The prevalence and incidence of CD were increased in RA, particularly in females.

Diagnostic outcomes after gluten challenge in adult patients with unconfirmed coeliac disease already on a gluten-free diet: A 20-year retrospective cohort study

BACKGROUND

In uncertain cases of coeliac disease (CD), gluten challenge (GC) may be necessary to confirm or exclude the diagnosis. However, data on diagnostic outcomes after GC are limited.

AIMS

We aimed to evaluate outcomes after GC in patients with unconfirmed CD who had already started a gluten-free diet (GFD), and identify predictors of a confirmed diagnosis.

METHODS

Patients with unconfirmed CD already on a GFD, who underwent GC and subsequent testing with endomysial antibodies (EmA) and duodenal biopsy between 06/2000-06/2021 were included. Clinical data, prior test results, and final diagnoses were retrospectively collected and analysed.

RESULTS

158 patients underwent GC (median duration 3 months, IQR 3-6) and CD was confirmed in 47/158 (29.7 %) (41 conventional CD, 1 CD + IgAdeficiency, 5 potential CD), non-coeliac enteropathies (NCEs) were diagnosed in 3 patients, and enteropathy was ruled out in 108. Prior positive serology strongly predicted CD diagnosis after GC (OR 36.8, 95 %CI 13.8-100.0, p < 0.001), whereas prior reported villous atrophy did not (p = 0.83), as this was frequently (35 %) due to incorrect sampling/interpretation of poorly oriented specimens. Duration of GC was also not associated with diagnostic outcomes (p = 0.37).

CONCLUSION

Prior positive serology strongly predicted CD diagnosis after GC, while histological results without positive serology should be interpreted cautiously. Clinicians should consider NCEs in older patients with severe symptoms.

Celiac Disease: A Transitional Point of View

Celiac disease (CeD) is a chronic, lifelong, multifactorial, polygenic, and autoimmune disorder, characteristically triggered by exposure to the exogenous factor "gluten" in genetically predisposed individuals, with resulting duodenal inflammation and enteropathy, as well as heterogeneous multisystemic and extraintestinal manifestations. The immunopathogenesis of CeD is complex, favored by a peculiar human leukocyte antigen (HLA) genetic predisposition, leading to gluten presentation by antigen-presenting cells to CD4+ T helper (Th) cells, T cell-B cell interactions, and production of specific antibodies, resulting in the immune-mediated killing of enterocytes and, macroscopically, in duodenal inflammation. Here, the most relevant correlations between cellular and molecular aspects and clinical manifestations of this complex disease are reviewed, with final considerations on nutritional aspects for disease management.

Celiac disease, non-celiac wheat sensitivity, wheat allergy - clinical and diagnostic aspects

In recent years, wheat- and gluten-free diets have increased in demand due to reported increases in various conditions reported to be driven by ingredients of these food products. Celiac disease, wheat allergy and non-celiac wheat sensitivity constitute the three main categories of wheat-related disorders. Celiac disease is a well-characterized immune-mediated disease caused by immune reaction against specific gliadin epitopes, the main protein in wheat. Screening studies of samples collected over time bring evidence that there is a true increase in prevalence not only driven by increased testing activity. Clinical presentation of CeD is diverse and there is an increased risk of autoimmune co-morbidities. Wheat allergy consists of IgE- and non-IgE-mediated reactions, driven by Th2-cells directing eosinophil and basophil responses. Rapid IgE-mediated reactions are characterized by specific IgE antibodies in conjunction with symptoms originating especially from the respiratory and gastrointestinal tract. There is an increased risk of other allergies and the majority recover during adolescence. Non-IgE-mediated wheat allergy is a less-well defined condition, which is often diagnostically challenging due to a longer interval between exposure and symptoms and lack of non-invasive biomarkers. In this condition, wheat as a trigger needs to be established by exclusion followed by dietary challenge. Non-celiac wheat sensitivity, despite being the most recently recognized, has the highest reported prevalence among the three wheat-related entities. It remains, however, particularly poorly characterized due to unclear pathophysiology and lack of diagnostic markers. This narrative review will scrutinize the shared and distinct clinical features of the three wheat-related conditions, focusing on epidemiology, clinical presentation, co-morbidities, diagnosis, treatment and prognosis.

Beyond gluten-free diet: a critical perspective on phase 2 trials on non-dietary pharmacological therapies for coeliac disease

Coeliac disease is an immune-mediated chronic enteropathy, with a prevalence of around 1% in the general population and occurring in genetically susceptible individuals after the ingestion of gluten proteins present in wheat, rye and barley. Currently, a strict lifelong gluten-free diet is the cornerstone of treatment of coeliac disease. However, maintaining strict dietary adherence is challenging for many patients, due to the high costs, the highly restrictive nature of the diet and the impact on patients' quality of life. Moreover, a tiny minority of coeliac patients can develop pre-malignant/malignant complications of coeliac disease, a group of conditions, that despite being rare, are still burdened by a poor prognosis due to the lack of effective therapies. Therefore, the development of pharmacological treatments as an alternative to or supportive of a gluten-free diet is still an unmet need. The identification of new pathogenetic targets in the last years has enabled the development of several candidates molecules, many of which have been investigated in phase 2/3 clinical trials. In this narrative review we aim to summarise the investigational therapies that have been evaluated in phase 2/3 trials and provide a critical overview on the latest advances in this field.

Universal Meals: A Novel Program to Provide Healthful Nutrition to Diverse Communities

Healthcare professionals recommending dietary changes to patients often find that institutional settings-businesses, universities, long-term care facilities, correctional institutions, among others-may not provide the healthful foods that healthcare professionals recommend. Moreover, such institutions encounter an increasing diversity of dietary restrictions, based on allergies, intolerances, religious mandates, or other reasons, that may be challenging to satisfy. To address these issues, experts in health, dietetics, culinary arts, religion, and ethics developed a simple set of guidelines that aim to meet the widest possible range of dietary needs. Three culinary teams then used these guidelines to create "Universal Meals"-simple recipes that were then adapted to larger production sizes for institutional use. The healthfulness of representative sets of meals drawn from these recipes was assessed using the Alternative Healthy Eating Index-2010 and found to be superior to that of a meal pattern based on National Health and Nutrition Examination Survey data.

Safety, clinical activity, pharmacodynamics, and pharmacokinetics of IMU-856, a SIRT6 modulator, in coeliac disease: a first-in-human, randomised, double-blind, placebo-controlled, phase 1 trial

BACKGROUND

IMU-856 is an orally available and systemically acting small molecule modulator of sirtuin 6 (SIRT6), a protein that serves as a transcriptional regulator of bowel epithelium regeneration. We aimed to evaluate the safety, clinical activity, pharmacodynamics, and pharmacokinetics of IMU-856 in healthy participants and in patients with coeliac disease.

METHODS

This study reports the results from a completed first-in-human, three-part, double-blind, randomised, placebo-controlled, clinical trial of IMU-856 in healthy participants and patients with coeliac disease done in Australia and New Zealand. In part A, healthy participants were enrolled in six cohorts and randomly assigned (3:1) using a block randomisation algorithm to receive single ascending doses of IMU-856 ranging from 10 mg to 160 mg or matching placebo. Based on the results from part A, three doses were selected for part B to evaluate the safety, tolerability, and pharmacokinetics of IMU-856 once daily for 14 days using the same randomisation algorithm. Part C enrolled patients with well controlled coeliac disease. Participants were centrally randomised 1:1:1 using an interactive web response system to receive either low dose or high dose of IMU-856 or placebo once daily for 28 days that included a 15-day gluten challenge starting on day 14. The primary objective was safety and tolerability of IMU-856. Safety analyses were done on all patients who received at least one dose of the study drug. The trial is registered with the ANZCTR registry (ACTRN12620000901909).

FINDINGS

Between July 27, 2020, and Oct 28, 2022, 71 healthy participants were enrolled in part A and B and assigned to either placebo (n=19) or IMU-856 (n=52). In part A and B, the IMU-856 doses were 10 mg (n=6), 20 mg (n=6), 40 mg (n=13), 80 mg (n=12), 120 mg (n=4), 160 mg (n=11). 43 patients with coeliac disease were enrolled in part C and assigned to either placebo (n=14), IMU-856 80 mg (n=14), or IMU-856 160 mg (n=15). Treatment-emergent adverse events (TEAEs) occurred in 24 (73%) of 33 participants in part A and 15 (79%) of 19 participants in part B receiving any dose of IMU-856 compared with six (50%) of 12 participants in part A and five (71%) of seven participants in part B with placebo. TEAEs were mainly mild in severity. In part C, TEAEs occured in 26 (90%) of 29 patients on any dose of IMU-856 and ten (71%) of 14 receiving placebo; the most common TEAEs with any dose of IMU-856 by preferred term were headache (13 [45%] of 29), nausea (nine [31%]), diarrhoea (eight [28%]), and abdominal distension (seven [24%]). Two serious adverse events occurred with IMU-856 treatment (one in part B [bacterial myocarditis] and one in part C [biliary colic]), both of which were unrelated to IMU-856. No dose-limiting toxicities, systematic safety laboratory changes, or deaths occurred during the study. In part C, mean decrease in villous height was -20·9 μm (SD 34·8) among patients who received IMU-856 80 mg, -22·5 μm (51·1) among those who received IMU-856 160 mg, and -60·3 μm (52·2) among those who received placebo.

INTERPRETATION

The favourable safety profile, along with preliminary activity, suggests that IMU-856 should be studied in future trials of coeliac disease.

FUNDING

Immunic Australia.

Effectiveness of a nutrition education programme for individuals with celiac disease and their supporters through social media (GLUTLEARN project)

INTRODUCTION

Social media has become a popular tool for patients with Celiac Disease (CD) to find information about their disease. However, limited research has been conducted to evaluate the impact of information shared on social media, specifically regarding CD.

OBJETIVE

This study aimed to assess the effectiveness of a nutrition education program on CD and gluten-free diet (GFD) delivered through social networks by experts in the field.

METHOD

The program, called GLUTLEARN, was delivered over six weeks via Instagram to individuals with CD and their supporters (people involved in the care of individuals with CD). Pre and post-intervention questionnaires were used to evaluate the program's effectiveness.

RESULTS

A total of 93 participants (63 with CD, 30 supporters), predominantly female (92.5 %) and European (93.5 %), took part in the program. GLUTLEARN has been found to be effective in improving the knowledge of people with CD and their supporters and improving attitudes among individuals. Furthermore, they showed a high level of concern about the disease and an interest in continuous learning.

CONCLUSION

Social networks give advantages for promoting nutrition education. Nevertheless, it is important to feed these nets with reliable information. The GLUTLEARN program is a valuable method for delivering reliable and current education about CD and the GFD, which leads to better disease control. It would be beneficial for more interventions to focus not only on individuals with CD but also on those who are avoiding gluten for various reasons or are involved in their care.

Meta-Analysis: Global Prevalence of Coeliac Disease in Type 1 Diabetes

BACKGROUND

Coeliac disease (CD) is common in patients with type 1 diabetes (T1D), but prevalence varies globally due to differing screening protocols. There have been substantial changes in screening guidelines over the past two decades.

AIM

To evaluate CD prevalence in patients with T1D, focusing on screening studies using antitissue transglutaminase (anti-tTG) antibody.

METHODS

We searched PubMed, Web of Science, Embase and Scopus for studies published up to 11 December 2023 using keywords related to CD and diabetes. We used random-effects models for overall prevalence and all subgroups, with heterogeneity assessed using Cochran's Q test and the I2 statistic performed in STATA 18.

RESULTS

We included 106 articles involving 65,102 T1D patients across 40 countries. The pooled CD seroprevalence and confirmed CD prevalence were 9% (95% confidence interval, CI, 8%-10%) and 6% (95% CI 5%-7%), respectively. The prevalence was higher in females and children. Denmark, Saudi Arabia and Libya exhibited the highest prevalence (11%), followed by India and Egypt (10%). Belgium, France, Germany, South Africa and the United States had the lowest prevalence (2%). High-income countries showed significantly a lower CD prevalence than middle-income countries (p = 0.03). Meta-regression based on the Human Development Index (HDI) indicated that countries with higher HDI have lower seroprevalence and confirmed CD prevalence.

CONCLUSION

Approximately 1 in 16 patients globally and 1 in 12 patients in Asia and the Middle East with T1D has CD. We suggest that all patients with T1D should be screened for CD.

Prevalence and etiologies of non-responsive celiac disease: A systematic review and meta-analysis

BACKGROUND AND AIM

Non-responsive celiac disease (NRCD) is defined as ongoing symptoms despite 6-12 months of gluten-free diet (GFD), the only known treatment for celiac disease (CeD). There is inconsistency in studies describing the proportion of patients having NRCD and its various causes among patients with CeD. We therefore conducted a systematic review and meta-analysis to determine the prevalence and causes of NRCD.

METHODS

The PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases were searched for original studies reporting the proportion of patients with persistent symptoms after ≥ 6 months of GFD. Studies reporting the etiologies of NRCD were also identified. The systematic review was conducted as per the Meta-analysis of Observational Studies in Epidemiology guidelines. Statistical analysis was performed in STATA.

RESULTS

Of 2965 search results, nine studies met the inclusion and exclusion criteria. Five studies (n = 4414) reported data on prevalence, and seven studies (n = 790) reported the causes of NRCD. The pooled prevalence of NRCD was 22% (95% confidence interval, 11-35%). Among patients with NRCD, inadvertent exposure to gluten was the most common cause (33%), followed by functional gastrointestinal disorders including irritable bowel syndrome in 16%. Refractory CeD type II along with its premalignant and malignant sequelae was observed in 7% of patients with NRCD.

CONCLUSION

One in five patients with CeD may not respond to GFD and would likely be classified as NRCD. Inadvertent gluten exposure was the cause of ongoing symptoms in one-third of patients with NRCD. Improving adherence to GFD along with developing novel therapeutics to mitigate symptoms due to ongoing gluten exposure is critical.

Endomysial antibodies or anti-tissue transglutaminase type 2 IgA antibodies as a confirmatory test in children with celiac disease

The no-biopsy approach to diagnose celiac disease (CD), introduced in the 2012 European Society for Gastroenterology and Hepatology and Nutrition guidelines, requires an anti-endomysial antibody (EMA) confirmatory serology test following a high-positive immunoglobulin A anti-tissue transglutaminase-2 (anti-TG2) antibody ≥10 times the upper limit of normal (ULN). The aim of this retrospective study is to compare EMA positivity and high-positive anti-TG2 in patients who had their confirmatory test within 2 months of their first high-positive anti-TG2 test. Among 933 patients who had high-positive anti-TG2 serology more than 10 times the ULN in their first sample, all had both high-positive anti-TG2 and positive EMA, most of them with very high EMA titers (99.6%) in their confirmatory test. In conclusion, we suggest that a repeated anti-TG2 test can replace the EMA test as the confirmatory serology test for the confirmation of the diagnosis of CD in the no-biopsy approach.

Social Adversities Associate with Worse Disease Control in Pediatric Celiac Disease

OBJECTIVE

To characterize how social adversities influence disease control in children with celiac disease (CeD).

STUDY DESIGN

We conducted a cross-sectional analysis of data from 325 eligible children ≤18 years old with CeD enrolled between 2015 through 2023 into iCureCeliac, a patient-centered US registry for CeD. We evaluated the associations between financial insecurity, social stigmatization, decreased health knowledge, and mental health comorbidity with 2 validated patient-reported outcomes on disease activity and gluten-free diet adherence: celiac symptom index and CeD adherence test, respectively. We used multivariable logistic and linear regression analysis to adjust for race, primary spoken language, and socioeconomic status.

RESULTS

Among 325 children with available financial insecurity data, the median age was 11 years (IQR 8, 15), 67% were female, and 88% were White. In multivariable logistic regression, the odds of elevated disease activity among children with financial insecurity, social stigmatization, decreased health knowledge, and mental health comorbidity were 2.6 (95% CI 0.9, 8.0; P = .09), 2.8 (95% CI 1.6, 5.1; P < .001), 4.8 (95% CI 2.4, 9.8; P < .001), and 1.9 (95% CI 1.1, 3.3; P = .03), respectively. For insufficient dietary adherence, the respective odds were 1.6 (95% CI 0.5, 4.7; P = .43), 3.3 (95% CI 1.7, 6.5; P < .001), 2.9 (95% CI 1.5, 5.7; P = .002), and 2.3 (95% CI 1.2, 4.2; P = .01). Statistically significant associations in logistic regression aligned with results of linear models.

CONCLUSIONS

Social stigmatization, decreased health knowledge, and mental health comorbidity were associated with worse disease control in pediatric CeD. Targeted interventions aimed at addressing these social adversities may improve disease activity and dietary adherence.

Comparison of sprouting, airfryer-drying, and airfryer-baking effects on technical, physical, and chemical properties of quinoa flour and quinoa snack

In this study, quinoa, which is a good alternative for celiacs, was tried to be used instead of flour by sprouting it and drying it in the airfryer. Flour obtained from quinoa seeds prevents spreading and hardens the product. It was predicted that this problem could be overcome by germination and drying in the airfryer. Morphologically, clean-cut structures were in the cookies using airfryer-dried quinoa flour. The melted surface appearance was characteristic of all airfryer-baked cookies. The thermal and pasting properties of quinoa flour were improved, resulting in better textural properties and digestibility of the cookie. Airfryer-baked cookies spread less. However, the spread increased with the use of airfryer-dried quinoa flour. Cookies containing airfryer-dried quinoa flour had low baking loss, high protein digestibility, and hardness values that were relatively closer to the control cookies. Airfryer-baked cookies were at moderate hardness level. Minimum baking loss and highest protein digestibility were found in airfryer-baked cookies with airfryer-dried quinoa flour. The spread problem can be alleviated by drying the grain sprouts in the airfryer. The highest color difference was seen in oven-baked cookie with airfryer-dried quinoa flour. Due to the airfryer's superior airflow properties, it is possible to reduce drying and baking time by 50%. However, airfryer drying has been found to further improve functional properties compared to airfryer baking.

Role of capsule endoscopy and double-balloon enteroscopy in the management of adult patients with coeliac disease and persisting symptoms

BACKGROUND

Small bowel capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are recommended for the management of patients with nonresponsive or refractory coeliac disease (CD). However, there is a paucity of data regarding the clinical profiles and outcomes of patients undergoing these investigations.

METHODS

We conducted a retrospective analysis of two databases of adult patients with CD who underwent CE and/or DBE between 2017 and 2022 at the National Centre for Refractory CD in England. Patient demographic, clinical and endoscopic data were collected, and clinically relevant outcomes were reported.

RESULTS

A total of 132 patients (median age 53 years, 64.4 % female) underwent 146 CEs and 25 DBEs. The most common symptoms were diarrhoea (51.5 %), abdominal pain (37.8 %), bloating (34.8 %), and weight loss (29.5 %). The overall detection rate of CE and DBE was 87.6 % and 92 %, respectively. Following CE and DBE, 14 patients (10.6 %) were diagnosed with CD-related complications such as ulcerative jejunitis, strictures and malignancy. Seven patients (5.3 %) died during follow-up, with five of these deaths directly attributed to CD. Older age, weight loss and anaemia were associated with poor outcomes.

CONCLUSIONS

The sequential approach of CE and DBE identified CD-related complications in almost 1 in 10 patients with nonresponsive or refractory CD. Older patients with persistent villous atrophy, weight loss and anaemia require close monitoring to help with the early diagnosis and management of complications.

A randomized, double-blind, placebo-controlled, multiple dose, parallel study to investigate the effects of a cathepsin S inhibitor in celiac disease

Celiac disease is a chronic, immune-mediated enteropathy with symptoms triggered by exposure to dietary gluten in genetically predisposed individuals. The only available management option is lifelong adherence to a gluten-free diet. This randomized, double-blind, placebo-controlled, parallel-group, single-center study tested the effects of the cathepsin S inhibitor RO5459072 on the immune response to a 13-day gluten challenge in 19 participants with celiac disease (ClinicalTrials.gov: NCT02679014). Nine participants in the RO5459072 arm received 100 mg study drug b.i.d. (200 mg daily); 10 received a placebo. The primary end point was the number of responders to the gluten challenge (defined as individuals with an increase in the number of gliadin-specific, IFNγ-secreting T cells detected using an ELISPOT assay). However, there was a weak response to the gluten challenge across both arms. Few participants had an increase in gliadin-specific, IFNγ-secreting T cells, and the antigen-specific responses (anti-tTG and anti-DGP antibodies) were weaker than expected in both arms. Therefore, the primary end point was not met, although the study was underpowered to detect a treatment effect under these circumstances. Pharmacodynamic findings suggested that RO5459072 had some beneficial effects. Fewer participants in the RO5459072 arm exhibited gliadin-specific IFNγ-secreting T cells after 6 days' gluten intake. Participants in the RO5459072 arm also showed decreased intestinal permeability, and a decrease in the number of circulating B cells, CD4+ and CD8+ T cells compared to baseline. Nevertheless, the absence of clear effects on the response to a gluten challenge indicates that inhibition of cathepsin S may not be an effective treatment strategy for celiac disease.

Clinical Presentations of Celiac Disease: Experience of a Single Italian Center

BACKGROUND/OBJECTIVES

In Italy, the prevalence of celiac disease (CeD) among children exceeds 1.5% and has steadily increased with a linear trend over the past 25 years. The clinical presentation is heterogenous and a change in onset symptoms has been described in recent years. The aim of the study is to describe the pattern of clinical presentation of CeD during the last 12 years in a single Italian center.

METHODS

We retrospectively enrolled all children diagnosed with CeD at Bambino Gesù Children Hospital, Rome between 1 March 2011 and 22 June 2023. To investigate the changes in pattern of clinical presentation, we divided the patient population into three groups of approximately 4 years each (respectively: 49, 48 and 48 months). Patients who previously received a CeD diagnosis in other centers were excluded.

RESULTS

Overall, 4478 patients were diagnosed with CeD at our center. 1082 were excluded, leaving 3396 available for analysis. We divided the study cohort into three groups: group 1 (n = 909), group 2 (n = 1103), and group 3 (n = 1384). Diagnoses of CeD increased by 17.5%. The trend of the non-classic form shows a significative increase (p = 0.000064), showing a high prevalence of bloating and abdominal pain and a significant reduction in celiac crisis (p < 0.0001).

CONCLUSIONS

Annual diagnoses of CeD increased during the study period, and the clinical presentation has changed in recent years, showing an increase in the non-classic form and a reduction in more severe forms of celiac crisis.

JAK inhibition decreases the autoimmune burden in Down syndrome

Background

Individuals with Down syndrome (DS), the genetic condition caused by trisomy 21 (T21), display clear signs of immune dysregulation, including high rates of autoimmunity and severe complications from infections. Although it is well established that T21 causes increased interferon responses and JAK/STAT signaling, elevated autoantibodies, global immune remodeling, and hypercytokinemia, the interplay between these processes, the clinical manifestations of DS, and potential therapeutic interventions remain ill defined.

Methods

We report a comprehensive analysis of immune dysregulation at the clinical, cellular, and molecular level in hundreds of individuals with DS, including autoantibody profiling, cytokine analysis, and deep immune mapping. We also report the interim analysis of a Phase II clinical trial investigating the safety and efficacy of the JAK inhibitor tofacitinib through multiple clinical and molecular endpoints.

Results

We demonstrate multi-organ autoimmunity of pediatric onset concurrent with unexpected autoantibody-phenotype associations in DS. Importantly, constitutive immune remodeling and hypercytokinemia occur from an early age prior to autoimmune diagnoses or autoantibody production. Analysis of the first 10 participants to complete 16 weeks of tofacitinib treatment shows a good safety profile and no serious adverse events. Treatment reduced skin pathology in alopecia areata, psoriasis, and atopic dermatitis, while decreasing interferon scores, cytokine scores, and levels of pathogenic autoantibodies without overt immune suppression.

Conclusions

JAK inhibition is a valid strategy to treat autoimmune conditions in DS. Additional research is needed to define the effects of JAK inhibition on the broader developmental and clinical hallmarks of DS.

Funding

NIAMS, Global Down Syndrome Foundation.

Clinical trial number

NCT04246372.

A machine learning tool for early identification of celiac disease autoimmunity

Identifying which patients should undergo serologic screening for celiac disease (CD) may help diagnose patients who otherwise often experience diagnostic delays or remain undiagnosed. Using anonymized outpatient data from the electronic medical records of Maccabi Healthcare Services, we developed and evaluated five machine learning models to classify patients as at-risk for CD autoimmunity prior to first documented diagnosis or positive serum tissue transglutaminase (tTG-IgA). A train set of highly seropositive (tTG-IgA > 10X ULN) cases (n = 677) with likely CD and controls (n = 176,293) with no evidence of CD autoimmunity was used for model development. Input features included demographic information and commonly available laboratory results. The models were then evaluated for discriminative ability as measured by AUC on a distinct set of highly seropositive cases (n = 153) and controls (n = 41,087). The highest performing model was XGBoost (AUC = 0.86), followed by logistic regression (AUC = 0.85), random forest (AUC = 0.83), multilayer perceptron (AUC = 0.80) and decision tree (AUC = 0.77). Contributing features for the XGBoost model for classifying a patient as at-risk for undiagnosed CD autoimmunity included signs of anemia, transaminitis and decreased high-density lipoprotein. This model's ability to distinguish cases of incident CD autoimmunity from controls shows promise as a potential clinical tool to identify patients with increased risk of having undiagnosed celiac disease in the community, for serologic screening.

Predictive factors for the diagnosis of coeliac disease in children and young people in primary care: A systematic review and meta-analysis

BACKGROUND

Coeliac Disease (CD) often has its onset in childhood and affects 1% of the population. This review aimed to identify important predictive factors for coeliac disease in children and young people which could help GPs decide when to offer testing.

METHODS

We searched MEDLINE, Embase and Cochrane Library to April 2024. Included studies were observational or randomized trials reporting the risk of CD when exposed to predictive factor(s) in people ≤25 years of age. Genetic factors were excluded. Risk of Bias was assessed using the Newcastle-Ottawa Scale. Random effects meta-analysis was performed for factors reported in ≥5 studies to calculate pooled odds ratios (OR) or standardized mean differences (SMD).

RESULTS

Of 11,623 unique abstracts, 183 were included reporting on 140+ potentially associated factors. Meta-analyses of 28 factors found 14 significant associations with CD diagnosis: having type 1 diabetes (OR 8.70), having a first degree relative with coeliac disease (OR 5.19), being of white ethnicity (OR 2.56), having thyroid disease (OR 2.16), being female (OR 1.53), more frequent gastroenteritis in early childhood (OR 1.48), having frequent respiratory infections in early childhood (OR 1.47), more gluten ingestion in early life (OR 1.25), having more infections in early life (OR 1.22), antibiotic use in early childhood (OR 1.21), being born in the summer (OR 1.09), breastfeeding (OR 0.79) older age at diagnosis of type 1 diabetes (OR 0.64), and heavier weight (SMD -0.21). The final three were associated with lower risk of CD diagnosis.

DISCUSSION

This is the first systematic review and meta-analysis of predictive factors for CD in children. Amongst the 14 factors we identified that were significant, three were potentially modifiable: breast feeding, antibiotic use and amount of gluten ingestion in early childhood. This work could inform the development of clinical support tools to facilitate the early diagnosis of CD.

Prevalence of celiac disease-specific antibodies and their association with clinical status and environmental factors

Background and aims

Celiac disease (CeD) affects 1-2% of the world's population. The aim of this study was to relate the incidence of CeD-related serological markers to symptoms, pathologies, and environmental exposure to wheat flour, given the number of flour mills present in the region.

Materials & methods

Serum samples were collected from 537 inhabitants from a rural city. Levels of anti-transglutaminase (a-tTg), anti-gliadin, anti-DGP antibodies and total IgA levels were measured. Volunteers completed a questionnaire covering environmental factors, demographics, pregnancies, other diseases, symptoms, and CeD diagnosis. Geo-referencing of volunteers' homes and mills in the city was performed, and correlations between the different parameters assessed were analysed.

Results

A CeD incidence of 1.76 % was found. However, a-tTg and a-gliadin levels were elevated in the population without CeD diagnosis (9.6 % and 30.1 %). Subjects with CD diagnosis showed diarrhoea and colic pain. Women with CeD had fewer pregnancies. Positive a-tTg and number of CeD-associated symptoms appear to correlate with proximity to flour mills.

Conclusion

A high prevalence of CeD-related specific antibody positivity in a rural population was found, possibly due to environmental factors related to flour mills. Further research is needed to better understand CeD's pathogenesis and its health implications.

Associations of Pregnancy Dietary Quality and Diversity with Childhood Celiac Disease

BACKGROUND

High gluten and low dietary fiber in pregnancy intake is associated with an increased risk of celiac disease (CeD) in the child. Early life higher dietary quality is suggested to reduce the subsequent risk of CeD.

OBJECTIVES

The aim was to investigate associations of pregnancy dietary quality and diversity with child risk of CeD.

METHODS

In The Norwegian Mother, Father and Child Cohort Study, 85,122 mother-child pairs had available data from a validated pregnancy food frequency questionnaire. Pregnancy dietary quality and diversity were estimated by a Pregnancy Healthy Eating Index [mean 99.3, standard deviation (SD) 9.9, range 48.8-128.3], and a Diet Diversity Score (mean 7.0, SD 1.0, range 1.6-9.8), respectively. Child CeD was captured by ≥2 diagnostic codes in the Norwegian Patient Registry. Logistic regression was used to estimate associations between pregnancy dietary quality, diversity and child CeD, adjusted for socioeconomic factors, and parents CeD [adjusted odds ratio (aOR), 95% confidence intervals (CI)]. CeD-susceptible human leukocyte antigen haplotypes (DQ2/DQ8) were present in 30,718 (45.5%).

RESULTS

Up to mean age 16.0 (SD 1.8, 12.4-19.8) y, 1363 (1.6%) children were diagnosed with CeD. Lower as well as higher pregnancy dietary quality associated with a reduced risk of CeD in the child (<5th percentile aOR = 0.67, 95% CI: 0.48, 0.93, >95th percentile aOR = 0.71, 95% CI: 0.52, 0.98, respectively, nonlinear squared term P = 0.011). Analyses on genetically susceptible children, adjustments for pregnancy iron supplementation, gluten, and dietary fiber intake, and child early life dietary quality, gluten intake and iron supplementation, supported the finding. Pregnancy dietary diversity was not associated with child CeD (aOR = 1.00, 95% CI: 0.94, 1.07/score).

CONCLUSIONS

In this population-based study, lower as well as higher pregnancy dietary quality associated with a reduced risk of CeD diagnosis in the child. In contrast, no such association was observed with maternal dietary diversity.

The influence of celiac disease on fertility and pregnancy: an Italian survey

BACKGROUND

Celiac disease (CD) is an inflammatory enteropathy that has been associated to obstetric and gynecological disorders. However, it is still not adequately tested by gynecologists due to the misconception that it is solely a gastrointestinal disease. This underestimation requires the development of targeted interventions.

PURPOSE

This study aims to evaluate the association between CD and obstetric/gynecological complications, highlight the importance of informing patients about CD manifestations, and assess the patient satisfaction with the information provided by healthcare professionals on the disease.

METHODS

A digital survey was administered to celiac women via the Italian Celiac Association's website.

RESULTS

We analyzed 493 questionnaires. Obstetric and gynecological disorders led to the diagnosis of CD in 11.7% of interviewed. The study revealed that untreated CD patients are more predisposed to miscarriages (41.8% vs 34% before/after diagnosis, respectively, p = 0.111), anemia in pregnancy (71.4% vs 40.4% before/after diagnosis, respectively, p < 0.001) and the risk of low birth weight (newborns weighing < 1500 g were 4.0% before and 1.1% after the gluten-free diet, p = 0.028). Women with CD, both before and after gluten-free diet, had higher infertility rates (about 19%) than the general population. Additionally, 73% of interviewees were dissatisfied with the information they received from health professionals about the reproductive implications of CD.

CONCLUSION

Our research contributes to a deeper understanding of the intersection between CD and reproductive outcomes, highlighting the main obstetric and gynecological problems related to it. It emphasizes the importance of patient's perspective and the need for greater awareness about celiac disease from healthcare workers.

Gastrointestinal manifestations in Williams syndrome: A prospective analysis of an adult and pediatric cohort

Williams syndrome (WS) is a multi-system condition caused by the deletion of 25-27 coding genes on human chromosome 7. Irritability, gastrointestinal (GI) reflux and slow growth are commonly reported in infants with WS, but less data exist regarding GI concerns in older children and adults with the condition. This study evaluates 62 individuals with WS (31 children aged 3-17, and 31 adults aged 18-62) as well as 36 pediatric and adult controls to assess current and historical rates of common GI symptoms. Data were evaluated using a regression model including age, sex, self-reported race, and diagnosis. Symptoms including food intolerance, reflux, dysphagia, choking/gagging, vomiting, constipation, bloating, diarrhea, hematochezia, rectal prolapse, abdominal pain, and weight loss are more common in those with WS relative to controls. In addition, people with WS utilize more GI medications, specialty care, procedures, and supplemental feeds. Among those with WS, symptoms were present at similar rates in children and adults, except for diverticular disease, which was not noted until adulthood. GI symptoms are frequent in people with WS and serve as a significant source of morbidity.

Development of the celiac disease symptom diary version 2.1© (CDSD 2.1©) patient-reported outcome measure

PURPOSE

For patients with celiac disease (CeD), the only current management option is adherence to a strict gluten-free diet (GFD); however, many patients on a GFD continue to experience symptoms with a significant impact on quality of life. Potential new treatments for CeD are under development and a validated patient-reported outcome measure is required to evaluate their utility in clinical trials. The purpose of this article is to provide a history of the development of the Celiac Disease Symptom Diary (CDSD) 2.1© for use in clinical trials.

METHODS

Qualitative and quantitative studies were conducted from 2010 to 2021, including concept elicitation and cognitive debriefing interviews with adult and adolescent participants with CeD (N = 93) diagnosed via biopsy and/or serology and input from eight interviews with CeD clinical experts. During these studies, different iterations of the CDSD were presented to the US Food and Drug Administration and the European Medicines Agency, and modifications were made in line with their feedback.

RESULTS

These studies ultimately led to the development of CDSD 2.1©, a daily diary which focuses on key symptoms of CeD (abdominal pain, bloating, diarrhea, nausea and tiredness). This patient-reported outcome measure was readily understood by adult and adolescent participants with CeD and content validity was demonstrated in both populations.

CONCLUSION

CDSD 2.1© is a content-valid patient-reported outcome measure developed in accordance with best practices and regulatory guidance. A thorough exploration of the psychometric properties of CDSD 2.1© for both adult and adolescent participants with CeD is ongoing to support utilization in clinical trials.

Food-related quality of life driven by hypervigilance and anxiety around eating in organic gastrointestinal conditions

BACKGROUND

Food-related quality of life (FRQoL) measures the impact of diet, eating behaviours and food-related anxiety on quality of life. Patients often view food and eating as central to symptom management. This is the first study to examine FRQoL in patients with inflammatory bowel disease, celiac sprue, achalasia and eosinophilic oesophagitis.

METHODS

A total of 289 adults aged ≥18 years completed self-report measures evaluating the use of dietary treatment, FRQoL and other psychosocial outcomes. Principal component factor analysis evaluated potential subscales within the Food-Related Quality of Life Scale (FRQoL-29), to date validated only with a total score. Univariate analyses investigated differences in FRQoL based on diagnosis, whereas correlations and hierarchical regression identified relationships between FRQoL and psychosocial outcomes.

RESULTS

Factor analysis revealed four subscales within the FRQoL-29, with hypervigilance around eating being the primary driver in total score. Patients reported substantial impacts of FRQoL, with those not using diet therapy scoring significantly higher for FRQoL than those on a diet with and without the support of a registered dietitian (RD). Both social (r = 0.41, p < 0.001) and physical (r = 0.31, p < 0.001) domains of health-related quality of life were higher in patients with greater FRQoL.

CONCLUSION

FRQoL is significantly degraded in patients with organic gastrointestinal illness diseases, and hypervigilance around food appears to contribute most to this. Use of dietary treatment and meeting with an RD were associated with lower FRQoL, though it is unclear if patients sought RD assistance before FRQoL declined. Future studies on the relationship between dietary treatment, RD support and FRQoL are warranted.