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Lenti MV, Aronico N, Bianchi PI, D'Agate CC, Neri M, Volta U, Mumolo MG, Astegiano M, Calabrò AS, Zingone F, Latella G, Di Sario A, Carroccio A, Ciacci C, Luzza F, Bagnato C, Fantini MC, Elli L, Cammarota G, Gasbarrini A, Portincasa P, Latorre MA, Petrucci C, Quatraccioni C, Iannelli C, Vecchione N, Rossi CM, Broglio G, Ianiro G, Marsilio I, Bibbò S, Marinoni B, Tomaselli D, Abenavoli L, Pilia R, Santacroce G, Lynch E, Carrieri A, Mansueto P, Gabba M, Alunno G, Rossi C, Onnis F, Efthymakis K, Cesaro N, Vernero M, Baiano Svizzero F, Semeraro FP, Silano M, Vanoli A, Klersy C, Corazza GR, Di Sabatino A. Diagnostic delay in adult coeliac disease: An Italian multicentre study. Dig Liver Dis 2022; 55:743-750. [PMID: 36567177 DOI: 10.1016/j.dld.2022.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are few data regarding the diagnostic delay and its predisposing factors in coeliac disease (CD). AIMS To investigate the overall, the patient-dependant, and the physician-dependant diagnostic delays in CD. METHODS CD adult patients were retrospectively enroled at 19 Italian CD outpatient clinics (2011-2021). Overall, patient-dependant, and physician-dependant diagnostic delays were assessed. Extreme diagnostic, i.e., lying above the third quartile of our population, was also analysed. Multivariable regression models for factors affecting the delay were fitted. RESULTS Overall, 2362 CD patients (median age at diagnosis 38 years, IQR 27-46; M:F ratio=1:3) were included. The median overall diagnostic delay was 8 months (IQR 5-14), while patient- and physician-dependant delays were 3 (IQR 2-6) and 4 (IQR 2-6) months, respectively. Previous misdiagnosis was associated with greater physician-dependant (1.076, p = 0.005) and overall (0.659, p = 0.001) diagnostic delays. Neurological symptoms (odds ratio 2.311, p = 0.005) and a previous misdiagnosis (coefficient 9.807, p = 0.000) were associated with a greater extreme physician-dependant delay. Gastrointestinal symptoms (OR 1.880, p = 0.004), neurological symptoms (OR 2.313, p = 0.042), and previous misdiagnosis (OR 4.265, p = 0.000) were associated with increased extreme overall diagnostic delay. CONCLUSION We identified some factors that hamper CD diagnosis. A proper screening strategy for CD should be implemented.
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Affiliation(s)
- Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Nicola Aronico
- First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Ilaria Bianchi
- First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carmela Cinzia D'Agate
- Department of Gastroenterology and Endoscopy, University Hospital "G. Rodolico", Catania, Italy
| | - Matteo Neri
- Department of Medicine and Ageing Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Maria Gloria Mumolo
- Department of General Surgery and Gastroenterology, Pisa University Hospital, Pisa, Italy
| | - Marco Astegiano
- SC Gastroenterologia AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Antonino Salvatore Calabrò
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio" University of Florence, Florence, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, and Gastroenterology Unit, Azienda Ospedale Università, Padova, Italy
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Di Sario
- Department of Gastroenterology and Transplantation, Polytechnic Marche University, Ancona, Italy
| | - Antonio Carroccio
- Internal Medicine Unit, "V. Cervello Hospital", University of Palermo, Palermo, Italy
| | - Carolina Ciacci
- Department of Medicine and Surgery, Gastroenterology Unit, University of Salerno, Salerno, Italy
| | - Francesco Luzza
- Department of Health Sciences, Magna Græcia University, Catanzaro, Italy
| | - Carmela Bagnato
- Clinical Nutrition Unit, Madonna delle Grazie Hospital, Matera, Italy
| | | | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giovanni Cammarota
- Digestive Disease Centre, Fondazione Policlinico Universitario A. Gemelli IRCCS, Medicina Interna e Gastroenterologia, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Antonio Gasbarrini
- Digestive Disease Centre, Fondazione Policlinico Universitario A. Gemelli IRCCS, Medicina Interna e Gastroenterologia, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Piero Portincasa
- Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Clinica Medica "A. Murri", Bari, Italy
| | - Mario Andrea Latorre
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Clarissa Petrucci
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Claudia Quatraccioni
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Chiara Iannelli
- Department of Health Sciences, Magna Græcia University, Catanzaro, Italy
| | - Nicoletta Vecchione
- Department of Gastroenterology and Endoscopy, University Hospital "G. Rodolico", Catania, Italy
| | - Carlo Maria Rossi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giacomo Broglio
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gianluca Ianiro
- Digestive Disease Centre, Fondazione Policlinico Universitario A. Gemelli IRCCS, Medicina Interna e Gastroenterologia, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Ilaria Marsilio
- Department of Surgery, Oncology and Gastroenterology, University of Padua, and Gastroenterology Unit, Azienda Ospedale Università, Padova, Italy
| | - Stefano Bibbò
- Digestive Disease Centre, Fondazione Policlinico Universitario A. Gemelli IRCCS, Medicina Interna e Gastroenterologia, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Beatrice Marinoni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Ludovico Abenavoli
- Department of Health Sciences, Magna Græcia University, Catanzaro, Italy
| | - Riccardo Pilia
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
| | - Giovanni Santacroce
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Erica Lynch
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio" University of Florence, Florence, Italy
| | - Antonella Carrieri
- Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Clinica Medica "A. Murri", Bari, Italy
| | - Pasquale Mansueto
- Internal Medicine Unit, "V. Cervello Hospital", University of Palermo, Palermo, Italy
| | - Margherita Gabba
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giacomo Alunno
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Rossi
- Department of Gastroenterology and Transplantation, Polytechnic Marche University, Ancona, Italy
| | - Francesca Onnis
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Konstantinos Efthymakis
- Department of Medicine and Ageing Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Nicola Cesaro
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marta Vernero
- SC Gastroenterologia AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | | | | | | | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia, and IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy; First Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Blais-Carrière J, Tétu A, Moreau B. Knowledge and opinions of asymptomatic adolescents and their caregivers on celiac disease screening. Paediatr Child Health 2020; 26:e145-e151. [PMID: 33936344 DOI: 10.1093/pch/pxaa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
Objectives Celiac disease (CD) is an immune enteropathy caused by sensitivity to gluten affecting one per cent of the general population. Most people with CD are asymptomatic and some may be affected from childhood. Despite the latest recommendations of paediatric gastroenterology societies, targeted screening is still uncommon in clinical paediatric settings. A poor understanding of the asymptomatic population's opinions creates obstacles for broader implementation of CD screening. This study aims to fill this gap by reporting on the knowledge and opinions of adolescents and caregivers of children on CD screening. Methods Adolescents with absence of classical symptoms of CD and caregivers of presumably asymptomatic children were asked about their knowledge and opinions of CD through a self-administered questionnaire. Results There were 227 respondents including 76 adolescents and 151 caregivers. A minority of respondents (8% of caregivers and 23% of adolescents) were identified as having a CD-associated condition (such as hypothyroidism, type 1 diabetes, Down syndrome, etc.). A majority of caregivers (84%) and half of adolescents (49%) already knew about CD. Half of the respondents (46%) were in favour of screening asymptomatic paediatric populations and this agreement increased to 81.7% when they were confronted with hypothetical risks of 10%. Conclusion This study reveals an increased willingness to screen when participants were faced with increasing hypothetical risks. This suggests that screening recommendations targeting high-risk populations, such as those of paediatric and non-paediatric gastroenterology societies, may be more widely accepted.
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Affiliation(s)
- Jasmine Blais-Carrière
- Department of Pediatrics, Centre Intégré Universitaire de Santé et Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Sherbrooke, Québec
| | - Amélie Tétu
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Québec
| | - Brigitte Moreau
- Department of Pediatrics, Centre Intégré Universitaire de Santé et Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Sherbrooke, Québec.,Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec
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Zubarik R, Ganguly E, Nathan M, Vecchio J. Celiac disease detection in hypothyroid patients requiring elevated thyroid supplementation: A prospective cohort study. Eur J Intern Med 2015; 26:825-9. [PMID: 26423749 DOI: 10.1016/j.ejim.2015.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/12/2015] [Accepted: 09/14/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Celiac disease (CD) is associated with hypothyroidism, but the disease prevalence is not thought to be great enough to warrant testing all hypothyroid patients. We hypothesized that hypothyroid patients with concomitant CD would require elevated doses of levothyroxine, and there is a threshold daily dose, above which, hypothyroid patients should be tested for CD. METHODS Hypothyroid patients presenting to the endoscopy or endocrinology clinics at the University of Vermont Medical Center were included. Patients were categorized by whether or not they required ≥125mcg/day of levothyroxine. A serum tissue transglutaminase (tTG) was performed on enrolled patients. Patients with an elevated serum tTG underwent endoscopy with duodenal biopsies. Symptoms were assessed by the Gastrointestinal Symptom Rating Scale. RESULTS Overall, 500 patients were enrolled and 29% (144 patients) required ≥125mcg/day of levothyroxine. CD was detected in 9 patients. The prevalence of CD ranged from 1.8% in our entire cohort to 12.5% in patients requiring ≥200mcg/day of levothyroxine. Eight patients with CD (89%) required ≥125mcg/day of levothyroxine. Patients who required ≥125mcg/day of levothyroxine had a significantly increased risk of CD (p<0.001). CD was detected in 5.6% of patients requiring ≥125mcg/day of levothyroxine. CONCLUSIONS Hypothyroid patients requiring elevated daily doses of levothyroxine are more likely to have CD. Hypothyroid patients requiring ≥125mcg/day of levothyroxine should undergo serologic testing for CD.
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Affiliation(s)
- Richard Zubarik
- University of Vermont Medical Center Divisions of Gastroenterology, Burlington, VT, United States.
| | - Eric Ganguly
- University of Vermont Medical Center Divisions of Gastroenterology, Burlington, VT, United States
| | | | - James Vecchio
- University of Vermont Medical Center Divisions of Gastroenterology, Burlington, VT, United States
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Olives JP. [Should the whole population be screened for coeliac disease?]. ACTA ACUST UNITED AC 2013; 61:e57-60. [PMID: 23726113 DOI: 10.1016/j.patbio.2011.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 03/23/2011] [Indexed: 01/27/2023]
Abstract
To address the issue of mass screening in coeliac disease strict criteria shall be defined. Principles and practice of screening for disease have been defined 40 years ago by Wilson and Jungner, there are still accurate and applied, specially in France for neonatal screening. Screening the whole population for gluten intolerance is not recommended at this time. Aress with gap in scientific knowledge are identified and further prospective epidemiologic studies are needed. These include the timing of screening, defining the natural history of screening-identified asymptomatic patients, developing tools to predict disease onset and disease remission and the potential risks of screening. At the present time, only identification and testing of high-risks groups is recommended.
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Affiliation(s)
- J-P Olives
- Gastro-Entérologie et Nutrition, Hôpital des Enfants, 330 Avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France.
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Nordyke K, Norström F, Lindholm L, Carlsson A, Danielsson L, Emmelin M, Högberg L, Karlsson E, Ivarsson A. Health-related quality-of-life in children with coeliac disease, measured prior to receiving their diagnosis through screening. J Med Screen 2011; 18:187-92. [PMID: 22106434 DOI: 10.1258/jms.2011.011081] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To compare the health-related quality-of-life (HRQoL) of children with screening-detected coeliac disease (CD), before they learned of their diagnosis, with that of children without CD and in those previously diagnosed with CD. METHODS In a cross-sectional CD screening study ('ETICS': Exploring the Iceberg of Coeliacs in Sweden), of 10,041 Swedish 12-year-olds invited, 7567 (75%) consented to participate, and 7208 (72%) children without previously diagnosed CD had serological markers analysed. Before the screening results were known, 7218 children (72%) and 6524 of their parents (65%) answered questionnaires. Questionnaires included the Swedish child-friendly pilot version of the EQ-5D instrument and proxy version of the EQ-5D instrument, which are generic tools used to describe HRQoL. RESULTS We found no significant difference in HRQoL between the groups of children with screening-detected CD, without CD, and those previously diagnosed with CD. CONCLUSION The HRQoL reported by 12-year-olds with screening-detected CD, before they learned of their diagnosis, was not worse than that of the children without CD or those previously diagnosed with CD. Thus, mass screening for CD should not be justified on the basis that children with unrecognized CD have a poor HRQoL. However, because these children rated their HRQoL before diagnosis and treatment, they may not have recognized or perceived symptoms as severe enough to seek medical attention which demonstrates how difficult clinical/active case finding can be. Mass screening may still, therefore, be considered if the aim is early detection and prevention of future complications.
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Affiliation(s)
- Katrina Nordyke
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, 901 85 Umeå, Sweden.
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Norström F, Lindholm L, Sandström O, Nordyke K, Ivarsson A. Delay to celiac disease diagnosis and its implications for health-related quality of life. BMC Gastroenterol 2011; 11:118. [PMID: 22060243 PMCID: PMC3233515 DOI: 10.1186/1471-230x-11-118] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 11/07/2011] [Indexed: 02/08/2023] Open
Abstract
Background To determine how the delay in diagnosing celiac disease (CD) has developed during recent decades and how this affects the burden of disease in terms of health-related quality of life (HRQoL), and also to consider differences with respect to sex and age. Methods In collaboration with the Swedish Society for Coeliacs, a questionnaire was sent to 1,560 randomly selected members, divided in equal-sized age- and sex strata, and 1,031 (66%) responded. HRQoL was measured with the EQ-5D descriptive system and was then translated to quality-adjusted life year (QALY) scores. A general population survey was used as comparison. Results The mean delay to diagnosis from the first symptoms was 9.7 years, and from the first doctor visit it was 5.8 years. The delay has been reduced over time for some age groups, but is still quite long. The mean QALY score during the year prior to initiated treatment was 0.66; it improved after diagnosis and treatment to 0.86, and was then better than that of a general population (0.79). Conclusions The delay from first symptoms to CD diagnosis is unacceptably long for many persons. Untreated CD results in poor HRQoL, which improves to the level of the general population if diagnosed and treated. By shortening the diagnostic delay it is possible to reduce this unnecessary burden of disease. Increased awareness of CD as a common health problem is needed, and active case finding should be intensified. Mass screening for CD might be an option in the future.
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Affiliation(s)
- Fredrik Norström
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden.
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Rosén A, Emmelin M, Carlsson A, Hammarroth S, Karlsson E, Ivarsson A. Mass screening for celiac disease from the perspective of newly diagnosed adolescents and their parents: a mixed-method study. BMC Public Health 2011; 11:822. [PMID: 22017750 PMCID: PMC3229548 DOI: 10.1186/1471-2458-11-822] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 10/21/2011] [Indexed: 12/16/2022] Open
Abstract
Background Mass screening for celiac disease (CD) as a public health intervention is controversial. Prior to implementation, acceptability to the targeted population should be addressed. We aimed at exploring adolescents' and parents' experiences of having the adolescents' CD detected through mass screening, and their attitudes towards possible future mass screening. Methods All adolescents (n = 145) with screening-detected CD found in a Swedish school-based screening study, and their parents, were invited to this study about one year after diagnosis. In all, 14 focus group discussions were conducted with 31 adolescents and 43 parents. Written narrative was completed by 91 adolescents (63%) and 105 parents (72%), and questionnaires returned by 114 parents (79%). Data were analyzed using qualitative content analysis. In addition, narratives and questionnaire data allowed for quantified measures. Results Adolescents and parents described how they agreed to participate "for the good of others," without considering consequences for themselves. However, since the screening also introduced a potential risk of having the disease, the invitation was regarded as "an offer hard to resist." For the majority, receiving the diagnosis was described as "a bolt of lightning," but for some it provided an explanation for previous health problems, and "suddenly everything made sense." Looking back at the screening, the predominant attitude was "feeling grateful for being made aware," but some adolescents and parents also expressed "ambivalent feelings about personal benefits." Among parents, 92% supported future CD screening. The most common opinion among both adolescents and parents was that future CD mass screening should be "a right for everyone" and should be offered as early as possible. However, some argued that it should be "only for sufferers" with symptoms, whereas others were "questioning the benefits" of CD mass screening. Conclusions Although the incentives to participate in the CD screening were partly non-personal, and diagnosis was met with surprise, adolescents and parents felt grateful that they were made aware. They welcomed future CD screening, but suggested that it should be conducted earlier in life. Thus, CD mass screening seemed acceptable to most of those who were diagnosed and their parents.
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Affiliation(s)
- Anna Rosén
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden.
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Rosén A, Ivarsson A, Nordyke K, Karlsson E, Carlsson A, Danielsson L, Högberg L, Emmelin M. Balancing health benefits and social sacrifices: a qualitative study of how screening-detected celiac disease impacts adolescents' quality of life. BMC Pediatr 2011; 11:32. [PMID: 21569235 PMCID: PMC3120678 DOI: 10.1186/1471-2431-11-32] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 05/10/2011] [Indexed: 12/14/2022] Open
Abstract
Background Celiac disease often goes undiagnosed. Mass screening might be an option to reduce the public health burden of untreated celiac disease. However, mass screening is still controversial since it is uncertain whether the benefits of early detection outweigh the possible negative consequences. Before implementation of screening programs, the experiences of those being identified as cases should be considered. The aim of our study was to explore how screening-detected celiac disease impacts adolescents' quality of life, as perceived by themselves and their parents. Methods All adolescents (n = 145) with screening-detected celiac disease found in a Swedish screening study, and their parents, were invited to share their experiences in a qualitative follow-up study. In total, we have information on 117 (81%) of the adolescents, either from the adolescents themselves (n = 101) and/or from their parent/s (n = 125). Written narratives were submitted by 91 adolescents and 105 parents. In addition, 14 focus group discussions involving 31 adolescents and 43 parents were conducted. Data was transcribed verbatim and analyzed based on a Grounded Theory framework. Results The screening-detected celiac disease diagnosis had varying impact on quality of life that related both to changes in perceived health and to the adolescents' experiences of living with celiac disease in terms of social sacrifices. Changes in perceived health varied from "healthy as anyone else with no positive change" to "something was wrong and then changed to the better", whereas experiences of living with celiac disease ranged from "not a big deal" to "treatment not worth the price". Perceptions about living with celiac disease and related coping strategies were influenced by contextual factors, such as perceived support from significant others and availability of gluten-free products, and were developed without a direct relation to experiencing changes in perceived health. Conclusions Screening-detected celiac disease has varying impact on adolescents' quality of life, where their perceived change in health has to be balanced against the social sacrifices the diagnosis may cause. This needs to be taken into account in any future suggestion of celiac disease mass screening and in the management of these patients.
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Affiliation(s)
- Anna Rosén
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden.
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Abstract
OBJECTIVE The aim of this study is to determine Swedish parents' willingness to pay (WTP) for coeliac disease (CD) screening of their child. SUBJECTS AND METHODS CD screening was undertaken involving 10,041 12-year-old children, with 7567 (75%) agreeing to participate. Blood samples from the children were analysed for CD serological markers. Parents received a questionnaire including a scenario describing the health-related risks of having CD and screening and diagnostic procedures. Parents were also asked whether they were willing to pay for CD screening, should this not be offered free of charge, and, if so, what their maximum WTP would be. Their WTP was compared with the average cost per child for the screening and case ascertainment procedures. RESULTS The questionnaire was answered by 6524 parents, and of 6057 valid responses 63% stated that they were willing to pay something. The mean WTP was 79 EUR and the median 10 EUR. The average cost per child for the screening and case ascertainment procedures was 47 EUR, which 23% of the parents stated they were willing to pay. Parents' WTP increased with higher education and income, and with child symptoms that may indicate CD. CONCLUSIONS Swedish parents' WTP for school-based CD screening of their child was higher than the average cost per child; however, only a minority of the parents were willing to pay that amount.
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Tjellström B, Stenhammar L, Högberg L, Fälth-Magnusson K, Magnusson KE, Midtvedt T, Sundqvist T, Norin E. Screening-detected and symptomatic untreated celiac children show similar gut microflora-associated characteristics. Scand J Gastroenterol 2010; 45:1059-62. [PMID: 20509753 DOI: 10.3109/00365521.2010.483738] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the metabolic function of intestinal microflora in children with screening-detected celiac disease (CD) to see if there is an aberrant gut flora in screening-detected CD similar to symptomatic CD and contrary to healthy controls. MATERIALS AND METHODS As part of a Swedish multicenter screening for CD, 912 12-year-old children were screened with serum anti-human tissue transglutaminase-IgA. Small bowel biopsy specimens from children with positive serology revealed 17 individuals with CD. The functional status of the intestinal microflora was evaluated by gas-liquid chromatography of short chain fatty acids (SCFAs) in fecal samples. Our previously published findings in children with symptomatic CD and healthy controls were used as comparison. RESULTS The children with screening-detected CD had a similar fecal SCFA profile to children with symptomatic CD, but differed significantly from that in healthy children. CONCLUSIONS This is the first study on SCFA patterns in fecal samples from children with screening-detected CD. The similarity of the fecal SCFA profile in screening-detected and symptomatic CD indicates common pathogenic mechanisms. This could open the way for new therapeutic or prophylactic measures based on novel biological principles.
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Affiliation(s)
- Bo Tjellström
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institut, Stockholm, Sweden.
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Toftedal P, Hansen DG, Nielsen C, Lillevang ST, Hansen TP, Husby S. Questionnaire-based case finding of celiac disease in a population of 8- to 9-year-old children. Pediatrics 2010; 125:e518-24. [PMID: 20123763 DOI: 10.1542/peds.2009-0375] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Antibody screenings and diagnosis of celiac disease (CD) among children with type 1 diabetes have suggested that a considerable proportion of children with CD may, in fact, have preclinical (undiagnosed) symptoms. We aimed to test if a questionnaire would lead to significant case finding in an unselected population of 8- to 9-year-old children. PATIENTS AND METHODS The study population included 9880 children aged 8 to 9 years. Before the study, 13 children from the study population were known to have CD. We developed a questionnaire on the basis of 5 simple items suggestive of CD and mailed the questionnaire to the families of all children in the study population who resided in the County of Funen, Denmark. In total, 7029 respondents returned the questionnaire (70%); among them, 2835 children had 1 or more symptoms. These children were invited for a blood test to determine their human serum immunoglobulin A (IgA) anti-tissue transglutaminase antibody (anti-tTG) levels. RESULTS Of the 1720 children who were tested for the human serum IgA anti-tTG, 24 participants had a positive result (range: 20 to >150 U). Seventeen of these children underwent an upper endoscopy procedure. Fourteen children had histologic signs of CD (Marsh classification stage III). Fourteen children met the diagnostic criteria for CD. The prevalence proportion of patients who were newly diagnosed with CD was 0.14% (95% CI: 0.08-0.24) (14 of 9967), and the estimate of the minimum total prevalence proportion of children with CD was 0.27% (95% CI: 0.18-0.39) (27 of 9980). The maximal prevalence proportion of patients with newly diagnosed CD was 1.22% (95% CI: 0.76-1.90) (21 of 1720), including those participants who had a positive anti-tTG result but not a final diagnosis of CD. The ratio of known to minimally symptomatic CD was approximately 1:1. CONCLUSION A number of preclinical and low-grade symptomatic patients with CD may be identified by their responses to a mailed questionnaire.
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Affiliation(s)
- Peter Toftedal
- DMSc, Hans Christian Andersen Children's Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark
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Gupta R, Reddy DN, Makharia GK, Sood A, Ramakrishna BS, Yachha SK, Thapa BR, Banerjee R, Anuradha S, Dutta U, Puri AS, Jain AK, Mulder CJJ, Kumar A, Boindala S. Indian task force for celiac disease: Current status. World J Gastroenterol 2009; 15:6028-33. [PMID: 20027674 PMCID: PMC2797658 DOI: 10.3748/wjg.15.6028] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There are limited data on celiac disease (CD) from India. The limited knowledge about CD in India might be attributed to several factors. The first meeting of the Indian Task Force for Celiac Disease was held in the Asian Institute of Gastroenterology, Hyderabad, India in December 2008. The objectives of the meeting were to focus research on prevalence of CD in the wheat-eating Northern vs the rice-eating Southern Indian population, low-budget serological assays to study the underprivileged population, to involve other medical subspecialties in CD, to suggest proper legislation regarding wheat food labeling, and to organize affordable food substitutes for patients with celiac disease.
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McGowan KE, Castiglione DA, Butzner JD. The changing face of childhood celiac disease in north america: impact of serological testing. Pediatrics 2009; 124:1572-8. [PMID: 19948628 DOI: 10.1542/peds.2008-2373] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The goal was to evaluate the impact of immunoglobulin A endomysial antibody testing on the incidence and clinical presentation of childhood celiac disease. METHODS The incidence and clinical presentation of celiac disease in patients <18 years of age in 1990-1996 (pretesting group) versus 2000-2006 (testing group) were compared. RESULTS The median age at diagnosis was 2 years (95% confidence interval: 2-4 years) in the pretesting group (N = 36), compared with 9 years (95% confidence interval: 8-10 years) in the testing group (N = 199; P < .001); the female/male ratios (1.6:1) were similar (P = .982). The incidence of celiac disease increased from 2.0 cases per 100000 children (pretesting group) to 7.3 cases per 100000 children (testing group; P = .0256). The frequency of classic celiac disease presentations decreased from 67% (pretesting group) to 19% (testing group; P < .001), but the incidence of classic celiac disease did not differ (0.8 vs 1.6 cases per 100000; P = .154). In the testing group, 13 previously unrecognized clinical presentations were observed in 98 children, including 35 with family history, 18 with abdominal pain, and 14 with type 1 diabetes mellitus. The frequency of Marsh IIIc lesions decreased from 64% (pretesting group) to 44% (testing group; P = .0403). In the testing group, classic celiac disease remained predominant (67%) in young children (<3 years), whereas atypical gastrointestinal and silent presentations predominated in older children. CONCLUSIONS Antibody testing for celiac disease tripled the incidence of celiac disease and quadrupled the median age at diagnosis.
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Affiliation(s)
- Kelly E McGowan
- Department of Pediatrics, University of Calgary, Calgary, Canada
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Anthropometric, serologic, and laboratory correlation with villous blunting in pediatric celiac disease: diabetics are different. J Clin Gastroenterol 2009; 43:622-6. [PMID: 19238095 DOI: 10.1097/mcg.0b013e3181886047] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We evaluated the correlation between level of tissue transglutaminase (TTG) and endomysial antibodies (EMAs) to different degrees of intestinal damage in celiac disease (CD) children with [presence of diabetes mellitus (DM)+] and without [absence of diabetes mellitus (DM-)] type I diabetes. We also assessed the correlation between albumin, hemoglobin (hgb), transaminases, symptom presence, age of cereal introduction, and body mass index (BMI) to different degrees of intestinal damage. METHODS Retrospective review of patients seen at the Children's Hospital of Philadelphia between January 2002 and June 2006 revealed 60 children (mean age 9.8 y) who had TTG, EMA, and other laboratory tests performed at time of histologic CD diagnosis from duodenal biopsies. Twenty-one of 60 children had DM. All children were stratified for histologic damage according to Marsh classification. RESULTS Overall, Marsh (M) I lesions were seen in 2 (3.3%), MII in 2 (3.3%), IIIa in 14 (23.3%), IIIb in 15 (25%), and IIIc in 27 (45%); no differences in DM- versus DM+ groups. TTG was positive in all and EMA was positive in all but 1 child. Among DM- and DM+ children, median TTG and EMA values were higher with MIIIa-c, respectively. For DM-, BMI percentile, hgb, and mean corpuscular volume were lower with advancing histology. However, in DM+, no significant correlation of BMI percentile, hgb, or mean corpuscular volume with grade was observed. Cereal introduction age, hypoalbuminemia, and hepatitis did not differ between MIIIa-c in any group. CONCLUSIONS TTG and EMA mean serum values are higher in CD children with severe enteropathy (MIIIc) than in those with mild enteropathy (MIIIa). CD in DM is accompanied by serologic and histologic findings identical to that of a non-DM CD population. As CD is identified through screening in DM, it is often silent and not associated with symptoms, growth abnormalities, or anemia. Clinical parameters (height, weight, hgb, symptoms) are not helpful in identifying silent CD in DM.
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Gueiros ACLN, Silva GAP. Soropositividade para doença celíaca em crianças e adolescentes com baixa estatura. REVISTA PAULISTA DE PEDIATRIA 2009. [DOI: 10.1590/s0103-05822009000100005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJETIVO: Avaliar a frequência da positividade do marcador sorológico para doença celíaca em crianças e adolescentes com baixa estatura, utilizando-se o anticorpo anti-transglutaminase humana como teste de triagem. MÉTODOS: Estudo descritivo com amostra obtida por conveniência. Foi realizado no período de abril a setembro de 2004 no Ambulatório Geral de Pediatria do Instituto Materno Infantil Professor Fernando Figueira e no Ambulatório de Crescimento e Desenvolvimento do Hospital das Clínicas. Foram considerados casos as crianças e os adolescentes portadores de baixa estatura, definida como aquela abaixo do percentil 3 para idade e sexo, utilizando como referência o gráfico de altura/idade do National Center for Health Statistics, 2000. Foi pesquisado o anticorpo anti-transglutaminase humana (AATGh), considerado positivo se concentração >20U/mL e, nos positivos, o anticorpo antiendomísio (AAE). RESULTADOS: Foram avaliados 78 pacientes, sendo 41 (53%) do sexo feminino. O AATGh foi positivo em 3/78 (3,8%) dos pacientes. O AAE foi positivo em um paciente, naquele com concentração mais elevada do AATGh. Considerando-se a positividade para os dois testes, a soropositividade foi de 1,3%. CONCLUSÕES: A presença de marcador sorológico para doença celíaca em crianças e adolescentes portadoras de baixa-estatura e pertencentes a famílias de baixa-renda aponta para a necessidade de investigação sistemática da doença celíaca nesses pacientes.
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Bone mineral content deficits of the spine and whole body in children at time of diagnosis with celiac disease. J Pediatr Gastroenterol Nutr 2009; 48:175-80. [PMID: 19179879 DOI: 10.1097/mpg.0b013e318177e621] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to determine whether children with celiac disease (CD) have deficits in spine (SP) and whole body (WB) bone mineral content (BMC) at time of diagnosis, and whether the deficits are related to altered growth and body composition. The secondary aim was to examine the effect of histological grade on BMC. PATIENTS AND METHODS A retrospective study of children who had undergone a dual energy x-ray absorptiometry scan at the time of diagnosis with CD between October 1, 2003, and June 15, 2006, were compared with a healthy reference sample of similar age and race from the same geographic region in the United States. SP and WB BMC were expressed as sex-specific z scores relative to age and relative to height to assess differences in the CD group versus controls. Pearson correlation, t tests, and analysis of variance were performed to determine predictors of BMC. RESULTS Forty-four children (mean age 10.6 +/- 3.4 years; 77% female, 96% white) with CD were evaluated and compared with 338 healthy children. Children with CD were shorter than children of similar age and sex. SP and WB BMC for age z scores were significantly lower in the CD group compared with controls. When adjusted for height, significant deficits in WB BMC persisted in patients with CD. Low SP and WB BMC correlated with advanced histological grade in CD. Low body mass index correlated with low WB BMC in CD. CONCLUSIONS Newly diagnosed children with CD may benefit from screening for low bone mineral content. Patients with low body mass index and those with advanced histological damage (Marsh grade IIIc) particularly may be at risk for osteopenia.
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Lohi S, Mäki M, Rissanen H, Knekt P, Reunanen A, Kaukinen K. Prognosis of unrecognized coeliac disease as regards mortality: a population-based cohort study. Ann Med 2009; 41:508-15. [PMID: 19551537 DOI: 10.1080/07853890903036199] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND AIM Clinically diagnosed coeliac disease patients carry an increased risk of mortality. As coeliac disease is markedly underdiagnosed, we aimed to quantify the risk of mortality in subjects with unrecognized and thus untreated coeliac disease. METHOD Blood samples from 6,987 Finnish adults were drawn in 1978-80, and sera were tested for immunoglobulin A (IgA)-class tissue transglutaminase antibodies (Eu-tTG) in 2001. Positive sera were further analysed for endomysial (EMA) and tissue transglutaminase antibodies by another test (Celikey tTG). EMA- and Celikey tTG-positive cases were compared to negatives as regards mortality in up to 28 years of surveillance, yielding a total follow-up of 147,646 person years. Dates and causes of death were extracted from the nation-wide database. RESULTS Altogether 74 (1.1%) of the participants were EMA- and 204 (2.9%) Celikey tTG-positive. The age- and sex-adjusted relative risk of overall mortality was not increased in either EMA (0.78, 95% CI 0.52-1.18) or Celikey tTG (1.19, 95% CI 0.99-1.42) -positive subjects. However, antibody-positive cases evinced a tendency to die from lymphoma, stroke, and diseases of the respiratory system. CONCLUSIONS The prognosis of unrecognized coeliac disease was good as regards overall mortality, which does not support screening of asymptomatic coeliac disease cases.
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Affiliation(s)
- Sini Lohi
- Paediatric Research Center, Medical School, University of Tampere, Tampere, Finland
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Hashemi J, Hajiani E, Shahbazin HBB, Masjedizadeh R, Ghasemi N. Prevalence of celiac disease in Iranian children with idiopathic short stature. World J Gastroenterol 2008; 14:7376-80. [PMID: 19109872 PMCID: PMC2778122 DOI: 10.3748/wjg.14.7376] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the prevalence of celiac disease (CD) in children with idiopathic short stature (ISS) and the diagnostic value of immunoglobulin (Ig) A G antigliadin antibodies (AGA) and transglutaminase (TTG) antibodies for CD.
METHODS: A total of 104 children (49 male, 55 female) with ISS without a specific etiology were studied. Extensive endocrine investigations had shown no abnormalities in any subject. Anthropometric parameters and IgA AGA and IgA TTG antibodies were evaluated in this study group. These antibodies were measured by enzyme-linked immunosorbent assay. All patients were referred for an endoscopic intestinal biopsy. The biopsy samples were classified according to revised Marsh criteria (UEGW 2001).
RESULTS: We detected positive IgA TTG antibodies in 36 and IgA AGA in 35 of these patients. Thirty one IgA TTG antibody positive and 28 IgA AGA positive subjects showed histological abnormalities compatible with celiac disease (33.6%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value for IgA AGA were found to be 80%, 88.4%, 77.8% and 89.7%, respectively. Sensitivity, specificity and PPV for IgA TTG antibodies were 88.6%, 94.2% and 88.6%, respectively.
CONCLUSION: We conclude that the prevalence of celiac disease is high in patients with ISS and it is important to test all children with ISS for celiac disease by measuring serologic markers and performing an intestinal biopsy.
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Menardo G, Brizzolara R, Bonassi S, Marchetti A, Dante GL, Pistone C, Marenco D, Rabellino V, Buscaglia S, Scarso R, Murialdo M, Venturino E, Marino CE, Descalzi D, Minetti F, Bagnasco M, Pesce G. Population screening for coeliac disease in a low prevalence area in Italy. Scand J Gastroenterol 2006; 41:1414-20. [PMID: 17101572 DOI: 10.1080/00365520600815605] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A screening program was proposed for the village of Carcare (population 5700), located in a region of Italy with an apparently low prevalence of coeliac disease (CD): only 1 patient diagnosed out of 2557 inhabitants. The study group comprised 1002 individuals (568 F, 434 M, age range 13-90 years) recruited from blood donors, secondary school pupils and people referred to the local outpatient facilities for routine blood chemistry. MATERIAL AND METHODS Total IgA, IgA anti-tissue transglutaminase (tTG) (ELISA, recombinant human antigen) and IgA antiendomysium (EMA) (IFI, umbilical cord substrate) antibodies were measured in the serum of all participants. All patients with IgA deficiency were investigated for IgG tTG antibodies, and in the case of disagreement between tTG and EMA, they were typed for HLA DQ2-DQ8 haplotypes. RESULTS Thirteen subjects were positive and 988 negative for autoantibodies (3/988 had IgA deficiency). One serum sample was positive for tTG antibodies but negative for EMA. Ten out of 13 positive subjects consented to undergo duodenal biopsy, which invariably produced evidence of CD despite the absence of clinical signs/symptoms. A post-diagnostic clinical investigation provided evidence showing mild iron deficiency (4 subjects) and osteoporosis (2 subjects). After counselling, all subjects accepted a gluten-free diet. CONCLUSIONS The prevalence of CD in the study group was 1:100 (1.0%; 95% CI: 0.5-1.8%): this indicates that CD is largely underdiagnosed in Carcare. Our results suggest that the low prevalence of CD observed in some regions is likely to be due to underdiagnosis.
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Affiliation(s)
- Giorgio Menardo
- Medicina Interna II ASL2 Savona, Ospedale S.Paolo, Savona, Italy
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Abstract
Perspective on the paper by Ravikumara et al (see page 969)
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Affiliation(s)
- R M Beattie
- Paediatric Medical Unit, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
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Abstract
AIM To report the case of a 14-y-old boy with coeliac disease and obesity. METHODS AND RESULTS A 14-y-old boy presented with episodic diarrhoea associated with eating spaghetti. His body mass index (BMI) at presentation was 37.2 kg/m2 (>99.9th centile). Both antigliadin and anti-endomysial antibodies were positive, and coeliac disease was diagnosed by jejunal biopsy. His diarrhoea ceased and the gliadin and endomysial antibodies disappeared after starting gluten-free diet. At 17 y, his BMI increased to 42.7 kg/m2 despite dietary support. CONCLUSION Obesity in a child does not exclude the diagnosis of coeliac disease, especially if presenting with suggestive symptoms.
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Affiliation(s)
- Olumuyiwa Oso
- Department of Paediatrics, County Hospital, Hereford, United Kingdom.
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Abstract
AIM To report the case of a 14-y-old boy with coeliac disease and obesity. METHODS AND RESULTS A 14-y-old boy presented with episodic diarrhoea associated with eating spaghetti. His body mass index (BMI) at presentation was 37.2 kg/m2 (>99.9th centile). Both antigliadin and anti-endomysial antibodies were positive, and coeliac disease was diagnosed by jejunal biopsy. His diarrhoea ceased and the gliadin and endomysial antibodies disappeared after starting gluten-free diet. At 17 y, his BMI increased to 42.7 kg/m2 despite dietary support. CONCLUSION Obesity in a child does not exclude the diagnosis of coeliac disease, especially if presenting with suggestive symptoms.
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Affiliation(s)
- Olumuyiwa Oso
- Department of Paediatrics, County Hospital, Hereford, United Kingdom.
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